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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.

Warning-2

Issue

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

Impact

  1. Redeployed staff from manual and time-intensive tasks to more sophisticated, customer-facing work
  2. 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
  3. Decreased leakage potential significantly by increased identification of claims with valid rejection reasons 
  4. Reduce amount of interactions with claimant  for high volume / low complexity claims
Code

Solution

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

Coverage Check

coverage decision graph
  1. Detect Claim type
  2. Identify Policy match
  3. Classify Submissions
  4. Extract relevant information
  5. Structure cost items
  1. Group costs by benefit type
  2. Categorize losses by peril
  3. Identify circumstances
  4. Enrich claim with identified risk exposures
  • Applicable Coverages
  • Insured perils
  • Exposures
  • Coverage Limits
  • Pre-conditions of policy
  1. Validate coverage conditions
  2. Confirm obligations
  3. Identified rejection reasons
  4. Cost adjustment due to coverage exclusions & limits
  5. Detect information gaps & information requests
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omni:us is proud to be one of Europe‘s Horizon2020 SME-Instrument and Fet Flag Champions.
We are grateful to have received funding from the European Union’s Horizon 2020 Research and Innovation Programme under Grant Agreement No 820323; 850053.

Co-financed by European Fund for Regional Development (EFRE)
Pro Fit-Project “Vollautomatisierung der Wertschöpfungskette im Digitalisierungsprozess von Archivdaten” with support of IBB/EFRE in 2016/2017.

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