Using DigitalOwl Identifies Misrepresentation in the Claim Process.
A 62-year-old female, working as a travel agency manager, submitted a slip-and-fall accident claim. While she was going down the stairs, she slipped and injured her back. She had an accident policy that would pay a lump sum benefit up to $500K for any disability caused by an accident.
The insurance company’s physician and claim analyst reviewed the claim as well as the insured’s entire medical record. The internal recommendation was to accept the claim for 30% disability due to fractures and kyphosis and pay the insured $150,000. Appropriately, the head of claims reviewed the case using the DigitalOwl system before signing off on the claim. The system identified evidence that the insured had suffered from kyphosis before the accident (a pre-existing condition) but she had withheld that information from the insurance company.
Using the DigitalOwl system, in this case, saved the insurance company from paying a fraudulent claim of $150,000.