Registration and Authentication: Allow users (policyholders, claims adjusters, insurance agents) to register, log in, and manage their profiles securely.
Role-Based Access Control: Define roles with specific permissions (e.g., policyholders, adjusters, administrators) and enforce access control.
Policy Management
Policy Information: Store and manage details of insurance policies, including policy numbers, coverage details, and terms.
Policy Verification: Verify policy details during the claims process to ensure coverage and validity.
Claim Submission
Claim Filing: Enable policyholders to submit claims online, including providing necessary documentation and details of the incident.
Document Upload: Allow users to upload required documents such as photographs, repair estimates, and police reports.
Claim Validation: Validate submitted claims to ensure completeness and compliance with policy terms.
Claims Processing
Claim Assessment: Evaluate claims based on submitted information and policy details. This may include assigning claims to adjusters for further investigation.
Adjuster Review: Provide tools for claims adjusters to review, assess, and document claims, including inspections and evaluations.
Fraud Detection: Implement mechanisms to detect and flag potential fraudulent claims.
Claim Decision and Settlement
Decision Making: Allow for decisions to be made on claims, such as approval, denial, or requests for additional information.
Settlement Calculation: Calculate the settlement amount based on policy coverage, deductibles, and other factors.
Payment Processing: Process payments for approved claims, including direct deposit or checks.
Communication and Notifications
Status Updates: Provide real-time updates on claim status to policyholders and adjusters.
Notifications: Send automated notifications for key events such as claim submission, status changes, and payment processing.
Reporting and Analytics
Claims Reports: Generate reports on claim metrics, including processing times, approval rates, and settlement amounts.
Performance Metrics: Track and analyze performance metrics for claims processing and adjuster efficiency.
Integration
Insurance Systems Integration: Integrate with other insurance systems, such as policy management and customer relationship management (CRM) systems.
Document Management: Integrate with document management systems for efficient handling and storage of claim-related documents.
Payment Systems: Integrate with payment gateways for processing claim payments.
Compliance and Security
Regulatory Compliance: Ensure compliance with insurance regulations and data protection laws (e.g., GDPR, HIPAA).
Data Security: Implement robust security measures to protect sensitive information, including encryption and secure access controls.
User Self-Service
Claim Tracking: Allow policyholders to track the status of their claims and view historical claims information.
Document Management: Enable users to manage their documents related to claims, including uploading, viewing, and downloading.
Non-Functional Requirements
Performance
Response Time: Ensure quick response times for claim submissions, status updates, and document retrieval (e.g., under 2 seconds for most operations).
Scalability: The system should handle increasing numbers of claims, users, and documents without performance issues.
Reliability
Uptime: Ensure high system availability with minimal downtime (e.g., 99.9% uptime).
Error Handling: Implement robust error handling and recovery mechanisms to manage system failures gracefully and maintain data integrity.
Security
Data Protection: Protect sensitive claim and personal data through encryption and secure storage.
Authentication and Authorization: Use secure authentication methods and enforce role-based access control to protect system access.
Compliance: Follow relevant standards and regulations for data protection and privacy.
Usability
User Interface: Design an intuitive and user-friendly interface for policyholders, adjusters, and administrators.
Accessibility: Ensure the system is accessible to users with disabilities, following accessibility standards (e.g., WCAG).
Maintainability
Code Quality: Write high-quality, well-documented code to facilitate maintenance and updates.
Documentation: Provide comprehensive documentation for users and administrators, including user guides and technical manuals.
Availability
Backup and Recovery: Implement regular data backups and establish procedures for data recovery in case of system failures.
Failover: Ensure the system has failover capabilities to switch to backup systems or servers if necessary.
Portability
Cross-Platform Compatibility: Ensure the system is compatible with various devices and operating systems, including desktops, tablets, and mobile devices.
Supportability
Technical Support: Provide mechanisms for users to obtain support and resolve issues, including help desks and online resources.
Error Reporting: Include functionality for users to report issues or bugs and track their resolution.
