BUSINESS CAPABILITY MAP - Health Insurance Claims Services

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Description	EN: The  Health Insurance Claims Services group all specific capabilities related to fraud prevention, recovery, complaints handling, and settlement of health insurance claims. FR: La  Gestion des sinistres assurance santé regroupe toutes les capacités spécifiques liées à la prévention de la fraude, au recouvrement, au traitement des plaintes et au règlement des demandes d'indemnisation d'assurance santé.
Name (FR)	Gestion des sinistres assurance santé
Implementing Functions	Health Insurance Underwriting
Packaging Library	Insurance

TREE VIEW

•    Health Insurance Claims Services

  The  Health Insurance Claims Services group all specific capabilities related to fraud prevention, recovery, complaints handling, and settlement of health insurance claims.

  •    Complaints Handling & Monitoring (*)

    Involves tracking and updating claims while ensuring clear communication with the insured. The goal is to resolve claims promptly and transparently, ensuring customer satisfaction.

  •    Fraud Prevention (*)

    Aims to detect and prevent fraud by analyzing claims and verifying information. The service includes using detection tools to identify irregularities. The expected result is to reduce fraud-related losses, maintaining process integrity.

  •    Health Insurance Claims Settlement

    Enables the finalization of indemnity payments after claim assessment and validation of amounts owed. The service includes communication with the insured and execution of payments. The expected result is to effectively close claims files with prompt and contract-compliant payments.

    •    Disability and Incapacity Benefits

      Involves paying daily allowances or lump sums in the event of work incapacity or disability. This includes analyzing incapacity conditions and processing payments. The expected result is timely and appropriate financial support for insured individuals who are incapacitated or disabled.

    •    Funeral Expenses

      Involves paying benefits to cover funeral expenses in the event of a death claim. This includes validating expenses and executing payments. The expected result is a prompt and accurate settlement of funeral costs, ensuring respect for the deceased's wishes.

    •    Insured’s Share

      Amount remaining payable by the insured after applying coverage limits, ceilings, and contractual deductibles.
      

    •    Medical Expense Reimbursement

      Involves reimbursing medical expenses and treatments according to the terms of health insurance contracts. This includes verifying costs and ensuring compliance with policy rules. The expected result is fast and accurate reimbursement, improving insureds' satisfaction.

  •    Recovery & Subrogation (*)

    Involves recovering amounts owed from third parties responsible for claims, such as other insurers. The service includes analyzing recovery opportunities and necessary legal steps. The expected result is to recover owed funds, thus reducing the insurer's claim costs.

MAP VIEW