SERDICA Claim Module

SERDICA Claim Module is a component of the SERDICA Suite that handles the processing of claims made by policyholders. It plays a role in the end-to-end management of insurance policies by facilitating the reporting, assessment, approval, and settlement of claims. Using the latest technologies for the whole IPAL PAS, the SERDICA Claim Module is streamlining the process of claims management, improving customer service, and ensuring that claims are processed accurately and efficiently while complying with insurance industry regulations and standards. The claim module provides a uniform way of claim processing that applies to all P&C lines of business. The full cycle of handling of a claim is maintained by Camunda BPM. The claim system is pre-integrated with IPAL Policy administration from where it receives the contracted policy conditions. Based on this information the claim system controls the limits defined in the contract and restricts the indemnity according to the deductibles defined per cover. It is also integrated with the SERDICA reinsurance module and automatically separates and allocates the reinsurers and/or co-insurers' share of the indemnity. The claim subsystem ensures effective control during the claim settlement against the cover, object, and contract states depending on the type of claim and according to the conditions of the contract. This control minimizes errors during the claim process including double indemnity payment or payment against non-covered events. As all the operator's actions are registered in the system the module could also prevent internal fraud or at least supply information for fraud detection thus lowering the risk. The following is the list of the business processes provided by the module.

• Claim notification registration.
• Open claim request.
• Reserving.
• Document control.
• Evaluation.
• Indemnity calculation.
• Indemnity payment request.
• Claim expenses.
• Claim subrogation and recovery.
• Claim payments: reimbursements, recurring payments, bulk payments to providers.

First Notice of Loss (FNOL)

FNOL can be registered using the WEB application or SERDICA LLM-based VA. The system provides a standard API for the registration of FNOL. In the FNOL registration, the system requires minimum data for claim notification to be captured. This data includes the date of the event, reference to the policy or insured object, and type of event; if more details are available they can also be captured during FNOL registration - damaged objects or injured persons, covers against which the claim will be settled, claimant details, preferred settlement way, etc. The information captured during FNOL can be modified at later settlement stages.

The FNOL launches a claim settlement process in the backend.

Claim settlement

The claim settlement process is initiated by FNOL posting. The process starts with claim file opening and registration of all necessary claim details. Using CAMUNDA BPM different claim processes can be configured for the different business lines implementing the specifics related to:

• damage evaluation principles.
• approval needs.
• specialists involved.
• task assignment rules.
• authorization requirements.
• eligibility checks.
• financial checks.

The business process can include various transition points where decisions are taken by executing rules from the SERDICA core library or added during the implementation customer specific library.

Therefore, the claim process can be driven depending on each particular case taking different paths, requiring different levels of inspection and different expertise from the claim adjuster, different authorization levels, and different approval sequences.

The settlement process includes the following main stages that correspond to the claim statuses.

Document collection

The documents that are required by the Insurance Company to support valid claims can be defined into a Product configuration module for each combination of insured object type, risk covered, and insurance event. An indemnity cannot then be paid until all these documents are collected and marked by the claims operators as received or unnecessary. The Company can modify the required document sets at any time.

Damage evaluation

Evaluation of the damages is registered in the system. There are two options – registration of the final cost of the damages or registration of details of the damage. The system provides a standard API for registration of evaluations provided by corresponding applications. A number of evaluations can be registered against a claim and each of those requests changes the claim reserve.

Indemnity calculation

During the indemnity calculation, the system sums up all the damages per each insured object. If there are deductibles and franchises registered in the policy the system automatically applies them when calculating the indemnity.

Payment

Payments to providers can be made for each invoice separately or a bulk payment can be made periodically. Reimbursements can be processed as a single payment or as a recurring payment

Claim expenses

A number of expenses can be added at any time to the processed claim. Those expenses can be either directly paid to the person who incurred the expense or be included in the indemnity to be paid to the beneficiary.

Subrogation

When registering the claim or at a later stage the system allows a third-party person liable for the event to be registered in the claim file. Additional information for third-party liability policy and insurance company is also registered in the claim file if available. A subrogation request can be closed manually writing off the outstanding recovery amount.

Recovery

The system allows the recovery of overpayments.

RBNS

Once the notification is accepted as a valid claim the system sets initial reserve automatically. For the initial reserve definition claim module has configuration per product and cover type. These configuration options are:

• Fixed amount
• Percentage of the insured value
• Statistical algorithm

During the claim settlement process, the system maintains a detailed outstanding loss reserve modification history. Any change in the damage evaluation, indemnity calculation, or partial settlements is automatically modifying the claim reserve. The loss reserve movements and the reason for movement are stored in a register and the history is visible in the user interface.

SERDICA Analytics module calculates IBNR.

Microservice architecture that provides enormous scalability, allowing a smooth mix between existing rule-based techniques and new AI/ML technologies.

Advanced Orchestration architecture that includes:

– A powerful BPMN workflow engine Camunda, is used to model all business processes in order to provide a good interface for customizing the system’s behavior; it provides a configuration-based approach to using any microservice in any process);

– An asynchronous message controller (Rabbit MQ) that ensures the entire communication and support of SERDICA microservice architecture

Utilizing LLM-based conversational transactional platform for various self-service operations, such as FNOL, document submissions, Receiving Information about claims, complaints, etc.

Claim Lifecycle Management. Advanced activity management, assign tasks, claim diary, reassignment.

Business Rules. Business rules for policy coverage identification, Assigning cases based on the Adjuster's competency and skills, and loading.

Settlement Module. The solution applies to all P&C lines of business. The solution automates all deduction scenarios, full eligibility checks, and all financial checks.

Reserves & Payment Management. Rule-based or manual and automated reserve allocation, Payment authorization, and payment management.

Vendor Management. Full list of API’s for integration with vendor systems – financial systems, evaluation systems, case management systems, etc.

Market competitiveness. SERDICA BMP assigns the right adjuster to work on the given claim based on complexity and loading. Preserves most of the existing insurance company employee’s user experience - no need for additional training as the reports, printouts, and back-office UI remain the same. Improves customer experience in claim settlement by changing the UI, related to the omnichannel self-service

Reduced Cost. The level of automation allows for a reduction of costs & expenses spent on each claim. Guarantees business continuity and distribution of the investment over a long period

Reduced Time. SERDICA LLM-based conversational transactional platform offers a unique opportunity to reduce the loading of claim adjusters because it allows for reducing direct communication with the customers. Provides tangible results in a short period

Cloud native. Ensures high scalability and public cloud-compatible environment due to the microservice architecture