ClaimSetu: An AI-Powered Solution for Group Health Insurance Claims
Policybazaar for Business (PBFB) has introduced ClaimSetu, an AI-driven platform that simplifies and speeds up Group Health Insurance (GHI) reimbursement claims. By integrating Artificial Intelligence (AI), Natural Language Processing (NLP), and Optical Character Recognition (OCR), ClaimSetu automates document processing, offers real-time updates, and reduces errors, potentially cutting claim processing time by up to 50%.
Overview
As the corporate division of one of India’s largest online insurance platforms, PBFB has supported claims for millions of employees. ClaimSetu takes this further by providing quantitative scoring, including claim insights and approval probabilities, helping users understand how their claims are expected to be processed. This adds transparency and confidence to a process often marked by uncertainty.
Features of ClaimSetu
ClaimSetu streamlines GHI reimbursement claims, traditionally slowed by missing paperwork and lack of timely updates. It supports employees, HR teams, insurers, and Third Party Administrators (TPAs) by speeding up claims by up to 50%, minimizing errors, and enhancing visibility throughout the claim lifecycle.
The platform automates the entire claim journey—from document submission to final approval—using AI, NLP, and OCR technologies. This transformation brings speed and clarity to an otherwise manual and opaque process.
Leadership Perspective
Sajja Praveen Chowdary, Director of Policybazaar for Business, states, “Reimbursement claims remain one of the tedious processes of group health insurance. With ClaimSetu, we are tackling the areas where friction is highest, removing ambiguity and empowering users with real-time updates.”
He adds, “This is more than automation; it’s about delivering clarity and trust at the most critical moment of the insurance experience.”
Addressing India-Specific Challenges
ClaimSetu is developed in India specifically for Indian enterprises, addressing unique operational and infrastructural challenges within the country’s corporate health insurance sector. It’s India’s first homegrown AI-led claims engine in the B2B insurance space, supporting the national vision for technology-driven transformation.
Currently, many GHI claims require multiple email exchanges and back-and-forth with TPAs or insurers. ClaimSetu replaces this with AI-powered document verification, automated validation, instant alerts, and live tracking via WhatsApp, reducing delays and increasing transparency.
Document Processing and Fraud Detection
The platform automatically identifies and extracts key information from documents such as bills, prescriptions, and discharge summaries using AI classification techniques. It flags inconsistencies against policy terms and can detect potential fraud, easing administrative tasks for HR teams and insurers.
Claims can be submitted through familiar channels including mobile apps, email, or WhatsApp. Real-time alerts notify claimants about missing or invalid documents, preventing delays from the outset.
Key Functionalities
- Automates reading of claim forms, hospital and pharmacy bills, prescriptions, discharge summaries, and other documents.
- Flags missing or incorrect documents instantly to avoid processing delays.
- Provides employees with detailed claim insights and approval estimates based on extensive historical claims data.
- Intelligent claim routing assigns cases to appropriate teams depending on document completeness, claim complexity, and required assistance.
Security and Future Readiness
ClaimSetu complies with strict data protection standards, ensuring enterprise-level security. It integrates smoothly with Customer Relationship Management (CRM) systems, insurer backend platforms, and HR tools.
While currently focused on GHI reimbursement workflows in its beta phase, ClaimSetu’s modular design allows expansion into Outpatient Department (OPD) claims and other insurance categories. This adaptability positions it as a future-ready solution for diverse insurance operations.
By removing manual work, shortening turnaround times, and improving the overall claims experience, ClaimSetu sets a new standard for enterprise claims management in India’s evolving corporate environment.
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