AI Agents

Context

Built for insurance within the Fraud detection & alerting stack, this agent supports special investigations units (SIU) across auto, property, and travel claims. It is used during assessment and pre-settlement when teams need behavior-led indicators that a claim warrants deeper review.

What it does

The agent analyzes a claim’s activity trail and surrounding context to surface suspicious behavioral patterns. It looks at filing timing vs. incident timing, repeated claimant/provider pairings, repair/medical utilization patterns, routing through specific networks, and narrative or document reuse across past claims. It produces a risk signal with concise reasons—linked to the underlying events—so investigators can see what triggered the alert and where to start.

Core AI functions

Sequence and timeline checks (incident → FNOL → evidence → invoices), peer and history comparisons for claimants, adjusters, providers, and locations, anomaly detection on utilization and cost curves, near-duplicate detection on text and documents, and reason-code generation that translates findings into clear, reviewable explanations. Thresholds align to your SIU referral criteria.

Problem solved

Rule-only approaches miss coordinated behaviors and generate noise. Investigators spend time rebuilding timelines and connections before they can assess substance. This agent consolidates meaningful behavior change and repetition into an explainable alert, reducing the reconstruction work.

Business impact

SIU hit-rates improve, leakage declines as manipulated patterns are stopped earlier, and investigation cycle time shortens because each case starts with a defensible rationale tied to evidence.

Integration and adjacent use cases

Integration is moderate: read claim, policy, provider, and historical claim data from your core or warehouse; ingest supporting documents and notes from DMS; write risk signals and reasons into your claims workflow or case management.

Common combinations in this stack:

• Claim vs policy consistency checker, Image & document authenticity detector,

• Network association risk detector, and

• Suspicious claim escalation agent for comprehensive SIU referrals.