Scenario: Automobile insurance claims
IBM® Case Manager provides a sample solution for creating and managing automobile insurance claims. With the case management system, you can associate the data about the claim and the submitter with the supporting documentation as it is submitted. The business analyst can quickly process any required changes to the automobile claim solution. By configuring a solution in IBM Case Manager, you can ensure that claims are processed completely and accurately.
Problem
Automobile insurance claims can involve input and supporting documentation from many sources, including the claim submitter, the repair shop, the police, and other official sources of information about vehicle value or road conditions. In addition, different analysts are often required to evaluate and add information to an insurance claim during processing. All documentation and claim information must be available and easily accessible to enable adjustors to properly evaluate and resolve the claim.
Individual claims can vary greatly. This variability can require case workers to start discretionary processes, to involve new roles, and to change how and when tasks are completed as the claim is routed through the organization.
Solution
Javier, a business analyst at the automobile insurance company, is working on making the automobile claims process more consistent. Javier uses Case Manager Builder to design a solution with tasks that involve multiple steps. He creates roles for each step in the claims process, and assigns permission to the roles for the groups of employees who perform the tasks at each stage in the process.
- Claim properties, such as policy number and accident details
- Roles, such as claims adjustor or fraud investigator
- Case types, such as general claims, claims with injury, or major loss claims.
In addition, Case Manager Builder enables Javier to create a flexible solution. He can quickly change roles, processing, or add tasks when they are needed. He can also use business rules to automatically update claim properties, such as to calculate a new premium after a claim is filed.
Scenario
Carly is driving on a roadway when her car strikes a large object. Although she is not hurt, her car is too damaged to drive. The police arrive, and a tow truck is dispatched. When Carly calls her insurance company, customer service representative Chris opens a case for her claim. He uses a First Notice of Loss (FNOL) form to record the information. When he enters her home phone number, many of the form fields are automatically populated with her data that is retrieved from the system.
Chris asks about her location, and tells her to have the tow truck driver take her damaged car to a specific nearby repair shop. The case information is forwarded to the car repair shop. Chris tells Carly how to use a PDF form that is available on the insurance company's website to provide details about the accident. He gives her the case number that was generated when he opened her case. She will include the case number on the form.
Chris recalls a memorandum about recent fraudulent claims involving collisions with roadway debris. He creates a discretionary task to involve a fraud investigator in the claim.
Later, Carly downloads the PDF form from the insurance company's website and enters the accident details and the case number. She mails the form back to the insurance company. Javier is using IBM Datacap to automatically scan and index the form into the case. Because this action is set as a precondition on Chris's task to review the claim, he is notified when the form is added to the case. Also, on the company website, Carly uses her case number to access a tool for uploading photographs of her damaged car.
John, the agent at the car repair shop, receives notification about the case. He creates a task to provide an estimate for repairs. John makes sure that the $4500 estimate for repair does not exceed the value of the car and submits the estimate to the insurance company. He uses Carly's contact information to let her know that the estimate was submitted.
The case is routed to Lisa, an adjustor. She reviews the case and the supporting documents, including the police report and the photographs of the damage. The estimate is below the threshold for investigation, and the fraud investigator has set the flag for possible fraud to false. Lisa approves the claim.
After the claim is approved, a task is triggered to automatically calculate the new premium for Carly. The new premium is calculated according to a business rule that evaluates whether the accident was caused by negligence, the number and severity of any other claims that Carly filed during the last few years, and the type of policy.
After the case is closed, the insurance company receives a report from the police that a freight company was charged with dropping the object that caused Carly's accident. Lisa reopens Carly's case. She contacts Javier, who adds a new role to the system called recovery expert. The recovery expert creates new tasks to attempt to reclaim the cost of the repairs from the freight company.
Because of the flexibility of this case management system, case workers can resolve problems more quickly and efficiently, and customers can close their claims more easily.