by Vishal Chawla

ICICI Lombard GIC embeds AI for cashless hospital claims

Sep 30, 20183 mins
Artificial IntelligenceBudgetingBusiness

As the cognitive AI engine is trained to reproduce a doctor's judgment, the platform helped ICICI Lombard GIC to optimize services, accelerate processes, and make better decisions.

In a fast-changing environment, ICICI Lombard General Insurance Company is able to keep pace with the evolving market and consumer dynamics by embracing and embedding innovation that revolves around the customers and their needs. 

Leveraging a cognitive AI platform
ICICI Lombard has implemented a cognitive platform using various computing layer where its systems do the admissibility and adjudication of the cashless health claims. Artificial intelligence and machine learning helped achieve this objective. The conventional approach to claims management based on an inflexible rule book has been made obsolete by intelligent algorithms that learn from historical cases and continuously evolve. Such engine systematically identifies and correct errors while avoiding unnecessary or ineffective interventions. 

ICICI Lombard GIC manages around 11000 to 18000 cashless claims in a month, and traditionally offered four hours of response time to issue authorization letters to each customer. Earlier cashless approvals were traditional in nature, wherein doctors go through the documentation submitted by hospital and checks the policy terms and conditions. Based upon these factors, doctors approved/rejected the claim request. This process was manual in nature, very cumbersome and consumed a lot of time. Due to delay in the approval process, patients had to wait for hours in the hospitals for the treatment to begin. 

Reducing time to seek medical treatment
Currently, for each case, the AI engine produces its recommendation on admissibility almost instantaneously, including an initial approval amount for the patient for the treatment. This reduces the wait time for the patient and their family members, and lets them start their medical procedures almost immediately. 

“The solution is designed keeping in mind medical emergencies. For policy holders, this would mean instant cashless processing of their request; thereby ensuring that they avail immediate treatment that is so important in case of medical exigencies. This solution will make claims processing faster, consistent and convenient for our customers, significantly enhancing their claim experience,” states Sanjeev Mantri, Executive Director at ICICI Lombard General Insurance Company. 

“Embedding artificial intelligence in the process of hospital claims management offers multiple benefits at once, not just for insurers but also for patients, given the saving potential. In short, the shift away from claims management based on rigid rule books in favor of smart algorithms leads to greater efficiency and more legitimate and contextual decisions—thus relieving the burden on all stakeholders and delivering better experience to customers when it is needed the most,” according to Goutam Datta, VP-Technology at ICICI Lombard General Insurance Company. 

Benefits gained with the initiative

The cognitive system not only simplifies and accelerates the overall claims management procedure, it also enhances its quality. As the cognitive AI engine is trained to reproduce a doctor’s judgment, the platform helped ICICI Lombard to optimize services, accelerate processes, and make better decisions. Thus, additional costs for redundant audit and rejection processes are eliminated. As a result, the system frees up capacity among administration staff, doctors and auditors, so that they can correctly pinpoint reduction potential and properly prepare intervention cases—thus further increasing prospects of success of claim management system. 

“We are able to maintain sustained leadership in redefining the business models by embedding the principles of innovation across all aspects of the enterprise – products, services, technology, infrastructure and people. Further, in tandem with the emergence of a hyper-connected world, we are able to fulfill customer expectations of positive and seamless experience at every touch point,” says Datta.