A mid-sized insurance company in Brazil receives hundreds of loss notices per month. Each notice triggers a chain of activities: registration, triage, inspection, document analysis, decision, and payment. The process involves brokers, adjusters, regulators, legal and finance teams — and must meet regulatory deadlines set by SUSEP (the Brazilian insurance regulator).
In practice, most claims operations still run on a combination of legacy systems, control spreadsheets, and email exchanges. The result: long cycles, missed SLAs, lost documents, and frustrated policyholders who cannot track the status of their claim.
This article describes the full claims management workflow in the Brazilian insurance market, identifies the most common bottlenecks, and shows how to structure operations for visibility, deadline compliance, and cost reduction.
The claims workflow: 6 stages
1. First Notice of Loss (FNOL)
The FNOL is the entry point. The policyholder — or the broker on their behalf — reports the occurrence. This notice may arrive by phone, email, the insurer's website form, or mobile app.
What needs to happen at this point:
- Record policyholder data, policy number, and event description
- Collect initial information: date, location, circumstances, third parties involved
- Generate a protocol with registration date and time
- Confirm receipt to the policyholder
The most common problem here is lack of standardization. When the notice arrives by email, essential data is missing. When it arrives by phone, the agent records information incompletely. The result: rework in the next stage.
2. Registration and triage
Once registered, the claim must be classified and routed. Triage defines:
- Insurance line: auto, homeowner, life, health, commercial
- Claim type: total loss, partial loss, theft, fire, third-party damage
- Coverage: preliminary check whether the event is covered by the policy
- Complexity: simple claims may follow an express track; complex claims require expert assessment
Triage also sets the case SLA. Brazilian regulation requires the insurer to conclude the adjustment within 30 days after receiving all required documentation. But in practice, the clock starts ticking in the policyholder's perception from the moment of the notice.
Poor triage leads to incorrect classifications, wrong routing, and rework that consumes days.
3. Inspection and expert assessment
For claims requiring on-site inspection — auto, homeowner, commercial — the insurer assigns an adjuster or inspection firm.
The adjuster must:
- Schedule the visit with the policyholder
- Conduct the inspection and document with photos and a technical report
- Assess the extent of damage and estimate the loss value
- Verify consistency between the policyholder's account and the evidence
This is often the biggest bottleneck. The adjuster's schedule depends on the policyholder's availability. The report takes days to finalize. Communication between the adjuster and the claims examiner happens via email, with no visibility for the operations manager.
In auto claims, for example, the vehicle may be in a storage lot accruing daily fees. Every day of inspection delay is additional cost for the insurer.
4. Document analysis
After the inspection, the claims examiner must gather and analyze all necessary documentation:
- Police report (theft, robbery, collision with third parties)
- Medical records (life, health, personal accident claims)
- Repair estimates (auto, homeowner)
- Invoices (proof of asset value)
- Personal documents of the policyholder and beneficiaries
- Active policy with endorsements and special conditions
The examiner checks document completeness, requests supplements from the policyholder or broker, and validates information consistency.
This stage is where the process stalls most. Documents arrive incomplete. The policyholder does not know exactly what to send. The examiner sends an email requesting supplementation, the policyholder is slow to respond, the deadline keeps passing.
Regulation requires the insurer to request all necessary documentation at once, clearly. Fragmented requests — asking for one document today and another next week — generate complaints and may result in sanctions.
5. Adjustment (decision)
With all documentation gathered and the inspection completed, the examiner analyzes the case and makes the decision:
- Full approval: claim covered, total value approved
- Partial approval: claim covered, but with deductible, depreciation, or exclusions applied
- Denial: claim not covered by the policy, with technical and legal basis
- Negotiation: cases where there is a value dispute and the parties need to negotiate
The decision must be substantiated, documented, and communicated clearly to the policyholder. In case of denial, the insurer must inform the reasons and the right to appeal.
Poorly substantiated decisions generate complaints to the regulator, consumer protection lawsuits, and court cases. A well-structured operation ensures that every decision has full traceability: who decided, based on which documents, on which date.
6. Payment and indemnification
Once the claim is approved, the insurer must make payment within the regulatory deadline. This involves:
- Final value calculation (insured amount minus deductible, depreciation, salvage)
- Verification of the beneficiary's bank details
- Payment order issuance
- Confirmation of receipt
For total loss auto claims, it also includes salvage transfer and document regularization. For life claims, it involves beneficiary verification and death or disability documentation.
Bottlenecks that slow operations
Excessively long cycles
Average adjustment time in the Brazilian market ranges from 20 to 45 days depending on the line. But many claims take 60, 90, or more days. Every extra day is operational cost, policyholder dissatisfaction, and regulatory risk.
Regulatory SLA violations
The regulator monitors insurers' average adjustment times. Systematic violations result in fines, warnings, and reputational impact.
Scattered documents
Reports in the adjuster's email. Police report in the broker's folder. Repair estimate on the examiner's WhatsApp. Policy in the legacy system. When someone needs to reconstruct a claim's history — for an audit, a complaint, or a lawsuit — they spend hours gathering pieces.
No visibility for the policyholder
The policyholder calls the broker asking for updates. The broker calls the insurer. The insurer checks with the examiner. No one has an updated answer in real time.
This lack of transparency is the top source of complaints in the sector. The policyholder does not care about internal complexity. They want to know: is my claim being handled? When will I get paid?
How to structure operations with orchestration
The problem is not that people do not know what to do. It is that the process has no visible structure. When you treat each claim as an orchestrated case, with defined stages, clear owners, and monitored deadlines, bottlenecks surface before they become problems.
Each claim is a case
A claim opens a case. That case has a number, an owner, a current stage, and a timeline that records every event from start to finish.
The case carries all information: policyholder data, policy number, claim type, estimated value, attached documents, decisions made. All in one place.
Stages with SLA
Each workflow stage — FNOL, Triage, Inspection, Document Analysis, Adjustment, Payment — has a defined deadline. When the deadline approaches, the system notifies the responsible person. When it breaches, the manager receives an alert.
This enables proactive management. Instead of discovering that a claim has been stuck for 20 days when the policyholder complains, the manager sees in real time which cases are at risk.
External portal for the policyholder
The policyholder accesses a portal where they track the claim status, submit documents, and receive notifications of each stage change.
This eliminates the cycle of unproductive calls. The policyholder does not need to call to ask. The broker does not need to mediate. The insurer reduces call volume while improving the experience.
Structured collection forms
Instead of requesting documents by email — where each request generates a new message exchange — the examiner sends a form with required fields. The policyholder fills it in, attaches documents, and submits. The system validates completeness before accepting.
This solves the problem of fragmented requests and incomplete documentation.
Alerts and automations
Automatic rules notify the team when:
- A claim has been stuck in a stage beyond the SLA
- A required document has not been received
- An inspection was scheduled but no report was submitted
- The regulatory deadline is approaching
The team acts on exceptions, not on manual pending lists.
Complete timeline for auditing
Every action on the claim — opening, classification, document submission, inspection scheduling, decision, payment — is recorded in the timeline with date, time, and responsible person.
In case of internal audit, regulatory inspection, or lawsuit, the insurer has the complete case history without needing to reconstruct it from emails.
Metrics that matter
With a structured process, the claims operation generates reliable data:
- Average adjustment time by line and claim type
- SLA compliance rate by stage
- Average policyholder response time for document delivery
- Denial rate and most frequent reasons
- Claim volume by stage (bottleneck identification)
- Operational cost per claim
These metrics guide decisions: where to hire more people, which stages to automate, which lines generate the most rework.
CaseFy for claims operations
CaseFy offers a claims management template designed for the Brazilian insurance market:
- Pre-configured stages: FNOL, Triage, Inspection, Document Analysis, Adjustment, Payment
- Specific fields: policy number, line, claim type, estimated value, deductible, approved value
- SLA per stage: configurable deadlines with automatic alerts
- Policyholder portal: real-time tracking, document submission, notifications
- Collection forms: structured documentation requests with completeness validation
- Auditable timeline: complete record of every action for regulatory compliance
- Automations: SLA notifications, pending documentation alerts, escalations
Claims operations do not need more spreadsheets or more status meetings. They need a visible, traceable, and measurable process.