What a financial audit of a claims application actually inspects

When an insurer asks for a financial audit of claims applications, the request is often framed as a process review. That is the wrong unit. The unit is the application sitting in the file: the form, the computation, the invoices, the discharge, and the payment.

We start with the figure the handler proposes to pay. Then we work backwards. Does the policy respond to that head of loss? Do the invoices add up to that figure? Has the excess been taken? Is betterment due on a replacement part? Has another insurer already contributed?

Handler comments and system timestamps help us understand sequence. They do not replace the papers. A status of “approved” without a worksheet is a finding, not comfort.

The audit opinion, such as it is in this kind of work, is therefore modest and useful: for the sample examined, these applications support the amounts paid, these do not, and these cannot be concluded. That is enough for a claims manager to act.

Discuss a batch of files