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RPA and Smart Automation
Case Studies

Claim Management Process 

Claim management is the process of verification and approval of a request made by an individual or organization to an insurance company or respective entity for demanding payment for something that is damaged or lost. To put it simply, claim management entails resolving demands to recover any type of losses, most commonly financial losses. 

For example, if your car gets damaged in an accident, you can submit a request to your insurance company to cover the cost of repair. 

Another common example would be claiming medical insurance in case someone is hospitalized due to severe conditions or injuries, the person can request the insurance company to cover costs and bills as per the contract made.  

The overall process involves several steps:


Problem/Pain Point: 

The insurance company receives a massive volume of requests from policyholders daily. Managing and responding to each one efficiently is quite difficult & tedious. To implement a practical solution, it is first important to identify the major pain points of the claim management process. Below are the identified pain points: 

  1. Increased chances of fraud. 
  2. Inefficiency in processing claims. 
  3. Delayed and denied claims leading to low customer satisfaction. 
  4. Complexity of handling various types of claims. 
  5. High volume of documents to be processed manually. 
  6. Validation of data submitted is difficult and this can lead to inaccuracy. 
  7. Endless paperwork to be carried out manually which increases the risk of error. 
  8. Dependency on human availability to process claims. 
  9. Lack of knowledge of the procedure to file a claim. 
  10. Lack of assistance at the right time. 




To help the insurance company overcome these pain points, we suggested the implementation of an automated system that could perform each task and help in each stage of the claim management process significantly, thereby reducing manual dependency & error and driving customer. 

We designed an automated system that accepts user claim request through an online form and populates information based on the history of the claimer. 

The system assesses the eligibility criteria of users based on basic assessment rules and prerequisites. It is also equipped to classify claims in categories using document classification techniques, such as the Naïve Bayes Classifier, Support Vector Machines, and decision trees. 

Predefined rules and combinations of ML and decision-based algorithms further aid claim adjudication based on factors such as policy limits, deductibles, and covered services. 

The decision thus made determines whether the claim will be denied, approved, and paid, or sent for further investigation under manual review. The customer on the other end will get an automatic response with an explanation of why the claim is denied/not paid, and why it requires further investigation, and will keep them updated at every stage of the process. 

In case of approval, claim can be automatically paid, and receipts sent directly to the policyholder via email. 

Some cases may require human review for thorough manual investigation if the system fails to make any decision. If such a scenario arises, the claim can be classified as a “Manual Review Require”.

Expected Benefits: 

Cost saving:

Saving labor costs and operational expense automation solutions can potentially help the organization to save up to 30% of its overall costs.


Reduced downtime:

The automated solution can save up to 50% of the time required for claim processing which could be a thousand hours of saving per year. 


Optimum accuracy:

The solution will reduce errors, omissions, and discrepancies owing to fewer human interventions and improve quality. 


Impactful data analytics:

Our client organization will be able to identify patterns, trends, and fraud, and explore opportunities that can eventually help in better decision-making and strategic growth improvements. 


Enhanced customer satisfaction:

Regular updates about the claim status, faster processing, and useful resources & guidance offered via email can significantly improve customer satisfaction 


Strategic impact and benefits: 

Customer retention:

Greater customer satisfaction translates to increased loyalty amongst policyholders and, consequently higher customer retention. Not only will the existing customers come back, but new customers will also find their way to the business.  


Improved fraud detection/risk management:

Eliminating the risk of fraud with proactive fraud detection and risk management ensures long-term sustainability in the market and secured growth.  


Competitive differentiation:

Cost-saving, impactful data analytics, faster claim processing, and increased customer satisfaction will help our client organization stand out in a competitive market and be future-ready with a technology-backed solution. 


Regulatory compliance:

Implementing an automated solution to manage claims effectively will allow the insurance company to meet regulatory requirements and avoid fines and other penalties for non-compliance.


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