[OR] [MLRE] [E3] [CBS] [2] [MD] Map Dependency

CBS-2 Claims Processing & Settlement

Introduction

In alignment with the principles articulated in the 2025 Discussion Paper on Operational Resilience issued by Bank Negara Malaysia, financial institutions are expected to identify and map the interconnections and interdependencies that support each Critical Business Service (CBS).

For Malaysian Life Reinsurance, CBS-2: Claims Processing & Settlement represents a time-critical service that directly impacts cedants, beneficiaries, regulators, and financial stability expectations.

This chapter maps the dependencies across people, processes, technology, and third parties for each Sub-CBS under Claims Processing & Settlement.

The objective is to provide visibility of upstream and downstream linkages, single points of failure, concentration risks, and critical connectivity paths — ensuring that the organisation can remain within impact tolerance during severe but plausible disruption scenarios such as system outages, data corruption, third-party failure, or liquidity stress.

Table P2: Map Dependency for CBS-2

Sub-CBS Code	Sub-CBS	Dependency Type	Dependency Detail (What/Who is involved)	Connectivity (How it connects/interacts)
2.1	Claim Notification & Receipt	People	Claims Intake Officers, Client Relationship Managers	First entry point of claim; interfaces with cedants and feeds data into the claims system
		Process	Standardised claim lodgement procedures, SLA tracking	Triggers verification workflow (2.2)
		Technology	Claims Management System (CMS), Email gateway, Web portal	Creates claim case ID; integrates with document repository
		Third Party	Cedants (insurance companies), brokers	Provide claim notification and initial documentation
2.2	Document & Data Verification	People	Claims Administrators, Data Verification Officers	Validates completeness before triage (2.3)
		Process	Checklist validation, KYC/AML screening	Escalates incomplete files back to 2.1
		Technology	Document Management System (DMS), OCR tools	Cross-checks policy data with the underwriting system
		Third Party	External medical institutions (if reports required)	Supplies supporting medical or incident documentation
2.3	Preliminary Assessment & Triage	People	Senior Claims Analysts	Categorises complexity and assigns case priority
		Process	Triage matrix (complex vs straightforward claims)	Routes claims to 2.4 or fast-track approval (2.6)
		Technology	Workflow routing engine	Connects CMS with analyst dashboards
		Third Party	None (primarily internal stage)	Internal routing within the Claims Department
2.4	Detailed Claims Assessment	People	Claims Assessors, Actuarial support, Medical Underwriters	Evaluate policy terms, exclusions, and treaty coverage
		Process	Policy contract interpretation, loss validation methodology	Feeds assessment findings to 2.6
		Technology	Underwriting System, Actuarial Modelling Tools	Cross-checks historical risk and reinsurance treaties
		Third Party	External medical experts	Provide independent opinions where needed
2.5	Third-Party Engagement & Investigation	People	Investigation Officers, Legal Counsel	Coordinates with investigators
		Process	Fraud detection protocol, dispute resolution framework	Supports 2.4 assessment findings
		Technology	Case management logs, secure file exchange	Links evidence into CMS
		Third Party	Loss adjusters, forensic investigators, law firms	Provide verification, fraud analysis, or legal opinion
2.6	Claims Decisioning & Approval	People	Head of Claims, Approval Committee	Authorises settlement or rejection
		Process	Delegation of authority matrix	Decision triggers 2.7 settlement process
		Technology	Approval workflow system	Records audit trail for compliance
		Third Party	Board Risk Committee (for large exposures)	Oversight for high-value claims
2.7	Settlement Calculation & Fund Disbursement	People	Finance Department, Treasury Officers	Validate payout amount and liquidity position
		Process	Settlement calculation methodology, fund release controls	Interacts with liquidity management
		Technology	Core Finance System, Payment Gateway, Banking Interface	Executes payment; confirms transaction status
		Third Party	Panel Banks	Transfer funds to cedants/beneficiaries
2.8	Claim Communication & Reporting	People	Client Servicing Team	Notifies cedants of outcome
		Process	Communication protocol, escalation management	Closes claim loop and updates 2.9 records
		Technology	CRM System, Email system	Syncs claim outcome to the reporting database
		Third Party	Cedants and brokers	Receive decision and settlement details
2.9	Record Archival & Compliance Reporting	People	Compliance Officers, Records Management Team	Ensure regulatory reporting accuracy
		Process	Data retention schedule, regulatory submission protocol	Feeds into 2.10 analytics
		Technology	Enterprise Archive System, Regulatory Reporting System	Submits required reports to BNM
		Third Party	External auditors	Audit trail verification
2.10	Continuous Improvement & Analytics	People	Risk Management, Data Analytics Team	Identify process bottlenecks and risk trends
		Process	Post-incident review, KPI tracking	Feedback loop to refine 2.1–2.9
		Technology	Business Intelligence (BI) tools, Data warehouse	Aggregates claims data for resilience metrics
		Third Party	Industry data providers	Benchmarking against market trends

Key Interdependency Observations (Aligned to BNM 2025 Expectations)

Consistent with the supervisory expectations outlined by Bank Negara Malaysia:

Technology Concentration Risk
The Claims Management System forms the backbone from 2.1 through 2.8. A prolonged outage would breach impact tolerance unless an alternate manual processing capability exists.

Third-Party Reliance Risk
Dependence on panel banks (2.7), medical institutions (2.2, 2.4), and investigators (2.5) introduces external vulnerability, requiring service-level monitoring and exit strategies.

Liquidity & Financial Stability Linkage
Settlement (2.7) is directly connected to treasury and capital adequacy management — aligning with BNM’s emphasis on operational-financial risk interlinkages.

Regulatory & Reputational Risk
Compliance reporting (2.9) ensures transparency and regulatory alignment. Failure here could escalate to supervisory intervention.
Feedback Loop for Resilience Maturity
Continuous improvement (2.10) connects back to all upstream stages, reinforcing adaptive resilience capability.

The mapping of interconnections and interdependencies for CBS-2: Claims Processing & Settlement demonstrates that operational resilience is not confined to a single department but spans claims, actuarial, finance, compliance, technology, and third-party ecosystems. For Malaysian Life Reinsurance, visibility of these dependencies enables identification of critical concentration points, escalation pathways, and systemic vulnerabilities.

In line with the 2025 operational resilience supervisory direction from Bank Negara Malaysia, this dependency mapping forms the foundation for setting impact tolerances, designing severe-but-plausible scenarios, and ensuring that claims settlement obligations can continue — even during material disruptions. Ultimately, resilience in claims processing safeguards contractual trust, cedant confidence, and the organisation’s financial soundness.

Building Organisational Resilience: An Operational Resilience Guide for Malaysian Life Reinsurance
eBook 3: Starting Your OR Implementation
CBS-2 Claims Processing & Settlement
CBS-2 DP	CBS-2 MD	CBS-2 MPR	CBS-2 ITo	CBS-2 SuPS	CBS-2 ST

For organisations looking to accelerate their journey, BCM Institute’s training and certification programs, including the OR-5000 Operational Resilience Expert Implementer course, provide in-depth insights and practical toolkits for effectively embedding this model.

More Information About OR-5000 [OR-5] or OR-300 [OR-3]

To learn more about the course and schedule, click the buttons below for the OR-300 Operational Resilience Implementer course and the OR-5000 Operational Resilience Expert Implementer course.



	If you have any questions, click to contact us.

Building Organisational Resilience: An Operational Resilience Guide for Malaysian Life Reinsurance

[OR] [MLRE] [E3] [CBS] [2] [MD] Map Dependency

Operational Resilience Certified Planner-Specialist-Expert

CBS-2 Claims Processing & Settlement

Introduction

Table P2: Map Dependency for CBS-2

Key Interdependency Observations (Aligned to BNM 2025 Expectations)

More Information About OR-5000 [OR-5] or OR-300 [OR-3]

Comments:

Building Organisational Resilience: An Operational Resilience Guide for Malaysian Life Reinsurance

[OR] [MLRE] [E3] [CBS] [2] [MD] Map Dependency

hbspt.cta._relativeUrls=true;hbspt.cta.load(3893111, '677f466a-109d-4603-b6e8-82e42e2f6e0b', {"useNewLoader":"true","region":"na1"});

Operational Resilience Certified Planner-Specialist-Expert

hbspt.cta._relativeUrls=true;hbspt.cta.load(3893111, '141492be-2bd8-434d-a664-dfdf2c7480ba', {"useNewLoader":"true","region":"na1"});

hbspt.cta._relativeUrls=true;hbspt.cta.load(3893111, '677f466a-109d-4603-b6e8-82e42e2f6e0b', {"useNewLoader":"true","region":"na1"}); CBS-2 Claims Processing & Settlement

Introduction

Table P2: Map Dependency for CBS-2

Key Interdependency Observations (Aligned to BNM 2025 Expectations)

hbspt.cta._relativeUrls=true;hbspt.cta.load(3893111, 'd9c4296b-54cd-48e0-ae66-b7f4a8a03ff7', {"useNewLoader":"true","region":"na1"});

More Information About OR-5000 [OR-5] or OR-300 [OR-3]

Comments:

CBS-2 Claims Processing & Settlement