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Insurance / APPLICATION BLUEPRINT

Insurance Claims & Settlement

Follow loss notification through evidence collection, authorised coverage review, settlement approval, payment reconciliation and closure.

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12 workspace menus · 12 business workflows · 5 role profiles

Application blueprint only. This is a proposed design, not a deployed or production-tested system. Screens and sample figures are illustrative; workflows, business rules, approvals, permissions and integrations require confirmation before build.

Designed for Insurance claims operations director

Insurance Claims & Settlement workspace interface preview; illustrative records and figures.
Insurance Claims & Settlement — operational workspaceIllustrative interface · Sample dataView full interface →

Explore an illustrative interface.

Illustrative workspace and record review. Select a concept screen to inspect it in full.

Insurance Claims & Settlement workspace interface preview; illustrative records and figures.
Insurance Claims & Settlement — operational workspaceIllustrative interface · Sample dataView full interface →
Insurance Claims & Settlement record interface preview; illustrative records and figures.
Insurance Claims & Settlement — record and workflow reviewIllustrative interface · Sample dataView full interface →

Operational dashboards and work queues.

Operational views

Review work, evidence, exceptions and authorised decisions within a defined operating scope.

Portfolio / service teamPeriodAssigned teamReview state

Dashboard measures

  • Active reconciliation items
    Count of all records in the selected workspace.
  • Review queue
    Records at the third stage of the business workflow.
  • Needs attention
    Records with an assigned review requirement.
  • Final-stage records
    Records in the fourth business workflow stage.

Business workflow and operating scope

Follow loss notification through evidence collection, authorised coverage review, settlement approval, payment reconciliation and closure. A claim changes hands between intake, assessment, decision and payment teams. Missing evidence or an unresolved coverage question can become difficult to see once the next team starts work. The system keeps those dependencies and the responsible decision-maker connected to the claim.

Operations

Operational overview

Review the work position and priority actions.

Loss notification intake

Coordinate loss notification intake with assigned responsibilities, linked records and review history.

Claim evidence

Coordinate claim evidence with assigned responsibilities, linked records and review history.

Coverage review

Coordinate coverage review with assigned responsibilities, linked records and review history.

Assessment coordination

Coordinate assessment coordination with assigned responsibilities, linked records and review history.

Settlement approval

Coordinate settlement approval with assigned responsibilities, linked records and review history.

Payment reconciliation

Coordinate payment reconciliation with assigned responsibilities, linked records and review history.

Customer closure records

Coordinate customer closure records with assigned responsibilities, linked records and review history.

Insights

Reports and saved views

Review the reporting scope and export agreed operational views.

Governance

Approvals and exceptions

Review delegated decisions, exceptions and recorded conditions.

Audit history

Trace accepted changes, decisions and accountable actions.

Access and configuration

Manage the agreed role permissions and configurable operating rules.

The end-to-end business journey.

From intake to authorised completion, with evidence at each decision.

01

Register the loss

Register loss notification and supporting evidence.

02

Review coverage

Assign authorised coverage and liability review.

03

Approve settlement

Approve repair or settlement proposal.

04

Reconcile and close

Reconcile payment and communicate closure.

Business workflows

Select a workflow to review the steps, responsibilities, approval and exception handling.

01 · Coordinate loss notification intake

Coordinate loss notification intake within Claims intake coverage review and settlement.

Trigger
Loss notification intake requires a new record, an agreed review or a controlled change.

Responsible role
Claims intake officer

  • Register loss notification intake and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

02 · Coordinate claim evidence

Coordinate claim evidence within Claims intake coverage review and settlement.

Trigger
Claim evidence requires a new record, an agreed review or a controlled change.

Responsible role
Coverage reviewer

  • Register claim evidence and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

03 · Coordinate coverage review

Coordinate coverage review within Claims intake coverage review and settlement.

Trigger
Coverage review requires a new record, an agreed review or a controlled change.

Responsible role
Coverage reviewer

  • Register coverage review and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

04 · Coordinate assessment coordination

Coordinate assessment coordination within Claims intake coverage review and settlement.

Trigger
Assessment coordination requires a new record, an agreed review or a controlled change.

Responsible role
Coverage reviewer

  • Register assessment coordination and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

05 · Coordinate settlement approval

Coordinate settlement approval within Claims intake coverage review and settlement.

Trigger
Settlement approval requires a new record, an agreed review or a controlled change.

Responsible role
Coverage reviewer

  • Register settlement approval and its operating scope
  • Compare amounts, attribution and accepted conditions
  • Route differences to the accountable finance reviewer
  • Record authorised adjustments and the accepted position

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Amounts, ownership or allocation evidence do not agree.

Outcome
A reconciled position, approved adjustments and separately owned outstanding items.

06 · Coordinate payment reconciliation

Coordinate payment reconciliation within Claims intake coverage review and settlement.

Trigger
Payment reconciliation requires a new record, an agreed review or a controlled change.

Responsible role
Coverage reviewer

  • Register payment reconciliation and its operating scope
  • Compare amounts, attribution and accepted conditions
  • Route differences to the accountable finance reviewer
  • Record authorised adjustments and the accepted position

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Amounts, ownership or allocation evidence do not agree.

Outcome
A reconciled position, approved adjustments and separately owned outstanding items.

07 · Coordinate customer closure records

Coordinate customer closure records within Claims intake coverage review and settlement.

Trigger
Customer closure records requires a new record, an agreed review or a controlled change.

Responsible role
Claims intake officer

  • Register customer closure records and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

08 · Register the operating requirement

Coordinate operating requirement within Claims intake coverage review and settlement.

Trigger
Operating requirement requires a new record, an agreed review or a controlled change.

Responsible role
Claims intake officer

  • Register operating requirement and its operating scope
  • Compare options, dependencies and operating constraints
  • Review the selected option with its accountable owners
  • Accept the plan and track its delivery conditions

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
An assumption changes, prerequisites are missing or stakeholders cannot accept the proposed commitment.

Outcome
An approved operating plan and owned actions for its accepted conditions.

09 · Resolve operating exceptions

Coordinate operating exceptions within Claims intake coverage review and settlement.

Trigger
Operating exceptions requires a new record, an agreed review or a controlled change.

Responsible role
Claims intake officer

  • Register operating exceptions and its operating scope
  • Gather the relevant evidence and review options
  • Route the case to the delegated decision owner
  • Record the outcome, conditions and follow-up obligations

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
The case exceeds delegation, contains a conflict or has disputed evidence.

Outcome
An authorised decision or escalation with accountable resolution actions.

10 · Verify completion and follow-up

Coordinate completion and follow-up within Claims intake coverage review and settlement.

Trigger
Completion and follow-up requires a new record, an agreed review or a controlled change.

Responsible role
Coverage reviewer

  • Register completion and follow-up and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

11 · Review controlled operating changes

Coordinate controlled operating changes within Claims intake coverage review and settlement.

Trigger
Controlled operating changes requires a new record, an agreed review or a controlled change.

Responsible role
Coverage reviewer

  • Register controlled operating changes and its operating scope
  • Collect the linked records and qualified evidence
  • Assign the responsible reviewer and record findings
  • Accept the outcome or assign corrective follow-up

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Evidence is incomplete, disputed, expired or outside the reviewer’s authority.

Outcome
A review finding, its accepted evidence and any accountable corrective actions.

12 · Prepare scoped operational reports

Coordinate scoped operational reports within Claims intake coverage review and settlement.

Trigger
Scoped operational reports requires a new record, an agreed review or a controlled change.

Responsible role
Claims intake officer

  • Register scoped operational reports and its operating scope
  • Assign the accountable owner and required actions
  • Review the relevant evidence and unresolved conditions
  • Confirm the accepted outcome and retain its history

Approval
Settlement approver records the decision when the action changes an accepted commitment or requires delegated authority.

Exception handling
Required information or responsibility is missing, or an operating condition changes.

Outcome
A completed operating record with its linked evidence and remaining obligations.

Governance and control

  • Every case must have an owner, priority and status.
  • Sensitive records must be visible only to authorised roles.
  • Escalation rules must be configurable by severity and elapsed time.
  • Decisions that affect entitlement, safety or payment require accountable human approval.
  • Closed cases may reopen only through a controlled path that preserves history.
  • Jurisdiction-, regulator- or authority-specific rules must be configurable and validated by an authorised domain owner before production use.
Operating rules by business workflow
  • For loss notification intake, the record retains an accountable owner, its supporting evidence and accepted outcome.
  • For claim evidence, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For coverage review, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For assessment coordination, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For settlement approval, adjustments require source evidence, a recorded reason and authorised financial review.
  • For payment reconciliation, adjustments require source evidence, a recorded reason and authorised financial review.
  • For customer closure records, the record retains an accountable owner, its supporting evidence and accepted outcome.
  • For operating requirement, the accepted plan records assumptions, rejected alternatives, dependencies and conditions.
  • For operating exceptions, a decision retains its authority, reason, supporting evidence and resulting obligations.
  • For completion and follow-up, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For controlled operating changes, evidence, reviewer authority and acceptance conditions are visible before a reviewed outcome is accepted.
  • For scoped operational reports, the record retains an accountable owner, its supporting evidence and accepted outcome.

Data, interfaces and operating requirements.

Core records

Case / requestPerson / customerService / issue typeTaskAssignmentDecisionEvidence / communicationResolution
Record fields and linked information
  • Record identifier — Stable reference for the operating transaction.
  • Portfolio / service team — Business scope used for responsibility and reporting.
  • Operating subject — The request, commitment or work item being handled.
  • Accountable owner — Named responsibility for the next action.
  • Workflow stage — Current position in the agreed business journey.
  • Review requirement — Required review and outstanding decision.
  • Due or review date — Agreed action window or review trigger.
  • Linked evidence — Source records supporting the operating decision.
  • Decision authority — The delegated authority relevant to the accepted outcome.
  • Accepted outcome — Recorded decision and its business consequences.
  • Follow-up obligation — Remaining responsibilities after an accepted action.
  • Revision history — Trace of accepted changes and their evidence.
  • Loss notification intake reference — Link the relevant loss notification intake to the operating transaction and its decision evidence.
  • Claim evidence reference — Link the relevant claim evidence to the operating transaction and its decision evidence.
  • Coverage review reference — Link the relevant coverage review to the operating transaction and its decision evidence.
  • Assessment coordination reference — Link the relevant assessment coordination to the operating transaction and its decision evidence.
  • Settlement approval reference — Link the relevant settlement approval to the operating transaction and its decision evidence.

Systems and interfaces

  • Policy administration records
  • Assessment service interfaces
  • Approved payment systems

Interface scope, data mapping and testing are agreed for each engagement.

Implementation requirements
Requires policy, assessment and payment integrations, product specific claims rules and accountable human approval of denials and material settlements.

Mobile and tablet access

Submit permitted claim evidence and complete authorised assessment tasks on suitable field devices.

Access approved workflows through the Dalfin mobile app. Device tasks and permissions are confirmed for the deployment.

Apple App Store ↗Google Play ↗

AI extensions

Summarise claim evidence for assessor review. Coverage denials and material settlement decisions remain human approved.

AI extensions are scoped around the required data, business outcome and review controls.

Engineered with Genesis.

Structured application engineering

Connect requirements, roles, records, workflows and interfaces through the agreed Genesis engineering process.

Controlled changes

Review dependency impact and validation requirements. Context Memory supports governed changes and accepted application revisions.

Deployment and support

Agree customer cloud or on-premises requirements, device access, implementation acceptance and ongoing engineering support.

AN EXAMPLE OPERATING SCENARIO

What to validate in a scoped demonstration.

A claim is returned for missing loss evidence. An authorised reviewer resolves a coverage question, the settlement proposal is approved within delegated authority and payment is reconciled. The claimant receives the approved closure communication.

What to review

  • A saved end-to-end transaction
  • An exception and its authorised resolution
  • Different operator, approver and reviewer permissions
  • Final records, history and the relevant report
Discuss this solution

Questions before implementation.

How is this system adapted to our organisation?

Roles, approval authority, business rules, records and reporting are configured around your operating model. Scope definition connects the required business outcome to workflows, interfaces and acceptance criteria.

How are approvals and responsibilities defined?

Operators, reviewers and authorised decision makers have defined responsibilities. Approval limits, exception handling and access permissions are agreed with your business owners and tested against the selected workflows.

Can it connect with our existing systems?

Interface requirements cover your existing business systems, data ownership, mapping and authentication. Connection design and testing form part of the agreed implementation scope.

What will we review in a solution walkthrough?

Start with a relevant business transaction, then review its approvals, an exception, role permissions and final records. Discuss the integrations, reporting and operating requirements that matter to your organisation.