Author
Bowtie Team
Updated on
2025-05-28
Disclaimer: This article is translated with the assistance of AI.
A claim adjuster handles insurance claims for companies and clients. What is the approval criteria according to Bowtie’s claim adjusters? Read to understand their job scope and factors in approving claims.
What Do Claims Adjusters Do in Insurance?
Claims adjusters play a crucial role in insurance companies, handling claim matters.
To ensure that Claims applications are processed fairly and to prevent fraudulent cases, claims adjusters must review the details and terms of various insurance products, legal provisions and amendments, and clients’ medical documents. Upon receiving a claim application, they collect relevant information from institutions such as hospitals, doctors, police stations, government departments, and courts.
Once all relevant information is gathered, they can determine if the claim is justified and assess the compensation amount. The types of claims they handle are diverse, depending on the products offered by the insurance company, covering areas like life, auto, medical, and property insurance.
Requirements and Qualifications for Claims Adjusters
To become a claims adjuster, continuous learning is essential to understand the operations of different industries and relevant laws. Due to the volume of documents involved, including policy terms, medical reports, and legal documents, they must work with a serious, cautious, and impartial attitude to ensure policyholders are treated fairly. Traits like detail-oriented, actively learning, and being open to new experiences are valued.
Does Bowtie Have Claims Adjusters?
As a virtual insurance company, Bowtie processes all claims online. However, due to the extensive document analysis required, Bowtie also employs claims adjusters to ensure customers receive fair and policy-compliant coverage.
Insurance Insights From Bowtie Claims Adjusters
1. What Are the Criteria for Approving Claims?
The criteria for approving claims are objective. Claims adjusters assess based on the policy terms, coverage, limits, and the client’s actual situation to decide if the claim is successful and the compensation amount.
For example, at Bowtie, adjusters consider the client’s health status, medical reports from doctors, the product they insured, and the coverage limits when processing claims.
2. Are There Cases of Claim Denials?
Over the past 2 years, Bowtie has successfully handled numerous Claims cases, with a payout ratio as high as 98.3%*. Of course, among these cases, there are instances where claims were not compensated. The reasons for denials are as follows, explained through real examples.
- In most cases, VHIS only covers hospitalization expenses, but a client applied for outpatient medical services, which fell outside the coverage and was not compensated.
- A client who knew they had hemorrhoids before purchasing insurance did not disclose the record. Bowtie discovered this through medical files during the claim process, leading to a policy requalification (where the insurer requalifies based on undeclared conditions at the time of purchase). As a result, “hemorrhoid-related expenses and conditions” were added as exclusions. Since the claim treatment related to an excluded item, it was not compensated.
Therefore, before purchasing insurance, remember to declare existing health conditions , arrange appropriate coverage, and choose suitable medical services to avoid unexpected costs from treatments.
- * The above represents the average approval rate for claims cases for Bowtie’s VHIS ‘Standard Plan’, ‘Flexi – Regular’, ‘Flexi Plan – Plus’, and Bowtie Pink as of February 2025.
Differences In Claims Handlers Between Bowtie and Traditional Insurance Companies
In traditional insurance companies, customers facing Claims issues can only contact agents/brokers or customer service representatives, who then relay opinions and questions to the claims handler. The claims handler also needs to go through customer service representatives to request any missing documents and information from the customer.
Bowtie claims handlers often communicate directly with customers, directly assisting them in resolving claims issues, allowing customers to get more direct responses, making the process more convenient and faster.
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