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📋 '''Claims workflow''' is the structured sequence of steps, decision points, and handoffs through which an [[Definition:Insurance claim | insurance claim]] moves from initial notification to final settlement or denial. In the insurance industry, the claims workflow defines how [[Definition:First notice of loss (FNOL) | first notice of loss]] is captured, how the claim is triaged and assigned, how investigation and [[Definition:Loss adjustment | loss adjustment]] activities are coordinated, how [[Definition:Reserving | reserves]] are established and updated, and how payment or dispute resolution is managed — all within the constraints of the [[Definition:Insurance policy | policy]] terms, regulatory requirements, and the insurer's service-level commitments.

⚙️ Modern claims workflows blend human judgment with automation at multiple stages. When a policyholder reports a loss — whether through a call center, a mobile app, or a broker portal — the workflow engine routes the claim based on rules tied to line of business, claim severity, coverage complexity, and fraud indicators. Low-complexity, high-frequency claims such as minor auto damage or straightforward travel delays increasingly follow [[Definition:Straight-through processing (STP) | straight-through processing]] paths where [[Definition:Artificial intelligence (AI) | artificial intelligence]] models assess damage from photographs, verify coverage, and authorize payment with minimal human intervention. More complex claims, such as large commercial property losses or [[Definition:Liability insurance | liability]] matters requiring legal coordination, trigger workflows involving [[Definition:Loss adjuster | loss adjusters]], appointed experts, [[Definition:Third-party administrator (TPA) | third-party administrators]], and sometimes [[Definition:Reinsurance | reinsurance]] recovery processes. Each transition between stages generates data that feeds the insurer's [[Definition:Claims management system | claims management system]], updating [[Definition:Case reserve | case reserves]] and informing downstream analytics.

🚀 Getting the claims workflow right is arguably the single most consequential operational challenge in insurance, because the claims experience defines the moment a policyholder's purchase of a promise converts into tangible value. Inefficient workflows — characterized by redundant touchpoints, manual rekeying of data, and opaque status tracking — erode customer satisfaction, inflate [[Definition:Loss adjustment expense (LAE) | loss adjustment expenses]], and delay reserve recognition. Across markets, from the [[Definition:Lloyd's | Lloyd's]] market's efforts to digitize claims processing through platforms like the Electronic Claims File to Asian insurers deploying chatbot-driven FNOL in high-volume personal lines, the trend is toward end-to-end digitization with real-time visibility for all stakeholders. [[Definition:Insurtech | Insurtech]] companies have also entered this space aggressively, offering modular claims orchestration platforms that allow insurers to redesign workflows without replacing legacy core systems entirely.

'''Related concepts:'''
{{Div col|colwidth=20em}}
* [[Definition:First notice of loss (FNOL)]]
* [[Definition:Straight-through processing (STP)]]
* [[Definition:Loss adjuster]]
* [[Definition:Claims management system]]
* [[Definition:Loss adjustment expense (LAE)]]
* [[Definition:Third-party administrator (TPA)]]
{{Div col end}}

Definition:Claims workflow - Revision history

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