Insurance > Claims

Claims is a classic payment application. There is usually a considerable analysis available as claims can be matched back to policy details and there are usually various claim types, reason codes and risk codes.

The following are commonly used tests (grouped by type).

Calculations

  • Cast (or total) outstanding claims
  • Prove posting totals

Analysis

  • Analyse by month, type and calculate average values
  • Group claims by product type
  • Matrix analyse date of incident to date claim reported as part of assessing claims incurred but not recorded

Exception Tests

  • High value claims
  • Identify claims with no movement in the last 6 months (some claims get reported but queries on the claim are not responded to leaving old expired claims on the system)
  • Identify negative balances (recoveries)

Gaps and Duplicates

  • Check for duplicate claims (same policy number and either same amount or same date of incident)
  • Check for multiple claims on the same policy (some policy holders are particularly unlucky. However, others make a business out of claiming more than once for an incident. This can be picked up by testing for claims with the same amount or same date of incident).

There are also a number of tests cross matching between files:

  • Test for existence of a policy in the same time period as the claim
  • Check details between claims and policies. It may be worthwhile to see how many new policies experience claims shortly after inception.