AUTOMATED CLAIMS SETTLEMENT PROCESS

Created by ChecklistGuro (https://checklistguro.com)

[ ] Retrieve Claim Submission: Fetch the initial claim entry submitted by the customer including policy details and incident description.
[ ] Fetch Policyholder Profile: Retrieve user data and historical claim records for the identified policyholder.
[ ] Retrieve Damage Estimates: Get all line items from the 'Damage Assessment' data model associated with this claim ID.
[ ] Calculate Total Estimated Loss: Sum the cost of all parts and labor entries from the Damage Assessment data model.
[ ] Calculate Deductible Deduction: Subtract the policyholder's mandatory deductible from the Total Estimated Loss.
[ ] Calculate Net Settlement Amount: Calculate the final payout amount (Total Loss - Deductible).
[ ] Update Claim Status to 'Under Review': Update the claim entry status to reflect that an adjuster is currently reviewing the file.
[ ] Assign Adjuster Task: Create a task for a Claims Adjuster to verify the validity of the damage estimates.
[ ] Check Fraud Flags: Retrieve data from the Fraud Detection model to check for suspicious patterns.
[ ] Determine Risk Score: Calculate a risk score based on claim frequency and fraud flag presence.
[ ] High-Risk Investigation Task: Create a high-priority task for the Fraud Investigation Unit if the risk score exceeds a threshold.
[ ] Update Claim Final Decision: Update the claim entry with the final approved amount and settlement decision (Approved/Denied).
[ ] Create Settlement Instruction: Create a new entry in the 'Payments' data model to trigger the bank transfer.
[ ] Notify Claimant of Approval: Send an automated email to the customer confirming their claim has been settled and providing the payout details.
[ ] Send Payout Alert: Send a brief SMS notification to the user's registered phone number regarding the funds transfer.
[ ] Update Policy Record: Update the user's policy data model to reflect the completed claim and any impact on premiums.
[ ] Generate Monthly Claims Report: Generate a summary report of all settled claims, total payouts, and average processing time for management.

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