Claim CLM-2024-001057

Claim CLM-2024-001057
12/60

Key Facts

LOB:HOME
Loss Type:Storm Damage - Roof
Outcome:Denied
Amount:GBP 38,490
Risk Score:23 (low)
Date of Loss:2024-11-22
Settlement:GBP 38,490

Timeline

2024-11-22Incident occurred
2024-11-23Claim reported
2024-11-29Assessment completed
2024-11-30Decision made
2024-12-04Claim closed

Analysis

NEEDS REVIEW
8 FAIL2 WARN16 PASS
FAILS1Duplicate Payments / Near-Duplicates
FAILS2Claim Timeline Coherence
FAILS2First Contact Timeliness

Inspections

28 inspections
Summary
FileDocument Quality / OCR RiskFAILS392%OCR failed on key document2
FileClaim Timeline CoherenceFAILS289%Payment dated before loss3
CommsFirst Contact TimelinessFAILS281%SLA breached3
CommsTimely and Reasonable InvestigationFAILS272%Investigation delayed 6 weeks3
CashVulnerability ConsideredFAILS285%No tailored support2
FinanceLarge Reserves/Payments Have Approval TrailFAILS285%15k payment without approval2
FinanceDuplicate Payments / Near-DuplicatesFAILS177%Duplicate detected2
FinanceClosed Claim with Open Reserves / Open TasksFAILS273%Claim closed with 5k open reserve2
CoverageSettlement Method Consistent with IndemnityWARNS281%Could be clearer1
InvestGradual Damage Decisions Supported by ProofWARNS279%Review recommended2
FileRequired Evidence Present (by Peril/Archetype)INCS239%Insufficient evidence to determine1
FileContents Itemisation CompletenessINCS243%Insufficient evidence to determine2
FileStructured vs Narrative Mismatch (Loss Type/Cause/Pathway)PASSS291%Loss type coding matches narrative1
CoverageExclusion Invoked Without Evidence PackPASSS184%Expert report confirms2
CoverageStorm Claim Definition/Conditions AppliedPASSS183%Weather evidence present1
InvestInvestigation Thoroughness RecordedPASSS274%Investigation thoroughly documented1
CommsNo-Update Gaps (Silence Periods)PASSS294%No communication gaps2
CommsDecline/Partial Settlement Explanation QualityPASSS277%Policy terms linked to outcome2
RepairRepair Route Scope/Completion EvidencePASSS278%Evidence captured1
RepairRepair Quality Risk (Rework Loop)PASSS279%No rework detected1
RepairOutsourced Handling Oversight PresentPASSS275%QA checks recorded1
CashCash Settlement Offered with Documented RationalePASSS274%Cash settlement rationale documented2
CashCash Settlement Oversight & Monitoring PresentPASSS292%Cash settlement controls present1
FinanceReserve/Exposure Structure PresentPASSS276%All cost areas covered2
FinancePayment Without Supporting DocumentPASSS284%Invoices linked2
RecoveryThird Party Involvement but No Recovery ReservePASSS189%Subrogation setup2
RecoveryRecovery Reserve Exists but No Action EvidencePASSS274%Progress evidenced1
RecoveryRecovery Received Without Matching ExpectationPASSS293%Recovery reconciled1
Evidence

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