The Claims Processor (TCP)

Overview

The Claims Processor (TCP) is a paper-less claims straight-through-processing platform. The system provides:

• Automate claims processing to achieve paper-less processing
• Single point claims processing system with workflow
• Rules based handling of claims processing
• Higher accuracy and audit controls
• Unified case view
• Reduced processing costs and reduced time-service
• Great Visibility and Reporting

High Level Functional Overview

Case Creation

• Ability to create a new cases through paper or electronic notification
• Ability to view case associated images through integration with imaging system
• Auto display all policy details
• Auto display of agent details
• Auto display of plan, coverage and Beneficiary details against each policy
• Ability to capture Claimant and Bank Details against each policy
• Ability to process various claims type, including:
  • Death
  • Living
  • Missing
  • Maturity
  • Annuity

Validation

• Ability to define Claims as Admissible and Non- Admissible Claims based on validation of product and policy provisions
• Auto validation of claimant, beneficiary, owner
• Validate payout options
• Cross reference with U/W system to validate any disputes
• Initiate contestability based on validations

Requirements Management

• Determine, track, order, and monitor requirements for processing claim
• Order new requirements, such as medical report, autopsy, third-party investigations,etc
• Auto follow-up on missing requirements
• Associate in-coming requirements (data and images) to the case file electronically

Administer

• Calculate Claim Amount and Advance Amount per coverage based on pre defined business rules
• Generate refund for excess premium
• Ability to allocate case to case-examiner, based on the business user defined rules
• Ability to send the case for approvals for exception processing
• Refer cases for opinions (legal, medical etc)
• Ability to log events for audit purposes
• Ability to mark the following recommendations on a case
  • Pay
  • Repudiate
  • Hold
  • Write-off
  • Ex-gratia
• Ability to refer a case for opinions (Legal, Medical and Actuarial)

Payout

Ability through the I-Hub to integrate with internal and third-party systems,including:

• Underwriting
• Policy Administration
• Accounting
• Imaging
• Email
• Re-insurance
• Third-Party data providers, including investigation, medical information, etc.

Reporting

The system offers both out of the box and customized reports, along with third party package interfaces for ad-hoc reporting. Standard report categories include:

• Workload reports
• Time-service reports
• Claims processed and pending reports
• Payout reports
• Exception processing reports
• Contested claims report