Name

ID
Actor

Precondition
Tasks

Post condition

Extension(extends)

Data Input
Business rules
Non functional requirements

Name
ID
Actor

Precondition
Tasks

Post condition

Extension(extends)

Data Input
Business rules
Non functional requirements
Approval of claim by insurance clerk
UC-002
Insurance Clerk
Customer has filled the form, customer has submitted the filled form, insurance clerk has logged in into the system, The
insurance claim is in the insurance clerk's tray
1.Clerk opens the claim display by the system
2.Compares the claim details of claim against the details provided in the rule book for claim in the portal.
3.Approves the claim

4.System routes the claim to the inhouse doctor team

System successfully routes the claim to the inhouse doctor department
3a.
1. Invalid claim, claim gets rejected

2. System sents a notification to the customer "Your claim has been rejected due to invalid details."
Rule book provided by insurance company
claim should be approved withing 24hrs of the submission of the claim by customer
Response time - 1 sec, available 7 X24X365 days

Approval of claim by in house doctors team

UC-003
Inhouse doctor team
1.Claim has to be approved by insurance clerk.
2.Claim is in the in house doctors' tray
1.In house doctors team opens the claim displayed by the system
2.Verifies the claim details such as the amount of claim, authenticity of the reason mentioned, date of admittance,
authenticity of signature of concerned authorities against the rule book provided in the system.
3. opens the medical records provided by customer as attachments

4.Verifies the medical records provided by the customer as attachments against the rule book provided in the system.
3.Approves the claim
4.System routes the claim to the manager
System successfully routes the claim to the manager's system.
3a.
1. Invalid claim, claim gets rejected
2. System sents a notification to the customer "Your claim has been rejected due to invalid details."
4a . 1. Inappropirate medical records, doctor responsible for claim approval form insurance agency calls/mails the hospital
for clarificaion of the clarification.

2.Hospital gives clarification.

Rule book provided by insurance agency
Claim should be approved withing 48hrs of the submission of the claim
Response time - 1 sec, available 7 X24X365 days