Business Context: Overview

What Problem Does This System Solve?

The Insurance Management System (INSMASTR) automates core insurance operations for policy lifecycle management and claims processing. It processes high-volume batch transactions for:

New policy enrollment with automated risk assessment and premium pricing
Policy renewal processing with loyalty rewards and discount calculations
Claims adjudication with integrated fraud detection and payment determination

The system eliminates manual underwriting calculations, reduces fraud losses through automated detection, and ensures consistent application of business rules across thousands of daily transactions.

End Users

Primary Users:

Insurance underwriters (review flagged policies and claims)
Claims adjusters (process manually reviewed claims)
Fraud investigators (investigate high-risk claims)
Policy administrators (manage policy lifecycle)

Secondary Users:

Billing department (receive premium calculations)
Payment processing (receive approved claim amounts)
Management (review reports and statistics)

Key Business Capabilities

Automated Policy Creation: Validates customer eligibility (age 18-85), calculates risk scores (0-100 scale), and determines premiums using multi-factor pricing (coverage amount, age, health status, occupation)
Intelligent Renewal Processing: Applies four renewal types (Standard, Upgrade, Downgrade, Multi-Year) with cumulative discounts up to 45% (loyalty, no-claims, multi-policy)
Claims Processing with Fraud Detection: Five-factor fraud scoring system flags suspicious claims (≥70 score) for investigation, auto-approves low-risk claims ≤$5,000, and calculates patient/insurance payment splits
Risk-Based Premium Calculation: Incorporates age factors, risk scores, deductible impacts, state taxes, and payment frequency discounts to generate actuarially sound premiums
Customer Financial Protection: Enforces deductibles, applies coinsurance/copays, and caps patient costs at out-of-pocket maximums

Major Business Workflows

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What Problem Does This System Solve?

The Insurance Management System (INSMASTR) automates core insurance operations for policy lifecycle management and claims processing. It processes high-volume batch transactions for:

New policy enrollment with automated risk assessment and premium pricing

Policy renewal processing with loyalty rewards and discount calculations

Claims adjudication with integrated fraud detection and payment determination

The system eliminates manual underwriting calculations, reduces fraud losses through automated detection, and ensures consistent application of business rules across thousands of daily transactions.

End Users

Primary Users:

Insurance underwriters (review flagged policies and claims)

Claims adjusters (process manually reviewed claims)

Fraud investigators (investigate high-risk claims)

Policy administrators (manage policy lifecycle)

Secondary Users:

Billing department (receive premium calculations)

Payment processing (receive approved claim amounts)

Management (review reports and statistics)

Key Business Capabilities

Automated Policy Creation: Validates customer eligibility (age 18-85), calculates risk scores (0-100 scale), and determines premiums using multi-factor pricing (coverage amount, age, health status, occupation)

Intelligent Renewal Processing: Applies four renewal types (Standard, Upgrade, Downgrade, Multi-Year) with cumulative discounts up to 45% (loyalty, no-claims, multi-policy)

Claims Processing with Fraud Detection: Five-factor fraud scoring system flags suspicious claims (≥70 score) for investigation, auto-approves low-risk claims ≤$5,000, and calculates patient/insurance payment splits

Risk-Based Premium Calculation: Incorporates age factors, risk scores, deductible impacts, state taxes, and payment frequency discounts to generate actuarially sound premiums

Customer Financial Protection: Enforces deductibles, applies coinsurance/copays, and caps patient costs at out-of-pocket maximums