02 — Capability · BC-1750
Insurance Claims
Keep the promise a policy makes when a loss happens, by taking the first report, investigating and valuing the loss, paying a fair settlement, recovering what others owe and stopping fraudulent claims. Covers property and casualty claims, life and disability claims and death benefits on annuities; designing and issuing the policy sits elsewhere.
- Claims Handling
- Claims Operations
- Loss Adjustment
- Benefit Claims Administration
In scope
- First notice of loss, coverage checks and claim triage
- Investigation, loss adjustment, liability decisions and case reserves
- Settlement, claim payments, repair networks and closure
- Subrogation, salvage and insurance claims fraud
Out of scope
- Claims an enterprise makes on its own insurance program (see BC-130.50)
- Policy issuance and servicing (see BC-1740.30)
- IBNR and actuarial reserves across the claims portfolio (see BC-1740.60)
- General customer contact and case handling outside claims (see BC-450.20)
Realized by · 0
- No product in the catalog yet.
Used in · 5
- First-Notice-to-Settlement · 01 Report the Loss via BC-1750.10
- First-Notice-to-Settlement · 02 Investigate & Reserve via BC-1750.20
- First-Notice-to-Settlement · 03 Settle & Pay via BC-1750.30
- First-Notice-to-Settlement · 04 Recover via BC-1750.40
- First-Notice-to-Settlement · 05 Close & Feed Back via BC-1750.30
Build it · 0
- Nothing in the library points here yet.
Decomposes into · 5
- BC-1750.10First Notice of LossCapture every new loss quickly and completely from any channel, confirm there is a policy that may respond, and send the claim to the right handler at the right priority. General contact center routing sits in Customer Service.
- BC-1750.20Claim Investigation & AdjustmentEstablish the facts, cause and value of each loss and who is liable, and hold a case reserve that reflects what the claim is expected to cost. IBNR and portfolio reserving sit in Actuarial Valuation & Reserving.
- BC-1750.30Claim Settlement & PaymentAgree a fair settlement and get the money or the repair to the right person promptly, then close the claim cleanly and reopen it only when new facts arrive. Legal defense of litigated claims is coordinated with Legal.
- BC-1750.40Subrogation & SalvageRecover what the insurer has paid from those responsible and from damaged property it has taken over, so claim cost reflects what the insurer finally bears. Reinsurance recoveries sit with reinsurance.
- BC-1750.50Claims FraudStop paying for staged, exaggerated or fabricated claims while keeping genuine claimants moving, by scoring claims, investigating suspicious ones and acting on organized fraud. Fraud on payments, cards and bank accounts sits in the financial crime lens.