Adjudicate health insurance claims with itemised settlement letters

Check cashless and reimbursement claims against policy coverage, waiting periods, sub-limits, hospital bills and medical records, and tie every deduction to its policy clause. Claims managers can approve, partly pay or repudiate with recorded reasons, and policyholders receive a letter explaining each deduction.

Starts when

A cashless request from a network hospital or a reimbursement claim from a policyholder.

Runs: Per claim, continuously every day.

People in the process

MMedical AdjudicationProcess Owner
CClaims IntakeParticipating Team
TThird Party AdministratorParticipating Team
CClaims ManagerParticipating Team
CClaims OperationsParticipating Team
FFinanceParticipating Team
IInternal AuditParticipating Team

The process is a starting point. The standards are yours.

Configure for the insurer, product, distribution model and applicable IRDAI requirements. Claims, underwriting, actuarial and grievance decisions stay with the authorised specialists.

Keep the work connected.

Claims Operations

Investigate and settle life insurance death claims

Verify the policy status, nomination, claimant identity and bank details for each death intimation, and route early or suspicious claims to field investigation against proposal disclosures. The claims review committee can decide repudiations on recorded evidence, and Finance pays interest where settlement runs late.

CCCCF

Premium Accounting

Reconcile daily premium receipts and clear unallocated deposits

Match each collection-account credit to a proposal, renewal or intermediary remittance, and check each policy's risk start date against premium realisation. Finance can apply, refund or move unmatched credits to unclaimed amounts, and the finance controller signs the daily reconciliation.

TPDCF

Fraud Monitoring Unit

Investigate suspected insurance fraud and report it to IRDAI

Log each fraud alert from claims, underwriting, distribution, staff or analytics and trace it through screening, payment holds and the investigator's written findings. The Fraud Monitoring Committee can decide denial, recovery, termination or a police complaint, and confirmed cases feed the annual IRDAI fraud return.

CFLFC

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