Claim

A claim represents an insured's report of a loss or incident that may be covered under their policy. This is the starting point of the claims workflow in insurance.

Structure

Name	Card.	Type	Description
RClaim			A claim represents an insured's report of a loss or incident that may be covered under their policy.
●resourceType	1..1	"Claim"	Fixed resource type discriminator
●id	0..1	string	Logical id of this resource.
●meta	0..1	Meta	Metadata about the resource
●status	1..1	open | closed | reopened | denied | subrogation	Current status of the claim.
●claimNumber	1..1	string	Carrier-assigned claim number
●policy	1..1	Reference	Reference to the policy under which the claim is filed
●coverage	0..1	Reference	Reference to the coverage section applicable to this claim
●insured	1..1	Reference	Reference to the insured
●dateOfLoss	1..1	string	Date the loss or incident occurred.
●dateReported	0..1	string	Date/time the claim was reported to the carrier.
●lossType	1..1	CodeableConcept	Type/cause of loss. terminology
●description	0..1	string	Narrative description of the loss or incident
●lossLocation	0..1	Address	Location where the loss occurred
●adjuster	0..1	Reference	Reference to the assigned adjuster.
[ ]claimants	0..*	Claimant	Claimant(s) — parties making the claim
●financials	0..1	ClaimFinancials	Financial reserves and payment summary
●litigationStatus	0..1	CodeableConcept	Litigation status. terminology
[ ]documents	0..*	Attachment	Supporting documents (photos, police reports, medical records, etc.)
●lossCause	0..1	CodeableConcept	Structured cause of loss. terminology
●lossKind	0..1	CodeableConcept	High-level loss category (property, liability, medical, auto, workers-comp). terminology
●lossTime	0..1	string	Time of day the loss occurred.
[ ]assignments	0..*	ClaimsAssignment	Assigned parties with roles — replaces single adjuster field for complex claims.
[ ]reports	0..*	ClaimReport	Police, fire, incident, and appraisal reports related to this claim
●subrogation	0..1	SubrogationDetail	Subrogation recovery tracking

Example

{
  "resourceType": "Claim",
  "id": "clm-2025-5001",
  "status": "open",
  "claimNumber": "CLM-2025-005001",
  "policy": {
    "reference": "Policy/pol-2025-1001"
  },
  "insured": {
    "reference": "Insured/ins-001",
    "display": "Acme Manufacturing Corp"
  },
  "dateOfLoss": "2025-09-15",
  "dateReported": "2025-09-16T08:30:00Z",
  "lossType": {
    "coding": [
      {
        "code": "BI",
        "display": "Bodily Injury"
      }
    ]
  },
  "description": "Employee slip and fall in warehouse area",
  "lossLocation": {
    "line": [
      "123 Industrial Blvd"
    ],
    "city": "Hartford",
    "state": "CT"
  }
}

JSON Schema

Full JSON Schema: Claim.schema.json