Accident, hospital and critical illness claims
How do we pay an accident, hospital indemnity or critical illness claim from the member's own report with the diagnosis or accident proof and the claim form collected once, and the claim paid or referred?
Make the claim a short, complete screen with the proof attached. Callvu identifies the member and prefills the certificate and the benefits (the covered events, the benefit amounts by event, the waiting period, the pre-existing condition clause), takes the member's report of the event on their phone with only the questions the benefit needs, requests the proof the event requires (an accident report or an emergency room record, a hospital admission record with dates, a physician's diagnosis statement or pathology report for a critical illness) through a link with the authorization where one is needed, reads and checks it against the benefit schedule, pays a claim within the rules by rule within the state's prompt pay period, routes a claim outside them to the claims examiner in the Decision Desk, and writes the claim and the payment to the claims system. Live at an insurance customer.
Live at an insurance customerSimpleCallvu moves: chase and verify, decide, write back
Last updated November 7, 2026.
The problem today
A hospital indemnity claim worth a few hundred dollars took the member three forms, two faxes and a month.
Supplemental benefits pay fixed amounts for defined events: an emergency room visit, a hospital admission, a fracture, a cancer diagnosis. The amounts are modest and the volume is high, but the claim process was designed for large claims: a paper form, a physician's statement on the insurer's form, a fax number. Members give up on the small ones, which is bad for the product, or complain about the slow ones, which is bad for the regulator's view.
The benefit schedule defines the events and the proof: a hospital admission needs the admission and discharge dates on a hospital record; a critical illness needs the diagnosis by a physician with the pathology or the test the policy names; an accident needs the date, the cause and the treatment record. The state's prompt pay rules set the period for payment after proof. The claim is a match between the proof and the schedule, which a rule can make.
A claim the member can file in five minutes with a photo of the record is a product that works.
How it runs
From the requestto the system of record.
A member reports an accident, a hospital stay or a diagnosis in the app, on the website, by phone or through an AI assistant. Callvu identifies them and opens the claim.
- Member
- Reports the event, uploads the proof and signs the claim form and any authorization on their phone.
- Provider
- Returns the diagnosis statement or the record through its link where the member cannot supply it.
- Claims examiner
- Decides claims outside the rules in the Decision Desk.
- Callvu
- Prefills the benefits, takes the report, chases the proof, checks it against the schedule, pays by rule, routes and writes.
Prefill and take the report
The certificate, the covered events and the benefit amounts, the waiting and pre-existing condition periods and the prior claims are prefilled; the member reports the event with only the questions the benefit needs (the date, the type of event, the facility, the dates of admission and discharge, the diagnosis), on their phone.
Chase and verify the proof
The proof the event requires under the schedule is requested: a photo of the emergency room or hospital record with the dates, the physician's diagnosis statement or the pathology or test report the policy names for the critical illness, the accident report or treatment record; a record only the provider holds is requested through the provider's link with the authorization; each is read on arrival and checked against the schedule (the event is a covered one, the dates fall after the waiting period and within the policy, the diagnosis meets the policy's definition, the admission length meets the benefit's terms).
Decide
A claim that matches the schedule within the rules (a benefit under the auto-adjudication limit, a covered event with proof, no pre-existing condition flag, no prior claim for the same event) is paid by rule; a claim above the limit, a diagnosis that needs clinical interpretation against the definition, a pre-existing condition question, a claim near the waiting period or a duplicate goes to the claims examiner in the Decision Desk with the proof and only the allowed outcomes (pay, pay a different benefit with the reason, request more proof, or deny with the reasons and the appeal rights).
Write back
The claim and the payment (by the member's chosen method) are written to the claims system within the state's prompt pay period, the member receives the explanation of the benefit paid and any denial with the rights, and a related benefit the event also triggers (a follow-up visit, a recovery benefit) is offered.
Where it ends: The member filed the claim from their phone with the proof attached once, the claim was matched to the schedule and paid by rule or decided by the examiner, and the claims system holds the claim and the payment inside the prompt pay period. The Decision Trace shows the schedule match and any decision; the Audit Trace shows the report, the proof and the payment with time.
Runtime enforcement
What is enforcedwhile the work runs.
The regulations preloaded in Callvu Studio and the bank's own policies, applied as steps that run, not lines in a binder. A step that breaks a rule does not run, so a completed run was compliant.
The handoff
Between the front doorand the back office.
The front door
The app, the website, a call or an AI assistant; the member reports and uploads on their phone.
The back office
The examiner decides only claims outside the rules; the rest pays from the record.
The Decision Desk
- A claim above the limit, a diagnosis needing interpretation, a pre-existing condition question, a waiting period edge or a duplicate goes to the claims examiner in the Decision Desk with the proof and only pay, pay a different benefit, request more proof, or deny with reasons and rights.
Proof
Live at an insurance customer.Published results only.
Each result is a published claim, with its code on agents.callvu.com, where its status, source and last verified date are kept.
Callvu requests missing documents from the right party on a clock, reads them on arrival (OCR) and checks each against what the case needs.
HND-04 · Self-asserted · verified 2026-11-02
When a person must decide, the case goes to the right reviewer in the Decision Desk, with only the allowed choices, and the run waits for the decision.
CAP-07 · Self-asserted · verified 2026-11-02
PHI masking is tested and live.
ENF-08 · Self-asserted · verified 2026-11-02
Questions
What buyers ask next,answered plainly.
What proof does the member need?
What the benefit schedule names for the event: a hospital record with the dates, a physician's diagnosis statement or the test the policy names, an accident or treatment record; uploaded as a photo or requested from the provider with the authorization.
Is anyone involved in paying a small claim?
No, within the rules: a covered event with proof under the auto-adjudication limit pays by rule within the prompt pay period; the examiner decides definitions, limits and flags.
What if the claim is denied?
The member receives the reasons and the appeal rights, and the appeal process starts on its clock.
Related processes
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