Illustrations

Below are some great examples of how smartC™ is very effective in performing a comprehensive analysis while gathering relevant data and thus providing the much needed ROI. smartC™ has proven through some of the examples below that an intelligent tool combined with management buy-in and improved processes can help customers enter into a trust bound insurance contract and for insurers to be compassionate, diligent and profitable


Example 1:

Claim: Let’s look at an example of an auto theft claim for a 2007 Honda Civic. The claim amount is for $13K. After being reviewed by the claims adjustor, the claim was flagged as questionable (false positive) and went to court.

Outcome: The claim goes to litigation because it is believed to be fraudulent due to indicators used to score claims. These indicators looks at some of the claims structured data elements and score it too high for adjustors to investigate. This delays the claim process thus leading the claims to litigation. The litigation causes increased claim costs of $120K.

Issue: After this process is over, claims handler discovers that the claim was legitimate and decides to payout. However your company has accrued a net loss of $107K, it takes 8 months to close the claim, and you’ve lost an honest customer.

With smartC™

Now, let’s look at the same claim, but this time smartC™ is used to assist with the claims validation process.

How does smartC™ handle the same claim differently?

smartC™ uses various data sources for its comprehensive analysis. The smartC™ claim validation algorithm quickly reviews:
  • internal claims data
  • policy information
  • financial data
  • adjustor information
  • weather data
  • bill of sale
  • external data sources like social media
  • external and public data (news feeds, etc.)

smartC™ Advantage:

After less than a minute to load, process, and detect all of this analysis, smartC™ uncovers no anomalies and the claim is fast tracked for payment.

Example 2:

Claim: Let’s look at an example of a workers compensation claim. It looked like a claimant was hurt at work while operating heavy machinery. The employee sought medical treatment with one of the most preferred providers of the insurer. It looked like there were 5 other claims with similar injuries of the same employer but this claim would be a long-term disability

Outcome: Long-term disability was paid to customer as the claim had gone to investigation and delay led to litigation. The claim was referred to SIU as there were 5 other claims from the same employer. The claims team decided to pay the claim once an attorney was appointed. A disability and indemnity payment of $5000 / month was being paid to the claimant

Issue: There were 2 more long-term disability claims before this current claim and it seemed like the employer and the attorney submitted too much information with very little time for the claims team to gather and analyze the information

With smartC™

Now, let’s look at the same claim, but this time smartC™ is used to assist with the claims validation process.

How does smartC™ handle the same claim differently?

smartC™ uses various data sources for its comprehensive analysis. The smartC™ claim validation algorithm quickly gathered all internal and external data and analyzed using its ARM approach:
  • Internal claims data
  • Policy information
  • Social media
  • Social network / link analysis
  • 3rd part data
  • Medical coding data
  • Emails
  • Claim notes
  • Loss Control reports
  • Doctors notes

smartC™ Advantage:

After less than a minute to load, process, and detect all of this analysis, smartC™ flags this claim as suspicious as the employer has some social media declaration of bankruptcy, medical coding validations fail with some of the medical billings, links established connects more than 10 claims with a similar pattern involving the same attorney, injury, treatment and doctor. Material misrepresentation was also found from loss control reports.

Example 3: LIFE

Claim: Life insurance claim has a single cause of death on the company’s claim form and the death certificate had multiple causes of death. The beneficiary did not mention that and sent in the forms as requested

Outcome: The claim was delayed for more than a month as their SIU (to whom the claim had been referred to) had to manually validate all the paperwork of this claim. After a while the claim was paid and the beneficiary was annoyed and posted on social media about the delay in paying the claim especially when her husband had died and she needed the money

Issue: There was a delay in processing the claim as information had to be manually assessed. And overall analysis going back into history was proving to be difficult.

With smartC™

Now, let’s look at the same claim, but this time smartC™ is used to assist with the claims validation process.

How does smartC™ handle the same claim differently?

smartC™ uses various data sources for its comprehensive analysis. The smartC™ claim validation algorithm quickly reviews:
  • internal claims data
  • policy information
  • external data sources like social media
  • external and public data (news feeds, etc.)
  • Claim form
  • Death certificate

smartC™ Advantage:

smartC™ was able to read the form data (using 3rd party service), bring the data with all other claims data for analysis. After less than a minute to load, process, and detect all of this analysis, smartC™ uncovers no anomalies and the claim is fast tracked for payment. smartC™ also found the obituary related to the insured with exact reasons of death as on death certificate. smartC™ fast tracked this claim.

Why smartC™?

Most business intelligence software focuses on internal data...

Savings

When processing a claim manually, there are many factors...

Features

Quickly and efficiently identifies genuine claims for faster...

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