> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Insurance Claim
> Record and process a policyholder's claim, track the approval, and settle the payment - with the system automatically handling the payment entry and closing the premium schedule.
**Final stage of the insurance lifecycle.** A claim is raised when a policyholder has experienced an event covered by their policy and is requesting a payout.
**Requires:** An active [Insurance Policy](./insurance-policy) and its associated [Insurance Premium Schedule](./insurance-premium-schedule)
**Ends:** Once the claim is paid, the system automatically closes the premium schedule and the policy is effectively complete.
***
## Overview
When a policyholder experiences an event covered by their insurance - an accident, a health emergency, a loss - they raise a claim. The Insurance Claim records what happened, how much is being claimed, and what the team has approved for payout.
The claims process involves verifying the details, approving the amount, and then settling the payment. The system handles the payment entry automatically and, once the claim is marked as paid, closes the premium schedule so no further invoices are raised.
***
## Who Uses This Feature
| Role | What They Do |
| -------------------------------- | ------------------------------------------------------------------------------------- |
| **Insurance Billing Specialist** | Creates claims, reviews supporting documents, processes approvals, initiates payments |
| **Insurance Manager** | Reviews and approves claims, confirms the payout amount, authorises settlement |
| **Accounts Team** | Processes the payment entry that the system creates, and marks it as complete |
| **Customer Service Team** | Can read and write Claim Type records, but does not process claims directly |
***
## Before You Start
Before you create an Insurance Claim, make sure the following already exist and are in order:
* **An active Insurance Policy** for the policyholder - the policy must be in **Active** status, not Lapsed or Closed
* **The Insurance Premium Schedule** linked to that policy - the claim must reference a specific schedule
* **The claim type** - the category of claim (e.g. medical, accidental, life). Claim Types are set up by your administrator.
* **Supporting documents** - the policyholder must provide evidence of the incident (hospital bills, accident report, photographs, etc.)
***
## How to Record and Process a Claim
From the **Insurance Management** workspace, go to **Insurance Claim** → **New**.
* **Insurance Policy** - search for and select the policyholder's active policy
* **Insurance Premium Schedule** - select the premium schedule linked to that policy
* **Policyholder** - this auto-fills from the policy, but confirm it is correct
* **Claim Type** - select the category that describes this claim (e.g. Medical, Accidental, Death)
* **Date of Incident** - the date the event occurred (required). This must match the supporting documents.
* **Remarks** - describe what happened in plain language. Be specific - this becomes the official record.
* **Claim Amount** - the total amount the policyholder is requesting
* **Company** - the company the policy was issued through
* **Insurance Company (Supplier)** - the insurance provider who will pay out
Go to the **Documents** section and attach all evidence provided by the policyholder:
* Hospital bills or medical reports (for medical claims)
* Accident or police report (for accidental claims)
* Death certificate (for life claims)
* Any other documents the insurer requires
Also attach any required signatures in the **Signature** field.
Click **Save**. The claim is now in **Draft** status. At this point it is a record only - no payment has been initiated.
Once all details are complete and documents are uploaded, click **Submit** to officially log the claim and move it to the review stage.
The **Claim Status** changes to **Submitted**.
The Insurance Manager opens the claim, reviews the documents and amounts, and sets the **Approved Amount** - this may be the same as or less than the claimed amount, depending on policy terms and the insurer's assessment.
The Manager then updates the **Claim Status** to **Approved**.
Once the claim is approved and saved, the system automatically creates a **Payment Entry** - a financial record of the payout - and links it to the claim. You can see this in the **Payment Reference** field on the claim.
The Accounts team then processes and confirms this payment entry.
Once the payment has been processed and the policyholder has received their money, update the **Claim Status** to **Paid** and save.
At this point, the system automatically closes the Premium Schedule - no further invoices will be raised for this policy.
***
## Field Guide
| Field | Purpose |
| -------------------------------- | ------------------------------------------------------------------------------------------------------------ |
| **Insurance Policy** | The active policy this claim is being made against |
| **Insurance Premium Schedule** | The payment schedule linked to the policy - the system uses this to close instalments when the claim is paid |
| **Policyholder** | The person making the claim - auto-filled from the policy |
| **Claim Type** | The category of the claim (e.g. Medical, Accidental, Life) - set up by your administrator |
| **Date of Incident** | When the event happened - required, and must be within the policy's active period |
| **Remarks** | Description of what happened and what is being claimed - be specific and factual |
| **Claim Amount** | The total amount the policyholder is requesting |
| **Approved Amount** | The amount the Insurance Manager has authorised for payout - may differ from the claim amount |
| **Claim Status** | Current state: Draft, Submitted, Approved, Rejected, or Paid |
| **Company** | The company the policy is administered through |
| **Insurance Company (Supplier)** | The insurance provider who will make the payment |
| **Payment Reference** | The payment entry created automatically once the claim is approved - auto-populated |
| **Documents** | Supporting evidence: medical bills, accident reports, certificates |
| **Signature** | Policyholder's or claimant's signed declaration |
***
## Workflow Journey
The claim moves through these statuses as it is processed:
```mermaid theme={null}
%%{init: {'theme':'base','themeVariables':{'fontFamily':'DM Sans','primaryColor':'#e7fdf6','primaryBorderColor':'#14f1b1','primaryTextColor':'#0f172a','lineColor':'#14f1b1'}}}%%
flowchart TD
A[Draft] -->|Submit| B[Submitted]
B -->|Approved| C[Approved
Payment Entry created automatically]
B -->|Declined| D[Rejected]
C -->|Payment confirmed| E[Paid
Premium Schedule closed automatically]
```
| Stage | What It Means | Who Acts |
| ------------- | -------------------------------------------------------------------------------------------------------------------------------- | -------------------------------------------------- |
| **Draft** | The claim has been started but not yet officially filed. You can still edit all fields. | Insurance Billing Specialist |
| **Submitted** | The claim has been officially filed and is awaiting review. | Billing Specialist submits |
| **Approved** | The Insurance Manager has reviewed the claim and authorised a payout amount. The system creates the payment entry at this stage. | Insurance Manager |
| **Rejected** | The claim has been declined. The status is set to Rejected with reasons recorded in the remarks. | Insurance Manager |
| **Paid** | Payment has been made to the policyholder. The system closes the premium schedule automatically. | Billing Specialist or Accounts Team updates status |
***
## What Happens Next
Once the claim is marked as **Paid**:
* The **Premium Schedule** linked to this policy is automatically **closed** - all remaining unpaid instalments are marked as done
* No further invoices are raised for this policy
* The policy's lifecycle is effectively complete
* A final record of the claim, approved amount, and payment reference is stored permanently against the policy
If the claim is **Rejected**:
* The Claim Status is set to Rejected
* The policyholder is informed
* The Premium Schedule continues as normal - premiums are still due
* The policyholder may appeal or submit a new claim if circumstances change
***
## Automatic Actions
As soon as a claim is approved and saved, the system automatically creates a draft Payment Entry in the accounts module. This payment entry is addressed to the insurance company (supplier) and pre-filled with the approved claim amount.
The payment entry is linked directly to the claim - you can find it in the **Payment Reference** field. Your accounts team processes and finalises this entry to complete the payment.
You do not need to create the payment entry manually.
When you update the Claim Status to **Paid** and save, the system automatically:
* Finds the linked Insurance Premium Schedule
* Marks all remaining **Unpaid** instalments as closed
* Changes the schedule's overall status to **Closed**
This means no further invoices are raised and the billing cycle stops. The policy is fully settled.
***
## Best Practices
### Do
* **Upload all supporting documents before submitting** - incomplete claims cause delays and may be rejected on that basis alone
* **Record the exact date of incident** - this is checked against the policy's active period; a claim for an event before or after the coverage dates will be declined
* **Be specific in the Remarks field** - a clear, factual description helps the manager assess the claim quickly and accurately
* **Confirm the approved amount with the Insurance Manager before processing payment** - the approved amount may differ from the claimed amount based on policy terms
* **Update the Claim Status to Paid promptly** - once payment is confirmed, mark it paid so the schedule closes and records stay accurate
### Don't
* **Don't submit a claim without documents** - supporting evidence is essential for approval
* **Don't enter a Date of Incident outside the policy's active period** - claims for events outside the coverage window cannot be approved
* **Don't edit the claim after submission** - the claim is locked once submitted. If a correction is needed, the Insurance Manager must cancel and amend it.
* **Don't confuse Claim Amount with Approved Amount** - the policyholder may request more than the policy covers. The Approved Amount is what gets paid.
* **Don't forget to check the Payment Reference after approval** - if the payment entry was not created automatically, alert your administrator immediately
***
## Common Mistakes & Troubleshooting
If the **Payment Reference** field is empty after the claim is approved and saved, the automatic payment entry creation may have failed. Do not process any payment manually - contact your administrator to investigate and resolve the issue before proceeding.
The **Claim Status** field must be updated manually as the claim progresses. The system does not automatically move a claim from Submitted to Approved - the Insurance Manager must review and change the status.
If you need to check whether a policyholder has made previous claims, open their Insurance Policy and look for the linked claims list. You can see all historical claims and their outcomes from the policy record.
Once a claim is marked as **Paid** and the Premium Schedule is closed, this cannot be undone without administrator involvement. Make absolutely sure the payment has been received and confirmed before updating the status to Paid.
If the **Insurance Premium Schedule** field is empty when you open a new claim, the policy may not have a schedule yet. This can happen if the policy was only recently approved. Wait a moment and refresh - if the schedule still does not appear, check with your administrator.
Rejected claims should have a clear reason recorded in the **Remarks** field before status is changed to Rejected. This protects the team if the decision is questioned later and helps the policyholder understand what went wrong.
***
## Workspace Access
You reach Insurance Claim through the **Insurance Management** workspace.
**Path:** Insurance Management workspace → **Insurance Management** card group → **Insurance Claim**
The visual workflow pipeline shows the claim's place in the business process. In the **Insurance Claim Process** lane, you can see the full chain:
```mermaid theme={null}
%%{init: {'theme':'base','themeVariables':{'fontFamily':'DM Sans','primaryColor':'#e7fdf6','primaryBorderColor':'#14f1b1','primaryTextColor':'#0f172a','lineColor':'#14f1b1'}}}%%
flowchart LR
IC[Insurance Claim] --> JE[Journal Entry] --> PE[Payment Entry]
```
This mirrors exactly what happens in the system: the claim record is followed by the payment entry (created automatically) and any journal entries your accounts team raises for the payout.
You can also access Payment Entries directly from the workspace by clicking **Payment Entry** in the Insurance Management card group - useful when checking the payment status of a claim.
***
## Number Cards - What to Watch
There are no number cards on the workspace dedicated specifically to Insurance Claims. Monitor your claims workload using the list view directly.
Open the **Insurance Claim** list from the workspace and use the Claim Status filter to create your own daily queue. Filter for Claim Status = Submitted to see claims awaiting review, or Claim Status = Approved to see claims ready for payment processing.
***
## Monitoring Without Reports
There are no dedicated reports for Insurance Claims. Use the **list view** with filters as your daily work queue:
| What You Want to See | Filter To Apply |
| ------------------------------------ | ----------------------------------- |
| New claims that need review | Claim Status = Submitted |
| Claims approved and awaiting payment | Claim Status = Approved |
| Claims that have been fully settled | Claim Status = Paid |
| Claims that were declined | Claim Status = Rejected |
| Claims for a specific policy | Insurance Policy = \[policy number] |
| Claims filed this month | Incident Date = This Month |
| High-value claims | Claim Amount > \[threshold] |
Sort the list by Incident Date (oldest first) to prioritise claims that have been waiting longest. Policyholders filing a claim expect prompt communication - don't let claims sit in Submitted status for more than a day or two without acknowledgement.
***
## Notifications & Alerts
There are no automated email notifications triggered specifically by Insurance Claim actions. All claim communication with the policyholder is currently handled manually.
**Recommended manual communications:**
| When | Who Sends It | What To Say |
| --------------- | --------------------------------------- | -------------------------------------------------------------------- |
| Claim submitted | Customer Service Team | Acknowledge receipt and give expected response time |
| Claim approved | Insurance Manager or Billing Specialist | Confirm the approved amount and expected payment timeline |
| Claim rejected | Insurance Manager | Explain the reason clearly; advise whether reapplication is possible |
| Claim paid | Billing Specialist | Confirm that payment has been processed |
If your organisation needs automated emails sent to policyholders when a claim is approved, rejected, or paid, this can be set up by your administrator. Contact them with the specific triggers and message content you need.
***
## Related Features
* [Insurance Policy](./insurance-policy) - the active policy this claim is made against
* [Insurance Premium Schedule](./insurance-premium-schedule) - closed automatically when this claim is paid
* [Policy Proposal](./policy-proposal) - the original application at the start of the policyholder's journey