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The artificial intelligence-based system aims to authorise cashless claims within 60-90 seconds and bring the turnaround time for investigations down to a one day, or even a few hours.
Illustration: Dominic Xavier/Rediff.com
ICICI Lombard General Insurance last week shifted to a real-time, mobile-based platform to verify health insurance claims. This was done in an endeavour to improve investigation operations.
The artificial intelligence-based system aims to authorise cashless claims within 60-90 seconds and bring the turnaround time for investigations down to a one day, or even a few hours.
"The moment a claim is triggered from the claims department, it gets into a queue and is assigned to the investigator via a notification on their app," said Girish Nayak, chief (service, operations and technology) at ICICI Lombard General Insurance.
Typically, when a customer files a health insurance claim, the insurer is notified and the claim is entered into their system for processing. In case the insurer (company executive) finds a fault, an external party or investigator is assigned to look into the claim.
"Depending on how extensive the investigation is, this could take multiple days to complete. All the while, the claim remains unprocessed till the investigation is completed. For customers, the turnaround time for the claim increases," he said.
The new platform is an upgrade from the previous web-based claims investigation system. Despite the older system being effective from what was once an entirely paper-based system, the main issue was that investigators could only upload the data and their findings once physically back in their office and logged on to the web platform.
With the help of the app, ICICIGI's empanelled third-party investigators may upload their findings after visiting the customer and hospital, as required, in real-time and the central or regional claims department will receive the data at the other end.
This will improve the accuracy and speed in assessing claims.
"The verifier, either regional or central, may sometimes require further information from the customer. Therefore, through the app, we can send the customer a link for a direct video-conference with the verifier to answer any questions," notes Nayak.
ICICIGI has addressed this issue in their internal claims' investigation system through a mobile app. The AI-based platform will read the customers' policy documents and intelligently deduce the exact coverage available to the customer, as well as doctors' recommendations and other documents/details.
"Using all these three data points, the AI engine will determine whether the claim is medically admissible, and the amount to be authorised. Before this doctors would have to determine whether a case was admissible or not," says Nayak.
In case investigators are sent to interior regions to look into medical claims filed by ICICIGI's customers, the app allows the investigator to upload documents and findings off-line. The moment he/she enters an area with good cellular connectivity, the app automatically sends the data to the central claims team.
Earlier, general insurance firms like ICICIGI had launched video-based claims platforms for their motor insurance customers and investigators, which are usually authorised garages.
The app is another innovation by insurance companies to their internal processes, using AI-based platforms to reduce delays in processing claims made by their customers.
