Definition:Claims review
🔎 Claims review is the structured evaluation of individual claims or a portfolio of claims to verify that handling decisions — coverage determinations, reserves, valuations, and settlements — are accurate, consistent, and aligned with policy terms and company guidelines. Reviews may be conducted by senior adjusters, dedicated quality-assurance teams, or external auditors, and they can target open files, recently closed files, or statistically sampled batches across a book of business.
📝 The process typically involves re-examining documentation against a checklist of key controls: Was coverage correctly confirmed? Are reserves set at appropriate levels given current evidence? Were required investigations completed? Did the adjuster follow litigation management protocols where applicable? Findings are scored or categorized, and patterns — such as chronic under-reserving in a particular class of business or repeated procedural lapses by a specific team — are escalated to management for corrective action. Many carriers embed automated triggers in their claims management systems to flag files that meet review criteria, blending technology with human judgment.
✅ Regular claims reviews are one of the most direct levers for controlling claims leakage and maintaining reserve adequacy. They also serve a compliance function: regulators and reinsurers frequently require evidence that an insurer's claims-handling practices are subject to systematic oversight. Beyond the numbers, a strong review culture sharpens adjuster skills through feedback loops and reinforces the standards that protect both the company's financial position and the policyholder's right to fair treatment.
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