Claim intake and triage
First notice captured across channels, completeness validated, severity and complexity triaged, routed to the right adjuster with the file assembled.
AI agents for insurance and claims
The short version: insurance and banking are leading sectors on AI agent deployment, though adoption rates vary by survey methodology and how “deployment” is defined. BCG’s 2024 research on AI adoption found customer service to be a considerable source of AI-generated value in insurance (24%) and banking (18%) — while also finding that only 26% of companies overall had built the capabilities to move beyond proofs of concept (BCG, “Where’s the Value in AI?”, October 2024). Where every transaction has a compliance trail and a fraud surface, agents replace analyst hours at margins horizontal tools can’t reach.
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Why determinism matters more here
The design constraint is absolute: an agent that hallucinates a policy detail creates regulatory liability. An agent that says a procedure is covered when it isn’t, invents a deductible, or misquotes claim status doesn’t create a customer service problem — it creates a compliance exposure.
The platforms winning here run deterministic decision engines executing verified logic rather than probabilistic generation for anything policy-determinative. We build the same way: language models handle language, rules handle coverage.
Workflows we automate
Coverage validation
Policy position established against the claim, with anything ambiguous escalated rather than decided.
Document collection and chasing
The evidence a claim needs, requested, tracked and validated on arrival.
Renewal and lapse prevention
Renewals worked systematically, with early engagement on the ones that matter.
Regulatory reporting
Decision trails and reporting assembled from captured activity.
Traditional vs agent-augmented
| Today | With an agent | |
|---|---|---|
| First notice | Phone, partial detail | Captured completely, any channel |
| Completeness | Found at assessment | Validated at intake |
| Document chasing | Manual, delayed | Automatic, escalating |
| Triage | Queue order | Severity and complexity |
| Decision trail | Assembled for audit | Continuous |
What we integrate with
- Policy administration and claims: major platforms with API access
- Document sources: email, portal, broker channels, mobile capture
- Payments and settlement: through the claims platform
- Channels: phone, email, portal, SMS
How we de-risk it
- Coverage determinations are deterministic or escalated. Never generated.
- No settlement authority. The agent assembles and recommends; a person decides.
- Vulnerability detection escalates immediately — claims frequently arrive at the worst moment of someone’s life, and that has to be handled by a human.
- Full decision trail on every action, because your regulator will ask.
Related use cases
The same workflows, described by the job rather than the sector.
Frequently asked questions
Can it decide coverage?
It establishes the deterministic position where rules are unambiguous and escalates everything else. It does not generate coverage opinions.
What about fraud detection?
It surfaces indicators for investigator review. It does not make fraud determinations.
How do we satisfy regulators?
Complete decision trails, deterministic logic on determinative questions, and human accountability at every decision point. Involve your compliance team from the audit onward.
What about vulnerable customers?
Detection and immediate human escalation, built as a hard rule.
Not sure this is your operation
Every sector page describes the workflows we’d expect to find. Yours will differ in ways that matter, and the audit is designed for exactly that — you get evidence about your own business rather than someone else’s.