CLAIMS INVESTIGATION PROCESS

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

[ ] Retrieve Claim Details: Fetch the initial claim entry and all associated incident reports from the Claims Data Model.
[ ] Fetch Policyholder Profile: Retrieve user data and policy coverage details for the person filing the claim.
[ ] Calculate Estimated Liability Score: Run a formula based on incident severity, evidence strength, and policy terms to determine initial liability probability.
[ ] Assign Investigator: Create a task for the Claims Department to assign a specialized investigator to the case.
[ ] Create Investigation Log: Generate a new entry in the Investigation Log data model to track all findings related to this specific claim ID.
[ ] Evidence Collection Task: Create a task for the investigator to gather photos, witness statements, and police reports.
[ ] Update Claim Status to 'In Investigation': Update the status field in the original Claim Entry to reflect the current stage of the process.
[ ] Retrieve Evidence Attachments: Fetch all uploaded files and documentation linked to the claim entry.
[ ] Sum Total Reported Damages: Aggregate all line-item repair estimates and medical bills to find the total estimated loss.
[ ] Calculate Deductible Impact: Subtract the policyholder's deductible from the total estimated loss to determine the net payable amount.
[ ] Fraud Detection Review: Create a task for the Fraud Unit if the calculated liability score exceeds a specific threshold.
[ ] Log Investigation Findings: Update the Investigation Log entry with the final conclusions and summary of the investigation.
[ ] Update Claim Value: Update the 'Final Estimated Loss' field in the Claim entry with the aggregated damage total.
[ ] Notify Policyholder of Decision: Send an automated email to the policyholder informing them if the claim has been approved, denied, or requires more info.
[ ] Urgent Update Alert: Send an SMS to the assigned investigator when a high-priority evidence piece is uploaded.
[ ] Final Settlement Approval: Create a task for the Claims Manager to review and digitally sign off on the final payout amount.
[ ] Finalize Claim Status: Update the Claim entry status to 'Closed' or 'Settled'.
[ ] Generate Payment Instruction: Create an entry in the Finance/Disbursement data model to trigger the actual fund transfer.
[ ] Monthly Claims Audit Report: Generate a monthly performance report summarizing investigation turnaround times and loss ratios.
[ ] Cleanup Draft Entries: Delete any temporary or duplicate investigation drafts created during the process to maintain data hygiene.

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