INSURANCE CLAIMS PROCESSING WORKFLOW

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

[ ] Retrieve Claim Details: Fetch the initial claim submission data, including policy number, claimant name, and incident date.
[ ] Fetch Policyholder Profile: Retrieve data from the Customer Data Model to check coverage limits and policy status.
[ ] Calculate Policy Deductible: Apply the deductible amount to the reported loss amount to determine the initial payout liability.
[ ] Assign Claims Adjuster: Create a task for the Claims Department to assign a qualified adjuster to the new claim.
[ ] Create Investigation Record: Generate a new entry in the Investigation Data Model to track findings and evidence.
[ ] Site Inspection Task: Create a task for the assigned adjuster to perform a physical inspection of the damage.
[ ] Update Claim Status to 'Under Investigation': Update the status field in the Claims Data Model once the adjuster is assigned.
[ ] Retrieve Incident Photos: Get all image/document entries linked to the claim incident.
[ ] Sum Repair Estimates: Aggregate all line items from various vendor repair estimates to calculate the total estimated cost.
[ ] Determine Fraud Risk Score: Run a formula comparing the claim amount against historical averages for this policy type to flag potential fraud.
[ ] Fraud Review Task: Create a high-priority task for the Special Investigations Unit (SIU) if the risk score is above a threshold.
[ ] Update Reserve Amount: Update the 'Financial Reserve' field in the Claim Entry with the new aggregated estimate total.
[ ] Generate Settlement Offer: Create a new entry in the Settlement Data Model containing the proposed payout breakdown.
[ ] Notify Claimant of Settlement: Send an email to the policyholder explaining the settlement amount and next steps.
[ ] Final Approval Task: Create a task for the Claims Manager to review and digitally sign the settlement offer.
[ ] Update Claim Status to 'Closed': Update the primary Claim entry to a closed state once payment is processed.
[ ] Remove Duplicate Sub-Claims: Delete any erroneously created duplicate claim entries identified during the review process.
[ ] Monthly Claims Loss Report: Generate a monthly summary report of all closed claims, total payouts, and average processing time.
[ ] Send Payment Confirmation SMS: Send an SMS notification to the claimant's registered mobile number confirming that funds have been released.

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