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Insurance

METLIFE (CLiCS & PAPS)

CLiCS is an ‘Insurance Claims Management Application’ that helps an Insurance company to efficiently manage, process and validate insurance claims. This application allows the insurance company to manage the claim process with automated workflows ensuring that all claim data and each detail of every processing step are recorded within a centralized system. Claim details can include claim submission data and files, document verification, claim adjudication, relevant policy information and claim payment settlement.

PAPS is a ‘Policy Admin Peripheral System’ that helps to manage insurance service requests (policy maturity/discontinuation) management, document storing against the policies, document validation and payment settlement.

Highlights

  1. Manual claim processes plagued the insurance company with delays, errors, and high costs.
  2. CliCs and PAPS revolutionized efficiency with automated workflows, slashing claim processing time by 70% and reducing costs by 70%.
  3. Customers now benefit from a faster, more transparent claim experience with features like online submission and auto-calculated benefits.

Challenge Faced

  • Manual Claim Submission, Review, and Validation:
    This traditional process was slow, prone to errors, and lacked transparency. It involved paper forms, manual data entry, and physical file handling, leading to delays and inconsistencies.

  • No Fraud Detection System:
    The manual approach made it difficult to identify fraudulent claims, potentially increasing costs for the insurance company and honest customers.

  • Slow Investigation of Claims and Settlements:
    Manual investigation often took a significant amount of time, frustrating customers who needed their claims resolved quickly. This could lead to customer dissatisfaction and churn.

  • Slow Customer Communication:
    Customers were kept in the dark during the claims process, lacking updates on the status of their claims. This communication gap could lead to frustration and a negative perception of the insurance company.

  • Duplication of Paperwork:
    Multiple copies of documents were often required, leading to wasted resources, increased storage needs, and potential loss of important information.

  • Benefit Calculation & Settlement Issues:
    Calculating benefits manually was error-prone and time-consuming. Delays or errors in settlements could negatively impact customer satisfaction.

Solution Provided

To tackle the challenges, we introduced CliCs (Claims Integrated Care System) and PAPS (Policy Admin Peripheral System) with the following key features:

  • Policy Management (Groups): There are mainly two types of policy management- Group and Individual. Groups can further be divided into clusters based on organizational positions. Policy customization e.g., products, benefits exclusion and inclusion, can be done for groups, clusters as well as individual enrollees in the groups. Nominee and beneficiary management for the enrollees of a group.

  • Policy Management (Individual): Individual Policy details are derived from Lifeline and managed to some extent and service requests are generated under these policies.

  • Documents Management: Necessary documents required for a service request/ claim settlement are scanned and stored. These documents are reviewed to approve or decline settlements. In case of wrong/faulty/insufficient document submission, the payee is notified for a re-submission.

  • Policy Based Assessments: Eligibility assessments for claim settlements are done based on policies. Claim benefits are also calculated according to each policy (Fixed/Multiplier/Pro-Rata).

  • Adjudications: Some Claims are adjudicated manually after the document validation and some claims are automatically adjudicated from the system based on policy nature.

  • Payment: Once a policy is matured or discontinued or a claim is adjudicated and eligible for payment, the claimants can get both electronic payment and physical payment. In the case of an EFT (Electronics Fund Transfer) Return the claim settlement process needs to go through the previous steps.

  • Review & Approval: When a customer makes a service request against policies with necessary documents, their documents are reviewed and validated several times and go through multiple approvals stages.

  • Notifications, History & Reports: There are multiple notification options for the customers i.e., SMS/mail/Standard Letter. Customers are promptly notified of cancellation/acceptance at every stage of the process. Users can view Claims Life Cycle, TAT & History Visualization. Multiple Graphical and Statistical reports format to summarize system procedures.

  • Additional Services: Payees can apply for additional services or loans based on their policies.

REsults

  • Claim Amount Calculation Time Reduced to 30 Seconds from 15-30 Minutes

Automated calculations based on policy details significantly streamline this process, saving significant time and resources.

  • 70% Faster Claim Settlement 

Streamlined workflows, automatic calculations, and reduced manual intervention lead to much quicker claim settlements, improving customer satisfaction and cash flow for the insurance company.

  • 70% Adjudication Efficiency Increase

Automated rules and criteria based on policies can handle many claims automatically, freeing human resources for complex cases and improving overall efficiency.

  • 70% Cost Avoidance (Printing, Stationaries & Supplies) 

The elimination of paper forms and documents reduces printing and office supply costs, contributing to environmental benefits as well.

  • 30% Cost Avoidance (Claim Investigation)

Fraud detection systems and faster claim processing can reduce the need for extended investigations, leading to cost savings.

Benefits

  • Claim Processing with a Customer-centric Attitude: Automated workflows ensure smoother processing and faster settlements, leading to a more positive customer experience.

  • Fraud Detection and Auto Adjudication: Built-in fraud detection systems help identify suspicious claims, protecting both the insurance company and honest customers. Additionally, automatic adjudication for clear-cut cases saves time and resources.

  • Online Claim Submission and Auto Calculation of Claim Amount: Customers can submit claims easily online, and the system automatically calculates benefits based on policy details, offering a convenient and efficient self-service option.

  • Reduced Claim Process Time and Claims Management Costs: Streamlined processes lead to faster claim turnaround times, improving customer satisfaction and reducing overall costs for the insurance company.

Technologies Used

Services We Provide 

Brain Station 23 is focused on delivering tailored services to meet the unique needs and expectations of their clients. Here we provided Insurance Solutions to our client. 

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