Lodge and pay a lump claim

A claimant has notified you that the life insured has died, or a life insured has suffered a claimable event such as trauma. You need to lodge the claim, gather supporting documents, assess the benefit, and pay out to the policy owner or beneficiary.

Lodge the claim

Open the policy and choose Create Claim from the Actions menu.
Set the Claim Contact from the following options: the life insured, the policy adviser, or other (any other person). If you select other, you can either look up an existing client in Simfuni or create a brand new client to hold their contact details.
Choose the event type and enter the event and notified dates.
Pick a claim reason, e.g. ‘Death due to overwork’. (The list of claim reasons can be customised to your requirements).
Leave the initial status as Notified and complete the wizard.

Note. Claim contact rules: For Death claims, the life insured cannot be the claim contact. Adviser can only be selected if the policy has an intermediary. If you choose Other, you must enter the relationship to the life insured.

On the policy selection step, each eligible policy has a link to view the policy version that was in force on the event date, opening in a new tab. If the policy was in force on that date but no policy version for that date is held in Simfuni (which can happen with migrated policies), a warning appears and the oldest in-force version is shown instead.

Tip. After lodging, the new claim is assigned a claim number using a configured prefix and a sequential number. Make a note of it: it's how the claim is searched and referenced from now on.

Track what you need

Open the new claim. The Requirements section already contains the default requirements for the riders on claim. You can add additional requirements from the configured library as needed.

When you receive the documents, mark off the corresponding requirements as Completed. You can also waive requirements if you determine they’re not needed.

Assess the benefit

Click Add Assessment.
In the Assessment Note field, capture a note explaining your reasoning.
Set the assessment outcome for each benefit: Accepted to accept; Ex-Gratia if you’re accepting outside the terms of the policy wording; Ineligible if the benefit will not be paid; leave as Pending if you’re not ready to assess this benefit yet.
For each benefit being accepted or accepted ex-gratia, check the payment amount is correct. The system will default the payment amount based on the configured rules, but there are cases where you may need to make a manual adjustment, e.g. to reduce a death benefit by the amount already paid out for an advance funeral benefit, or to deduct policy arrears.
Click Send for Review.

Important. If you try to Accept the death benefit while the death certificate is still Open, the system displays an error and won't let you save. Complete the requirement first.

Review the assessment

To review the assessment, you need a friend with Claims-Review permission (or a separate login for yourself as another user with Claims-Review permission). The Tasks Queue shows an Assessment review task. Open the claim, enter a review comment, and click Approve. The case status moves to Pending Payment Approval and a payment is created.

Note The assessor and reviewer have to be different people. The system enforces this and disables the Approve/Reject buttons for the assessor on their own assessment.

When the reviewer approves, the new payment is given an initial status that reflects what still needs to happen before it can be paid:

Initial payment status	When the system uses it
Awaiting Reinsurance Recovery	At least one accepted benefit is configured as needing a reinsurance recovery to be receipted first.
Awaiting Payment Details	Payee bank account details haven't been captured yet.
Pending	Payee details are in place, and reinsurance recovery is either receipted or not needed at this stage. Ready for Finance approval.

Add payment details and approve

If the policy has beneficiaries set up for the life insured, the Payees section is pre-populated with the beneficiary names and their percentage shares. Bank account details still need to be captured. If there are no beneficiaries, the Payees section starts empty.

On the claim sidebar, open Edit Payees. The beneficiary names should appear automatically if the policy has them.
Add the bank account details for each payee.
Open the Financials tab. The payment should now be in Pending status.
As a Finance user, open the Outgoing Payments screen, find the claim payment, and approve it.
Repeat with a second Finance user. After the second approval, the payment moves to Approved.

What you should see at the end: the case status is Closed, the claim outcome is Accepted, and the Financials tab shows the payment with a Paid status. The life insured's record shows the Deceased tag.