An insurance claim is a formal request by a policyholder for coverage or compensation of a covered loss or policy event by the insurance company. The loss that is sustained, or the event that occurred is the basis for filing a claim. The claim process starts when the policyholder submits a (first) notification of loss (FNOL) in order to inform the insurance provider.
The claims department of the insurance provider will create a claim file and verify whether the loss or event is actually covered by the policy. If not, the claim file is closed, else the claim handling process starts. This claim process often involves third parties who assess the extent of the loss and carry out salvage and repair activities. See also the Order section.
A claim is settled by payment(s) made by the insurance provider to compensate the cost of replacement and/or repair. The settlement amount depends on the incurred loss, the coverage and conditions of the policy which can stipulate deductibles. The deductible amount is not compensated by the insurer, and remains for the cost of the policy holder.
Once a claim has been either rejected or completely settled, the claim file will be closed. Closing the claim file does not mean it the file is to be discarded, even in the case a claim was rejected. The data is kept to provide management information on claims handling, and as part of a regulatory audit trail. It is also possible that a claim needs to be reopened if new information comes to light, or if a ruling from a court or regulatory body on behalf of the policy holder impacts the original settlement.
Because of the aforementioned reasons the
deleteClaim function has not been added to the function group. Once a claim is older than the mandatory retention period it can be removed from the system of record. The removal of claims is part of database management, and does not necessarily require API access. See also this section