Claims Process Research Articles

Analyzing Underlying Factors of Rework in Generating Contractual Claims in Construction Projects

Claim management plays an essential role in the success of construction contracts. The enhancement of the contractual claim process in construction projects improves the relationship between parties and impacts conflicts and disputes. Previous studies related to contractual claims focused primarily on general causes with relatively little attention paid to reasons associated with reworking. Rework in construction contracts generates cost overruns and delays, resulting in claims, conflicts, and disputes. Given the causal relations of rework, contractual claims, and disputes in construction projects, the necessity to implement rework management has become more critical. Although construction reworks lead to claims and disputes, a quantitative approach has not been undertaken to analyze the relationship between rework causes and contractual claims. This study aims to identify the key causes of rework that affect construction contracts and categorize them as rework factors in generating contractual claims by apprising the correlative rework causes and contractual claims. A quantitative approach is considered an appropriate method for data collection. Based on a review of the literature, a questionnaire including a comprehensive list of rework causes was developed, and the collected data were then analyzed using the exploratory factor analysis method. The results provided evidence of categorizing the causes of rework under four underlying factors: process, management and planning, material and equipment, and human resources. This study bridges the knowledge gap of dimensionality between rework and contractual claims, which can create measures to address rework causes in generating contractual claims. The paper suggests that effective rework management could reduce contractual claims through attention to the causes of rework at the early stages of contracting.

BIBLIOMETRIC ANALYSIS ON BIG DATA APPLICATIONS IN INSURANCE SECTOR: PAST, PRESENT, AND FUTURE RESEARCH DIRECTIONS

In this study, the key areas and current trends in the field of big data applications in the insurance industry are identified, along with suggestions for future research initiatives. We identified the most prominent authors, journals, organizations, and countries based on their total publications and citations, showing their significance within the network, using bibliometric analysis on a sample of 191 articles retrieved from Scopus from 1976 to 2021. VOSviewer and R-Biblioshiny tools were used to generate the bibliometric output on these retrieved papers. The findings showed that although while a good number of writers from other parts of the world contributed to the literature on big data applications in the insurance industry, during this time, most research papers have listed the United States, India, and China as their affiliated countries. The yearly publication was either one or two, with some discontinuity, from 1976 to 2011, but since 2012, it has increased, exhibiting an exponential growth tendency. The three journals “Risks,” “Applied Stochastic Models in Business and Industry,” and “Expert Systems with Applications” are the most popular for including a sizable number of papers in the field of big data technologies in the insurance sector. Each of the top 10 authors in this field published two research papers during these 46 years. Seven areas, including fraud detection and prevention, risk assessment, pricing & rate making, technology utilization, risk management, claim processing & prediction, and finally digitalization, were the major focus of research papers on bigdata applications in the insurance business. The human-centered AI system development, adoption of wearable technology, personalization, and other topics were found to have received very little attention in this study. As a result, the researchers may now direct future research in this area. This study is completely new of its kind in the domain of insurance though few documents are available on the broad concept of finance.

Insurance Industry and Block Chain Technology: An Analysis of Opportunities and Challenges

Blockchain is incorporated into our distributed platform design as a system service to facilitate the execution of transactions in insurance procedures. The insurance sector is highly reliant on several procedures between parties engaged in a transaction for opening, retaining, and closing various types of policies. Our view of data management and security has undergone a paradigm shift as a result of the emergence of blockchain technology. Blockchain technology is essential to the insurance industry for optimization of claims processing and policy automation, resulting in lower costs and greater efficiency. Additionally, the ability of blockchain to increase transparency and reduce fraudulent activity promotes credibility and trust between the insured and insurer. This paper explains how the insurance sector might profit from blockchain technology investments. We review the fundamentals of blockchain technology, major platforms currently in use, and offer a simple explanation of the insurance sub-processes that blockchain might enhance. This paper also discuss about the challenges that must be overcome for blockchain solutions to be completely adopted in the insurance industry.

Safety of the BNT162b2 COVID-19 Vaccine in Children Aged 5 to 17 Years

Active monitoring of health outcomes after COVID-19 vaccination offers early detection of rare outcomes that may not be identified in prelicensure trials. To conduct near-real-time monitoring of health outcomes following BNT162b2 COVID-19 vaccination in the US pediatric population aged 5 to 17 years. This population-based study was conducted under a public health surveillance mandate from the US Food and Drug Administration. Participants aged 5 to 17 years were included if they received BNT162b2 COVID-19 vaccination through mid 2022 and had continuous enrollment in a medical health insurance plan from the start of an outcome-specific clean window until the COVID-19 vaccination. Surveillance of 20 prespecified health outcomes was conducted in near real time within a cohort of vaccinated individuals from the earliest Emergency Use Authorization date for the BNT162b2 vaccination (December 11, 2020) and was expanded as more pediatric age groups received authorization through May and June 2022. All 20 health outcomes were monitored descriptively, 13 of which additionally underwent sequential testing. For these 13 health outcomes, the increased risk of each outcome after vaccination was compared with a historical baseline with adjustments for repeated looks at the data as well as a claims processing delay. A sequential testing approach was used, which declared a safety signal when the log likelihood ratio comparing the observed rate ratio against the null hypothesis exceeded a critical value. Exposure was defined as receipt of a BNT162b2 COVID-19 vaccine dose. The primary analysis assessed primary series doses together (dose 1 + dose 2), and dose-specific secondary analyses were conducted. Follow-up time was censored for death, disenrollment, end of the outcome-specific risk window, end of the study period, or a receipt of a subsequent vaccine dose. Twenty prespecified health outcomes: 13 were assessed using sequential testing and 7 were monitored descriptively because of a lack of historical comparator data. This study included 3 017 352 enrollees aged 5 to 17 years. Of the enrollees across all 3 databases, 1 510 817 (50.1%) were males, 1 506 499 (49.9%) were females, and 2 867 436 (95.0%) lived in an urban area. In the primary sequential analyses, a safety signal was observed only for myocarditis or pericarditis after primary series vaccination with BNT162b2 in the age group 12 to 17 years across all 3 databases. No safety signals were observed for the 12 other outcomes assessed using sequential testing. Among 20 health outcomes that were monitored in near real time, a safety signal was identified for only myocarditis or pericarditis. Consistent with other published reports, these results provide additional evidence that COVID-19 vaccines are safe in children.

Rehabilitation access for individuals with cognitive-communication challenges after traumatic brain injury: A co-design study with persons with lived experience.

Adults with traumatic brain injuries (TBI) frequently experience cognitive, emotional, physical and communication deficits that require long-term rehabilitation and community support. Although access to rehabilitation services is linked to positive outcomes, there can be barriers to accessing community rehabilitation related to system navigation, referral processes, funding, resource allocation and communications required to ensure access. This study aimed to identify barriers to accessing insurer funding for rehabilitation and healthcare services, for adults with TBI injured in motor vehicle collisions (MVCs). We used a co-design approach to collaborate with persons with lived experience to design a survey of adults who sustained a TBI in an MVC. The survey examined access to insurer funding for rehabilitation services and was disseminated through brain injury networks in Ontario, Canada. Respondents (n = 148) identified multiple barriers to accessing rehabilitation services through insurer funding, including delays of more than 2 years (49%), mandatory duplicative assessments (64%) and invasion of privacy (55%). Speech-language therapy and neuropsychological services were denied most frequently. Negative experiences included insurers' poor understanding of TBI symptoms, denials of services despite medical evidence demonstrating need and unsupportive insurer interactions. Although 70% of respondents reported cognitive-communication difficulties, accommodations were rarely provided. Respondents identified supports that would improve insurer and healthcare communications and rehabilitation access. The insurance claims process had many barriers for adults with TBI, limiting their access to rehabilitation services. Barriers were exacerbated by communication deficits. These findings indicate a role for Speech-language therapists in education, advocacy and communication supports during the insurance process specifically as well as rehabilitation access processes in general. What is already known on this subject There is extensive documentation of the long-term rehabilitation needs of individuals with traumatic brain injury (TBI) and their challenges in accessing rehabilitation services over the long term. It is also well known that many individuals with TBI have cognitive and communication deficits that affect their interactions in the community, including with healthcare providers, and that SLTs can train communication partners to provide communication supports to individuals with TBI in these communication contexts. What this study adds This study adds important information about barriers to accessing rehabilitation, including barriers to accessing SLT services in the community. We asked individuals with TBI about challenges to accessing auto insurance funding for private community services, and their responses illustrate the broader challenges individuals with TBI face in communicating their deficits, conveying service needs, educating and convincing service administrators and self-advocating. The results also highlight the critical role that communication plays in healthcare access interactions, from completing forms to reviewing reports and funding decisions, to managing telephone calls, writing emails and explaining to assessors. What are the clinical implications of this work? This study shows the lived experience of individuals with TBI in overcoming barriers to accessing community rehabilitation. The results show that best practices in intervention should include evaluating rehabilitation access, which is a critical step in patient-centred care. Evaluation of rehabilitation access includes evaluating referral and navigation, resource allocation and healthcare communications, and ensuring accountability at each step, regardless of model of service delivery or funding source. Finally, these findings show the critical role of speech-language therapists in educating, advocating and supporting communications with funding sources, administrators and other healthcare providers.

Unclaimed Maturity Benefits in LIC Insurance Policies: A Comprehensive Review

This review paper aims to analyze the issue of unclaimed maturity benefits in LIC insurance policies due to customer ignorance. The study investigates the reasons behind this phenomenon and examines the existing literature on the subject. The methodology involved a thorough search of relevant databases and analysis of published articles, reports, and other relevant sources. The review concludes with suggestions for LIC to improve customer awareness and facilitate the claiming process for unclaimed benefits. Key word: Unclaimed benefits, Maturity Benefits, Insurance Policies, Customer Awareness, LIC

Blockchain-Based Business Process Management (BPM) for Finance: The Case of Credit and Claim Requests

Because of the competitive economy, organizations today seek to rationalize, innovate, and adapt to changing environments and circumstances as part of business process improvement efforts. The strength of blockchain technology lies in its usage as an apt technology to enhance the efficiency and effectiveness of business processes; furthermore, it prevents the use of erroneous or obsolete data and allows sharing of confidential data securely. The use of superior technology in the execution and automation of business processes brings opportunities to rethink the specific process itself as well. Business processes modeling and verification are essential to control and assure organizational evolution, therefore, the aim of this paper is three-fold: firstly, to provide business process management patterns in finance, based on blockchain, specifically for the loan-application process in the banking industry and claim process in the insurance industry that could be used and customized by companies; secondly, to critically analyze challenges and opportunities from the introduction of such approach for companies, and thirdly, to outline how companies can implement the loan business process as a web service. Partner companies (a bank and an insurance company) formulated the potential requirements for M2P along with the application of blockchain technology. An experimental design framework was established that gave the necessary services to model the requirements, check the models, and operationalize the models. The applied research methodologies are as follows: design science research paradigm and software case study, model-to-programming (M2P) of business processes, and utilization of patterns of workflow and blockchain.

Data Driven Analysis of Insurance Claims Using Machine Learning Algorithm

The insurance industry is undergoing major changes with the integration of big data and artificial intelligence technologies. The design and research of an insurance survey claims system based on big data analysis aims to improve the efficiency and accuracy of insurance claims processing. The system uses image recognition, computer vision systems, language recognition, and other AI technologies to analyze case information and accelerate the speed of insurance claims settlement. The system also includes an intelligent customer service feature that uses AI algorithms such as language processing and big data statistical analysis to provide processing suggestions to policyholders. The system implements an individualized insurance service that collects, stores, and analyzes data on policyholders to create personalized insurance products and perform precise marketing. Big data analysis in the insurance personalized service primarily uses association rule analysis, classification and clustering analysis, and change and deviation analysis to improve the service. The one-click reporting function simplifies the reporting process for policyholders, allowing them to report a case from anywhere at any time. The intelligent claims processing feature separates liability in claims cases and deals with non-controversial cases through the use of AI, shortening the processing time and reducing manpower costs. The insurance survey and claim system has undergone five iterations under an agile development model and has achieved the goals of personalized insurance services, one-click reporting, intelligent claims processing, and intelligent customer service. The practical application results demonstrate that the system can improve the efficiency and accuracy of insurance claims processing while also providing policyholders with a more convenient and personalized experience. In conclusion, the design and research of an insurance survey claims system based on big data analysis has the potential to revolutionize the insurance industry and greatly benefit both insurance companies and policyholders

FASTER: The European Commission’s Plans to Improve the Withholding Tax Claim Process within the European Union

In this note, the authors discuss the Fast Track Assured and Safer Tax Excess Refunds (FASTER) proposal, the European Commission’s initiative to unify and simplify the European Union withholding tax landscape.

Roles and Responsibilities while Rethinking the Movement to Get Moving: Archives and Records in the Road Accident Fund

This paper reports on the findings of a Master of Information Science dissertation. The purpose of the study was to determine the Road Accident Fund’s readiness for electronic records. The study was qualitative, and a case study was used as the design for the investigation. Data were collected through document analysis. The findings revealed that two business units in the organisation have similar record-keeping mandates, which is confusing. Records Management forms part of the Information Governance unit at head office, while Correspondence and Document Management Services are responsible for performing records management functions in the regional offices. These business units do not form part of Information Governance, as is the case at head office, but are stand-alone regional units entrusted with records management. There is one such unit in every regional office across the country. The organisation has a central records manager who operates from the head office in Centurion. However, these regional records management business units exist and operate in isolation. As a result, there is dis-integration between paper records and the electronic processing of claims, which hinders the institution from providing timely services to motor vehicle accident victims. To improve its records management practices, the study recommended developing and implementing a records management programme, which will facilitate records management policy implementation and the development of standard processes and procedures within the organisation for managing paper and electronic records in an integrated manner.

Artificial intelligence service agents: a silver lining in rural India

PurposeThe study aims to examine the impact of an artificial intelligent service agent (AISA) on customer services to the rural population provided by KAYA, Kotak Life's AI-enabled insurance chatbot avatar that offers quality insurance services.Design/methodology/approachMulti-stage cluster sampling method was adopted to collect the responses from the 707 customers across the rural population of southern states of India. SPSS V.2 and Smart PLS 4 were used to apply simple percentage analysis, multiple linear regression analysis, and structural equation modeling (SEM) to validate the hypothesis. The dependent variables are economic performance and market performance based on the independent variables: efficiency, security, availability, enjoyment and contact.FindingsThe study revealed that efficiency and security are the highest predictors and the most influencing variables in predicting the economic and market performance of the insurance companies in determining the quality of service when rendered through AISA among the customers. Efficiency, security, availability, contact and enjoyment are the critical dimensions of AISA. It has a more significant impact on quality service (claim processing) to the rural population. It improves the economic and market performance among the insurance companies and the rural population.Originality/valueCustomers need convenience when making claims. Even little challenges might lead to stress and unhappiness, depending on the situation. Restrictions on where customers can file claims may not be the most outstanding service insurance firms can offer, given rising travel and commuting costs and widening geographical borders. Customers value proactive communication from service providers about the status of their insurance claims.

Application of Enterprise Architecture in Digital Transformation of Insurance Companies

Implementation of enterprise architecture is a major requirement for companies that want to develop business processes according to their needs. Business architecture is the company's initial plan to support the company's operations. An insurance company is a company that provides insurance services. Insurance is a form of contract in which the guaranteed party pays a premium to the insurance company. Insurance companies provide payment guarantees in the event of certain risks that are guaranteed in the insurance contract. Therefore, this company must think about operational forms to provide the best service for its customers. Structuring business processes starting from the sales process, administrative processes, claims processes, to financial processes which are the most vital processes. Insurance companies are different from other financial services companies, such as banking companies, fintech companies and others. The insurance company's unique process is to provide guarantees to its customers in carrying out risk protection. Before starting to implement enterprise architecture, the company already has a business architecture blueprint which is the enterprise architecture of a company. The design begins with running architectural business processes, architectural applications, architectural databases and architectural technology. Enterprise architecture implementation certainly cannot be separated from project management. Because project management is a process that manages the project so that the project becomes more organized in its implementation

CLAIMS MANAGEMENT PRACTICES AND FIRM PROFITABILITY OF LISTED INSURANCE COMPANIES IN NIGERIA

The insurance sector provides financial protection for policyholders by pooling and investing premiums from which those who experience unforeseen losses are compensated. As a result, an efficient and timely claims settlement by insurance companies has been identified as a measure with the potential to boost the industry's growth and profitability. However, many insurance companies struggle to consistently improve their claims operations due to a poor claims process and unrecognized claims department staff, which Chief executive officers hinder their performance. This study examined the effect of Claim management practices and firm profitability of listed insurance companies in Nigeria. Survey research design was adopted. The target population of the study are the full-time top management employees of the listed insurance companies in Nigeria with a total population of 2183. Sample size of 776 was determined using Kerjcie and Morgan (1970). Proportionate stratified sampling technique was adopted. A validated questionnaire was used to collect data. Cronbach’s alpha reliability coefficients for the constructs ranged from 0.772 to 0.857. The response rate was 86.5%. Data were statistically analysed using descriptive and inferential statistics. Findings revealed that claims management practices have significant effect on profitability of the selected insurance companies in Lagos State Nigeria (Adj.R2 = 0.840; F (5, 655) = 695.900, p<0.05). 17.928, p < 0.05). The study concluded that Claims management practices dimensions have significant effect on firm profitability of listed insurance companies in Lagos State, Nigeria. The management of insurance companies in Nigeria should develop a policy to link claims management ancillaries and departments in order to make the sector profitable and sustainable in the long run. Such a policy would be the anchor of actions adopted by or proposed by the firms in matters pertaining to market dominance.

Vehicle Insurance Damage Detection

Abstract: These days every process we see has been automated. The Use of Artificial Intelligence and Machine Learning have been adopted by many people and businesses all around the world. One of the adoption is in the sector of vehicles, wherein it can identify the parts that have been damaged of a vehicle with the use of the widespread technologies that are present. The Machine can do many things like predict the repair the damage needs and the cost estimation for the damage. All of this is possible due to the Annotation of Images/Videos of the vehicles that have been damaged and building Computer Vision ML Models. The ML models does everything from detecting, predicting the amount of damage occurred and the cost required to repair it. With the help of these data Insurance Companies can be benefitted by eliminating the scope of fraud in claims processing.

B-SAHIC: A blockchain based secured and automated health insurance claim processing system

In recent years, blockchain technology has been successfully used in many distributed environments where different stakeholders, who do not have any trust between them, interact with each other through a secured and transparent platform. The use of blockchain in healthcare insurance industry has not been studied methodically. In this study, we develop a blockchain based Secured and Automated Health Insurance Claim (B-SAHIC) processing system. First, we design an Entity-Relationship (ER) diagram identifying all actors with their respective data and relations between them. We also develop the business model and algorithms for all necessary steps. We implement the system in Hyperledger Fabric and deploy a smart contract to implement these algorithms. We introduce CouchDB to store the OffChain data where we store World-State Database. B-SAHIC provides a web-based portal for all actors who interact with the blockchain. Privacy of clients’ claim-related data is ensured by encrypting treatment-related data with a new key that is derived uniquely for each new submission done of clients’ personal documents. We have also deployed Hyperledger Explorer, a user-friendly web application tool for monitoring the health state of each node participating on the blockchain network. We have studied the performance of B-SAHIC for two to six peer nodes. Moreover, our performance study shows that B-SAHIC is fast and scalable. In our study, the average query latency is decreased from 0.07 second (for two peer nodes) to 0.02 second (for six peer nodes) in case of 1300 queries per second while the average transaction latency remains unchanged (around 3.5 seconds) for 300 transactions per second. Moreover, B-SAHIC consumes minimum resources, around 350MB only for two peer nodes. We believe that the development process of this blockchain based platform can be applicable for the automation of other insurance industry too.

Figures fighting figures – unpacking state authority's mis/trust in PISA statistics

ABSTRACT How can we understand the uncertainties in high-stake measures such as PISA in relation to the claims that different authorities make from them? In this paper, we use a rather remarkable case from Sweden involving conflicting interpretations of the PISA 2018 results at a national political level and a fight over statistics between two national agencies: National Agency for Education and the National Audit Office. The aim of this paper is to unpack processes of interpretations and claims that are often black-boxed in PISA debates: How can we understand the process that led up to the fight and what followed? Our data consist of media articles, broadcasts from the national television and radio (2018–2021), reports and memos from the two-state authorities involved in this debate, and email conversations between the two. Our results stress the need for further transparency in how PISA data are collected and calculated.

Tinjauan Maqashid Syariah terhadap Penyelesaian Klaim Produk Asuransi Jiwa Brilliance Hasanah Sejahtera di PT. Sun Life Financial Indonesia Cabang Medan


 This study aims to determine the process of resolving claims for the Brilliance Hasanah Sejahtera product and to review it from the Maqashid Syariah aspect. The type of research used is descriptive research with a qualitative approach, namely research that provides an overview of the situation being studied in the form of a narrative description. The conclusion of this study is that the settlement of Brilliance Hasanah Sejahtera life insurance claims is in accordance with the specified conception which consists of notification of claims, submission of claim files, investigation of claim files, and payment of claims. Then in the process of settlement of Brilliance Hasanah Sejahtera life insurance claims in terms of maqashid sharia aspects, PT Sun Life Financial Indonesia Medan branch has realized maqashid sharia in the aspects of hifzh ad-din (property protection) and social benefit. The forms of hifzh ad-din (property protection) in the settlement process for Brilliance Hasanah Sejahtera life insurance claims at PT Sun Life Financial Indonesia Medan branch are: the false. Second, the management of claim funds in the form of tabarru funds is issued with sharia values ​​and does not contain elements of usury. Third, the administration of fund claims can be quickly provided to customers because the investigation of claims submission is carried out in a fast, responsive and strict procedure so that handling feels safe for customers and the company. And fourth, claims for payment of funds are made by transferring to each customer's account, so there is no need to worry about fraud or elements of gharar. However, the hifzh ad-din (property protection) aspect in the claim settlement process cannot be separated from other aspects of maqashid sharia which include hifzh ad-din (religious protection), hifzh an-nafs (life protection), hifzh al-aql (protection of reason) and hifzh an-nasl (protection of offspring) because all aspects of maqashid sharia influence one another. In the realization of the benefit of the existing maqasyid sharia values, the level lies at the first level, namely dharuriyat.
 Keywords: Maqashid Syariah, Claims, Life Insurance, Brilliance Hasanah Sejahtera

Commentary: Blockchain technology and its current importance in toxic anterior segment syndrome outbreak in India.

Commentary: Blockchain technology and its current importance in toxic anterior segment syndrome outbreak in India.

A Legal Confiscation: The 1851 Land Act and the Transformation of Californios into Colonized Colonizers

In 1848, the US Senate ratified the Treaty of Guadalupe Hidalgo, which held that treaty citizens' land claims would be "inviolably respected." Three years later, the US Senate passed the 1851 Land Claims Act, which violated the treaty by requiring private Mexican land grant holders to prove the legitimacy of their claims to the US Land Commission. This article examines Anglo-American and Californio settlers' efforts to establish legitimate landholding practices according to their culturally specific racial logic. By tracing encounters between the commission and Californios, this article argues that through their participation in the land claims process, Californios became "colonized colonizers" and were instrumental to statemaking in California.

Penyelesaian Klaim Pada Asuransi Kendaraan Bermotor Melalui Badan Mediasi dan Arbitrase Asuransi Indonesia (BMAI)

Insurance or about liability is an agreement between two or more parties in which the insurer binds himself to the insured by accepting insurance premiums to provide compensation to be taken due to loss, damage or expected loss, or take the law to third parties who may suffer from events that are not absolutely covered by the insured, or provide a payment based on the death or life of someone who is covered (Article 1 sentence (1) of Law No. 1992). In a motor vehicle insurance agreement, it is not closed to the possibility of disputes, these disputes are usually within the period of claims caused by the insured and the insurer. One way to resolve the dispute is through the Indonesian Insurance Mediation Warm Up (BMAI). The Indonesian Insurance Mediation Agency (BMAI) is an independent body that has independent mediators assigned to conduct insurance claim disputes resolved between the insured and the underwriter. An insurance claim dispute is a dispute between the insured and the insurer that respects one of the parties does not carry out the agreement that has been made with all due consideration or even because there is a party who defaults, to the detriment of one of the parties. The procedure for resolving motor vehicle insurance claim disputes goes through 2 stages, namely the mediation stage and the adjudication stage. If the dispute can best be resolved at the mediation stage then resolve the dispute, otherwise if the dispute cannot be resolved at the mediation stage then the settlement is drawn to the adjudication stage. Not all claim disputes can be resolved through the Indonesian Insurance Agency Mediation (BMAI) because there are conditions that must be met by the insured. Even though the conditions have been met, it does not rule out the possibility that the dispute over the insurance claim process through Warms Up Indonesian Insurance Mediation (BMAI) will be constrained.