Streamlined Claims Processing for an Insurance Company

Project overview

Client: A leading insurance company aiming to modernize and streamline its claims processing operations.

Objective: To develop a Pega-based solution for automating the end-to-end claims management process. The goal was to reduce processing times, improve accuracy, enhance customer satisfaction, and ensure compliance with regulatory standards.

Solution: Implemented a claims automation system leveraging the Pega Platform, with AI-powered decision-making, automated workflows, and real-time reporting.

The challenge of project

Manual Processes: Claims were handled manually, leading to delays, errors, and inefficiencies.
Inconsistent Decision-Making: Lack of standardized processes caused variability in claim approvals and increased the risk of disputes.
High Costs: Manual verification and processing required significant staffing, inflating operational costs.
Customer Dissatisfaction: Customers experienced long wait times and a lack of transparency during the claims resolution process.
Regulatory Compliance: Meeting compliance requirements, such as maintaining audit trails and fraud detection, was resource-intensive and error-prone

Solution

To address these challenges, the insurance company adopted a Pega-based claims management system, which included the following components:

A. Automated Claims Workflow

Claims Submission Portal

A user-friendly portal was developed for customers to submit claims online with required documents and details.
Mobile and web compatibility allowed easy access.

Dynamic Case Management

Pega’s Dynamic Case Management automatically created and routed claims cases based on predefined rules and customer inputs.
Tasks were assigned to the appropriate teams or automated based on the complexity of the claim.

End-to-End Automation

From claim submission to resolution, the system automated data collection, verification, and processing.

B. AI-Driven Decisioning

Fraud Detection

AI models integrated into the Pega platform analyzed claims for potential fraud by identifying anomalies in historical patterns.

Straight-Through Processing (STP)

Simple and low-risk claims were processed automatically without manual intervention, reducing delays.

Decision Automation

Pega’s decisioning engine evaluated claims against policy terms, customer profiles, and regulatory requirements to approve or reject them instantly.

C. Customer Communication

Real-Time Updates

Customers received real-time notifications about the status of their claims via SMS, email, or the portal.

Transparency and Self-Service

A self-service dashboard allowed customers to view their claim’s progress, required actions, and expected resolution time.

D. Compliance and Auditability

Comprehensive Audit Trails

Every action in the claims process was logged, ensuring transparency and simplifying compliance audits.

Regulatory Integration

The system was configured to adhere to local and international insurance regulations, such as anti-fraud standards and data protection laws.

E. Analytics and Reporting

Real-Time Dashboards

Managers could monitor claims processing times, bottlenecks, and team performance in real time.

Predictive Insights

Analytics identified trends in claim types and volumes, enabling better resource planning.

Customer Feedback Integration

Post-resolution surveys were integrated into the platform to capture and analyze customer satisfaction data.

Final results

The implementation of the Pega-based claims management system yielded measurable benefits:

Reduced Processing Time: Claims resolution time was reduced by 60%, with simple claims processed in real time.
Increased Efficiency: Automation reduced manual effort by 50%, allowing staff to focus on high-value tasks.
Enhanced Customer Satisfaction: Transparency and faster processing resulted in a 40% increase in customer satisfaction scores (CSAT).
Cost Savings: Operational costs decreased by 30% due to reduced staffing requirements and improved efficiency.
Improved Fraud Detection: AI-driven fraud detection reduced fraudulent payouts by 20%.
Regulatory Compliance: The system ensured full compliance with all applicable insurance regulations, reducing the risk of penalties.

Project Details

Don't hesitate to contact us

At our IT solution company, we are committed to exceptional

Get in Touch

Let’s work together

Each demo built with Finative will look different. You can customize anything appearance of your website with only a few clicks

Let’s Start a Project