SYSTEM REQUIREMENT SPECIFICATIONS FOR CLAIM PROCESSING SYSTEM
PURPOSE OF THE SYSTEM
The Claim processing system is an automated insurance facility for all walks of life. The root of the system starts from registration of the customer. This follows with a series of procedures like inspection and other verifications which ultimately end up with either registration or rejection.
This system is enhancing the facilities provided to the customers by converting it into an automated and online system. The employers can directly register under the Insurance firm online and as far as the rest of the process is concerned, the entire processing of transactions is automated. The access of the data is restricted to un-authorized users of the head office and the branch office. And the official details are kept confidential. The time lag involved in the manual system is completely wiped out. Registering, declaration by the employees and ultimately the claim, payment etc is computerized. Retrieving information and follow up about each aspect becomes easier. The Objective of this system is to provide the functionalities to the policyholders, which is helpful to claim their auto accident and damages of the vehicle online. It facilitates companywide integrated system covering all functional areas of a claim processing.
A claim is a legal action to obtain money, property, or the enforcement of a right against another party. The legal document which carries a claim is called a Statement of Claim.
An insurance claim is the actual application for benefits provided by an insurance company. Policy holders must first file an insurance claim before any money can be disbursed to the hospital or repair shop or other contracted service. The insurance company may or may not approve the claim, based on their own assessment of the circumstances.
Individuals who take out home, life, health, or automobile insurance policies must maintain regular payments called premiums to the insurers. Most of the time these premiums are used to settle another person's insurance claim or to build up the available assets of the insurance company. But occasionally an accident will happen which causes real financial damage, such as a automobile or a work-related accident. At this point the injured policy holder has the right to file an insurance claim in order to receive money from the insurance company.
In general, the insurance claim is filed with a local representative of the insurance company. This agent becomes responsible for investigating the specific details of the insurance claim and negotiating the payment from the main insurers. Many times a recognized authority (doctor, repair shop, building contractor) can file the necessary insurance claim forms directly with the insurance company. However, sometimes the policy holder may not want to file an actual insurance claim if the damage is minor or another party has agreed to pay out-of-pocket for their mistake.
After an insurance claim is filed, the insurance company may send out an investigator called an adjustor or surveyor. The insurance adjustor's job is to objectively evaluate the insurance claim and determine if the repair estimates are reasonable. This is to prevent possible fraud by contractors who may inflate their bills for additional compensation. Insurance companies tend to accept the adjustor or appraiser's evaluation as the final word on the insurance claim.
THE EXISTING SYSTEM
Some insurance claims may not be recognized by the insurance company for any number of reasons. If a claimant's premiums have not been paid in full, the policy itself may not be active. Another insurance company may have already agreed to pay for the damages listed in the claim. This happens quite often in automobile accidents where one party is held responsible. Another reason an insurance claim may be rejected is a failure to fall under covered conditions. Most insurance policies spell out specific areas which qualify for benefits. If the accident or damage claim was caused by carelessness or an unavoidable "Act of God", the insurance company has the right to withhold payments.
Existing system is a semi automated system. Here the policy holder needs to apply for any claims he can able to approach the policy office manually. Here the policy holder applies for his insurance claims through paper and submit necessary documents in Xerox copies. The insurer can receive the claim application from the policy holder and stores the information in local system database like ms word, excel etc. To investigate a claim, the surveyor needs to collect the claim request through manually, and submit the claim process details also manually. It is a time delay process to solve more number of claim requests.
Problems of Claim Processing Systems through manually:
1. Program-Data Dependence. Claim descriptions are stored within each application program that accesses a given file.
2. Duplication of Data. Applications are developed independently in file processing systems leading to unplanned duplicate files. Duplication is wasteful as it requires additional storage space and changes in one file must be made manually in all files. This also results in loss of data integrity. It is also possible that the same data item may have different names in different files, or the same name may be used for different data items in different files.
3. Limited data sharing. Each application has its own private files with little opportunity to share data outside their own applications. A requested report may require data from several incompatible files in separate systems.
4. Lengthy Development Times. There is little opportunity to leverage previous development efforts. Each new application requires the developer to start from scratch by designing new file formats and descriptions
5. Excessive Program Maintenance. The preceding factors create a heavy program maintenance load.
6. Integrity Problem. The problem of integrity is the problem of ensuring that the data in the database is accentuate.
7. Inconsistence data
The proposed system is fully automated system here the system need to maintain the centralized database to store the information. Existing system maintain the data in local database only. To share the data from this local database is tedious job. The RDBMS database like SQL Server can able to share the data to all users simultaneously. Policy holder can able to apply a claim request through this online system. The request directly received insurer, and send this request to surveyor directly. Here no need to sending Xerox copies as documents. The policy holder information is stored in centralized database which can be shared by all the users of this system. The time will be reduced while using the centralized database for data sharing.
Our web-based technology empowers your Workers Compensation bill review process with up-to-the-minute information on claims, providers, payments, databases, tables and schedules ensures your claim re-pricing will net the absolute maximum amount allowable.
The claims-processing strategies that support the value chain include these:
• An integrated and. flexible architecture
• Business intelligence enabled by more sophisticated data management, analysis and reporting throughout the enterprise
• Deeper integration of business processes, as well as visibility provided by monitoring, mails and reporting
• Cost-effective migration from legacy systems
• Industry and technology standards
Three tactics to use for giving a system design a future orientation:
• Build redundancy into the current system.
• Maintain a future file on every system.
• Develop documentation.
• Produces a system blueprint
• General rather than technical format
• Converts the blueprint into the specific detail required to construct the code
• Includes specifying complete descriptions of files, input, and output.
In the flexibility of uses the interface has been developed a graphics concepts in mind, associated through a browser interface. The GUI’s at the top level has been categorized as follows:
1. Administrative User Interface Design
2. The Operational and Generic User Interface Design (The Insurer, Customer, Surveyor are comes under this category.)
The administrative user interface concentrates on the consistent information that is practically, part of the organizational activities and which needs proper authentication for the data collection. The Interface helps the administration with all the transactional states like data insertion, data deletion, and data updating along with executive data search capabilities.
The operational and generic user interface helps the users upon the system in transactions through the existing data and required services. The operational user interface also helps the ordinary users in managing their own information helps the ordinary users in managing their own information in a customized manner as per the assisted flexibilities.
NUMBER OF MODULES
A module is a bounded contiguous group of statements having a single name and that can be treated as a unit. In other words, a single block in a pile of blocks.
Guidelines for Modularity
• Make sure modules perform a single task, have a single entry point, and have a single exit point.
• Isolate input-output (I-O) routines into a small number of standard modules that can be shared system-wide.
• Isolate system-dependent functions (e.g., getting date or time) in the application to ease possible future conversions to other computer platforms or to accommodate future operating system revisions.
The system after careful analysis has been identified to be presented with the following modules:
4. Customer (Policy Holder)
1) Can Add Insurance details into the system (like Accident, Fire, General, etc., Fire Insurance in this case).
2) Can Add/Update the Insurer (insurance company) details into the system.
3) Can generate Reports based on Insurance type, Insurer, Surveyor, duration like Monthly & Yearly, etc.
1) Will receive the request claim from the Policy Holder for a particular Policy.
2) Will verify the uploaded documents and reviews the documents against the items damaged which are Covered and NOT Covered under the policy.
3) Assign the task to the Surveyor by sending the request details along with attached documents.
4) Should get the Comments of the Surveyor about the survey.
5) He/she can Accept/Reject/Modify the Insurance claim Amount along with necessary remarks.
6) Can update the status of the Insurance claim into the system.
1) Should able to Login to the system.
2) Should Receive the Claim Request details of the Policy Holder along with necessary documents attached.
3) Should able to send back the Comments about the Survey to the Insurer along with Survey Reports.
1) Customer can register with the Site and login to the site.
2) Can update the details of Insurances has taken against the Assets (like House, Computer, Car, Vehicle, Goods, etc.)
3) Should make the Request for Insurance Claim along with necessary details.
4) Should upload the Police Complaint report as attachment for the Request.
5) Should able to check the Status of Request through online system.
Various types of reports are generated by the system.
1. Claims reports which are processed or not processed
2. Accept/Reject Claims Reports
3. Claims transactions like monthly, yearly etc.
Search is a module which can be used by all the user of this requirement. Admin can able to search Insurer details, insurance type, surveyor details etc. Insurer can able to search the insurance information and documents of a policy holder while checking the claim request. Policy holder can able to search the status of request through the system interface for his claims.
Authentication is nothing but providing security to the system. Here every user must enter into the system throw login page. The login page will restrict the UN authorized users. A user must provide his credential like user Id and password for log into the system. For that the system maintains data for all users. Whenever a user enters his user id and password, it checks in the database for user existence. If the user is exists he can be treated as a valid user. Otherwise the request will throw back.
INPUTS AND OUTPUTS
The major inputs and outputs and major functions of the system are follows:
Administrator enter his user id and password for login to authenticate in this system
Administrator Upload new branch details
While upload admin can able to provide branch information like
1. Branch Code
2. Branch City
4. Date of Register
Administrator can able to register insurance companies
Administrator can able to register new claim methods
New insurance types information uploaded by the insurer
The surveyors are registered by insurers.
Customer can able to register in this system, while register they have to provide their details like:
Name, DOB, Contact Number, Address, City
For recover and change password settings site admin need to submit their log information.