Coverage Check

A mid-sized insurer wanted to automate the coverage verification process for high-frequency claims. omni:us empowered the highly manual claims coverage check process to automate the process for low-mid complex high-frequency claims.

Issue

Inefficient manual process of checking the coverage on high-frequency and low to mid complexity claims
Lengthy and ambiguous check results in numerous additional status request by customer
Complex landscape of product generations and terms/conditions results in frequent false manual coverage decisions resulting in increased leakage

Impact

Redeployed staff from manual and time-intensive tasks to more sophisticated, customer-facing work
Increased ratio of black box processing in the claims handling process reducing overall claims handling costs and end-to-end process time significantly by applying automation procedures
Decreased leakage potential significantly by increased identification of claims with valid rejection reasons
Reduce amount of interactions with claimant for high volume / low complexity claims

Solution

Consolidated terms/conditions and policies of various product generations to be digitally available
Extracted relevant criteria from the policy and the terms and conditions (e.g. insured objects and values, exclusions)
Trained the AI to determine relevant coverage check details from underlying terms/conditions and policies database
Automated decision based on matching provided claim notification information (e.g. invoices, damage descriptions) and the trained conditions
Automated propagation of AI decision directly into claims process management system to trigger relevant next interaction / information steps