Simplifying Insurance Claims Management with Rules Engines


An insurance claim is a defining moment for the insurer — it's an opportunity to fulfill their obligation to the policyholder. It’s when a loss occurs that policyholders really need their insurer to hold up their part of the bargain and act instantly.

Traditionally, the insurance industry viewed claims only as an obligation, and not as a way of building loyalty, satisfying policyholders, or increasing customer retention rates. This is one of the reasons why the industry as a whole has a hard time maintaining meaningful customer engagement and developing new business models.

In the competitive insurance industry, delivering an outstanding claims experience is the key differentiator.

Policyholders expect excellent customer service from their insurers, and a claims process is essential to providing such an experience. That's why it's important to make necessary investments in insurance claims management.

Claims Management Is An Opportunity

Unfortunately, many insurance carriers still use outdated technology and handle claims processes with barely any automation and with very little focus on customer satisfaction.

Regulators have recently noted a spike in complaints about slow and bureaucratic reimbursement processes, which certainly doesn't lead to satisfied customers. Therefore, it's critical that the claims procedure is geared towards providing a first-rate claims experience.

insurance claims management

Streamlining insurance claims should be the priority of every insurance company. The goal of managing claims involves finding ways of reducing costs and fraud while boosting customer satisfaction.

Successful claims handling requires attention at every touchpoint in the claims cycle — from first notice of loss to reimbursement.

What is Insurance Claims Management?

What are all the steps involved in a successful insurance claims management process?

  • Receiving the notice of claim from the policyholder automatically, which automatically opens the client file.
  • Examining the coverage and determining whether the loss is insured and up to what amount.
  • Requesting supporting documents and relevant data such as police reports of car accidents, photos of property damage, medical reports, etc.
  • Establishing the cost of the claim.
  • Investigating whether the claim is fraudulent.
  • Carrying out repairs in cases of property claims.
  • Reimbursing the policyholder for damages they suffered.

In the unfortunate event that a policyholder has a claim, they would first get in touch with the claims adjusters of their insurance provider to file the claim. Once all the basic data is collected, then it's up to the claims department to move the claim along and come to an appropriate decision while keeping the claimant in the loop. A claims tracking option for claimants is helpful.

What Do Policyholders Expect From Insurers?

Clients expect a prompt reaction after the first notice of loss. Insurers should immediately acknowledge the claim and ask for the necessary contact details.

In cases involving more complex claims, insurers should make sure that experts contact the claimants to discuss next steps. It's important to reassure the policyholder about the scope of their coverage as soon as possible.

Speed Up the Claims Journey

Indemnifying claimants is just one feature of the insurance claims management process. The process starts with the insured filing a claim. The subsequent steps show whether a claim is valid along with the amount the carrier will have to pay. 

Policyholders expect that their insurers will settle claims quickly and fairly. According to a report from Insurance and Mobility Solutions, over 40% of policyholders are likely to switch insurers if the claims process isn't fast, accurate, and transparent.

Since fast claims settlements translate into higher customer satisfaction levels, the way insurers can get a competitive edge is by streamlining the claims process.

Therefore, an efficient claims management process and operational excellence make good business sense.

Human Touch is Still Necessary

Despite major advances in artificial intelligence, human adjusters will remain an integral part of the insurance claims management process. And thanks to rules engines, they’ll be able to work more efficiently while still conveying authentic human empathy.

Typically, complicated claims require nuanced judgment.

Higson can help insurers confirm routine and straightforward claims with predictable characteristics and outcomes. This frees up the claims managers to focus on more complex cases. When new conditions arise, adjusters can easily make changes in the rules engine in mere minutes.

Learn more about rules engines

Higson is a business rules engine that expedites claims-processing times while providing rigorous claims management. 

Remaining Proactive

Insurers should be proactive and anticipate and meet customers’ needs.

Claims Status

The claims departments may communicate next steps, or provide updates on the claim's status using the policyholder’s preferred method, from Messenger to email.

For example, a policyholder involved in a car accident receives repair status updates via text messages. Or an insurance company could have rules that notify the insurer that a claimant has not completed a series of necessary treatments, prompting the company to follow up with the policyholder.

Carriers that interact with policyholders by using business rules to predict their needs will lower the number of unnecessary calls to the claims departments, thereby improving the customer experience.

Fraud Prevention

Insurance along with the financial services industry is one of the sectors that’s hardest hit by fraud.

The FBI estimates the cost of insurance fraud to be around $40 billion per year in the US alone.

Obviously, reimbursing fake claims costs insurers money. This expense is in turn passed on to policyholders. As a result, the underwriting and risk management criteria become more stringent and the cost of premiums increases. 

Preventing Fraud with Rules Engines

One of the most effective ways to spot fraudulent claims in real-time is with a business rules engine.

An insurance company can use rules to inspect payment history and identify trends in claim payoffs to help the carrier spot fraud.

For instance, the number of times the same policyholder files a claim can be an indication that the claimant might be filing a fraudulent claim.

A rules-based fraud prevention solution facilitates the settlement of claims in a timely manner while reducing the likelihood of paying out bogus claims.

Rules Engines Power Claims Management Systems

Insurance companies can seamlessly handle the entire claims lifespan with Higson — from first notice of loss to reimbursement. Higson is a hyper-efficient rules engine designed to optimize insurance companies' decision-making processes.

Whether the claim is a minor car accident or a complex workers’ compensation liability claim, our rules engine provides all of the features needed to boost the performance and accuracy of your claims operations procedures, reduce costs, and improve customer management processes.

Claims management systems that are connected to Higson enable insurers to:

  • Simplify the claims management process by expediting claim routing with business rules. So, the right type of claim goes to the appropriate adjuster or employee in the claims department.
  • Optimize workflow by enabling different types of employees to manage rules in real-time.
  • Speed up the claims process so that policyholders are quickly reimbursed. 

Higson can be integrated into insurance claims management software or customer relationship management software (CRM) powered by advanced analytics to help insurers streamline their end-to-end claims resolution processes.

Improve Customer Experience and Retention

Higson automates tedious tasks allowing the insurance carrier to form a human connection with the policyholder and maintain empathy during the difficult period. Insurance companies can streamline the entire claims lifecycle and accurately evaluate and approve claims.

To learn how Higson can optimize your claims management system and operational efficiency, schedule your free call with us today.

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