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Transforming the health insurance experience
AI in action at AIA

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Customer demands and expectations are increasing…
… and global volume and scale are growing.
The world of health insurance is changing.

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…is to feel supported through injury and illness. They need help to
get back on their feet as quickly as possible so they can get on with
their lives.
They expect a seamless, convenient and stress-free experience.
But what they’re getting is long-winded, heavy-handed paperwork.
Uncertainty. Frustration. Inconvenience.
What customers want…

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You can access your banking online in a matter of seconds.
You can buy products or services from the other side of the world.
You can watch your favourite movies or programmes at the touch
of a button.
But when it comes to making an insurance claim, it’s a
different world.
Imagine you’re a customer…

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Helping them get back on their feet after illness or injury is a crucial part of this.
Whatever claim they’re making, they’re already under stress and out of pocket.
Making a claim should be a positive, stress-free experience.
Which is why we’re working with markets across Asia to automate our claims
process for outpatient healthcare and improve our straight-through processing
(STP).
At AIA, we’re helping customers live healthier,
longer, better lives.

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Our objective: to develop an AI solution to automate the claims assessment for OPD cashless claims. Maximizing claims auto-adjudication, but minimizing claims leakage.
Claims
Incident
Digital Claims
Submission
By Provider through
Smart Claims system
CMIC
Claims Management
Platform
Document Review
Electronic Submission
vs
Billing Documents
Claims Adjudication
AI MODEL
Accept Claim
Above Threshold
>=0.64
Below Threshold
< 0.64
Decline
Claims maybe denied by the
Smart Claims System based on
policy status, ICD codes etc.
The customer is then required to
file a cash (non-digital) claim.
Coverage Eligibility
Medical Necessity
Customer Profile
Claim No. Claim Assessment Score
34595683 0.56
23566578 0.87
34676 0.21
Majority of claims were
subject to manual
assessment. Only a small
sample was subject to QC.
Claims Assessors
Review
Our game-changing Claims Automation Model

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In 2019, we processed 2.457 million claims with a STP rate of just 3%.
On average, customers were waiting up to three days for a response to their claim. Some
customers were waiting much longer.
With AI and machine learning, we’ve automated 41% of all claims and 80% of outpatient
claims approvals.
It’s transformed the claims experience.
Straight-through processing for outpatient healthcare increased from 3% to 41% during 2020,
with more improvements to come.
We expect the results at scale to be significant.
Our pilot market, Thailand, has already seen
staggering results.

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Transforming the claims experience in Thailand
The AI Solution has already contributed to increase the Claims E2E STP rate from 6% in 2019YE to ~41% in Dec 2020.
6%
39% 40% 41%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20
Thailand Claims STP Rate
Parallel Run
Full Production

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Data attributes for our AI model
Document
Review
Claims
Adjudication
Coverage Eligibility
• Diagnosis Code (ICD Codes)
• Historical amendments
• Providers
• Doctors
• Claim amount
• Historical claims amendments
• Accident Date
• Hospitalization Date
• Policy Exclusions
General, specific, diagnosis codes etc.
• Cause of Illness
Accident vs General
• Credit Limit
Max. benefit, claim frequency, incident date, location etc.
• Document submission date etc.
• Other (IPD claims)
Impairment code, contestable period, chronic illness, waiting period
• Diagnosis (ICD10 Codes)
• Injury type
• Claims history
Accepted claims, declined claims
(by diagnosis)
• Procedure Codes (IPD only)
OPD Cashless Claims IPD Cash + Cashless Claims
Medical Necessity Customer Profile
• Age
• Customer Segment
• Suspicious Activities
Claim frequency, declined claims,
further claim etc.
• Other (IPD only)
EarlyClaims
Policy
Status
• Policy Status
Premium paying, lapsed etc.
• Claims vs Premium Payment
Claims made during grace period, after lapse etc.
Working together with theThailand ClaimsTeam, we considered more than 580 data attributes for model development
to reflect the key claims assessment criteria.

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Customers with simple claims receive a much faster decision and get their
money quicker.
They can move on with their lives.
Customers with more complex claims get the personal attention of human
assessors.
The reassurance of expertise.
Our customers are at the heart of everything we do.

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The new process frees up the time of our busy claims assessors so they can
focus their expertise where it matters.
It’s transformed from a complicated people- and paper-intensive process
to a streamlined, simplified experience.
Customers are happier. Claims assessors are less stretched.The move
from paper to digital makes the world a better place.
It’s a win-win-win.

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The future is now.