Insurance Claim Processing

Human ↔ Human

Insurance claim lifecycle from filing through documentation, investigation, settlement negotiation, and payment.

6 nodes · 6 edgesinsurance

humansystem

Visual

File Claimhuman

Policyholder files a claim with incident details, date, and supporting photos.

↓sequential→ Documentation Collection

Documentation Collectionhuman

Claims handler requests and gathers police reports, medical records, or repair estimates.

↓sequential→ Adjuster Investigation

Adjuster Investigationhuman

Field adjuster inspects damage, interviews witnesses, and assesses liability.

↓sequential→ Settlement Offer

Settlement Offerhuman

Claims manager calculates payout and presents settlement offer to policyholder.

↓conditional→ Negotiation

↓conditional→ Issue Payment

Negotiationhuman

Policyholder and claims manager negotiate final settlement amount.

↓sequential→ Issue Payment

Issue Paymentsystem

System processes approved payment via direct deposit or check.

Open in Editor

uc-claim-processing.osop.yaml

osop_version: "1.0"
id: "claim-processing"
name: "Insurance Claim Processing"
description: "Insurance claim lifecycle from filing through documentation, investigation, settlement negotiation, and payment."

nodes:
  - id: "file_claim"
    type: "human"
    subtype: "input"
    name: "File Claim"
    description: "Policyholder files a claim with incident details, date, and supporting photos."

  - id: "collect_docs"
    type: "human"
    subtype: "input"
    name: "Documentation Collection"
    description: "Claims handler requests and gathers police reports, medical records, or repair estimates."

  - id: "adjuster_investigation"
    type: "human"
    subtype: "review"
    name: "Adjuster Investigation"
    description: "Field adjuster inspects damage, interviews witnesses, and assesses liability."

  - id: "settlement_offer"
    type: "human"
    subtype: "input"
    name: "Settlement Offer"
    description: "Claims manager calculates payout and presents settlement offer to policyholder."

  - id: "negotiation"
    type: "human"
    subtype: "input"
    name: "Negotiation"
    description: "Policyholder and claims manager negotiate final settlement amount."

  - id: "payment"
    type: "system"
    subtype: "action"
    name: "Issue Payment"
    description: "System processes approved payment via direct deposit or check."

edges:
  - from: "file_claim"
    to: "collect_docs"
    mode: "sequential"
  - from: "collect_docs"
    to: "adjuster_investigation"
    mode: "sequential"
  - from: "adjuster_investigation"
    to: "settlement_offer"
    mode: "sequential"
  - from: "settlement_offer"
    to: "negotiation"
    mode: "conditional"
    when: "policyholder_accepts == false"
    label: "Policyholder disputes offer"
  - from: "settlement_offer"
    to: "payment"
    mode: "conditional"
    when: "policyholder_accepts == true"
    label: "Offer accepted"
  - from: "negotiation"
    to: "payment"
    mode: "sequential"