Functional requirements of Insurance Claim Management System with non-functional

Functional Requirements

1. User Management
   • 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.
2. Policy Management
   • Policy Information: Store and manage details of insurance policies, including policy numbers, coverage details, and terms.
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   • Policy Verification: Verify policy details during the claims process to ensure coverage and validity.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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

1. 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.
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2. 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.
3. 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.
4. 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).
5. 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.
6. 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.
7. Portability
   • Cross-Platform Compatibility: Ensure the system is compatible with various devices and operating systems, including desktops, tablets, and mobile devices.
8. 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.