Close hospital and TPA queries against treatment evidence

Link pre-authorisation, discharge summary, itemised bill and TPA or hospital queries to the relevant health cover. The claims officer resolves medical or policy questions with qualified reviewers so a patient receives a substantiated decision.

A notice, complaint, missed commitment or disputed amount opens a case.

People in the process

HHealth ClaimsProcess Owner
TTPAParticipating Team
HHospitalParticipating Team
MMedical reviewerParticipating Team

Records it works with

Relevant agreement, policy or governing record
Transaction, performance and payment history
Notices, communications and supporting evidence

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

Resolve coverage questions before a claim decision

Reconstruct the operative policy schedule, endorsements, loss facts, exclusions and expert assessment. A claims specialist records the reasoned coverage position, tests contrary evidence and identifies what the policyholder still needs to supply.

Claims

Turn surveyor findings into a defensible loss assessment

Connect the survey report, damage inventory, repairs, salvage and policy limits for a general-insurance loss. Claims staff resolve inconsistencies with the surveyor and document the approved settlement basis rather than treating an external estimate as the decision.

Claims

Carry an authorised claim to the right payee

After the claims decision, match settlement terms, beneficiary or hospital details, deductions and finance payment reference. Resolve rejected transfers or competing payee instructions before telling the policyholder the claim is paid.

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Order for the work. Room for the people.