AI Agents

Context

Built for insurance within the Insurance regulatory & compliance stack, this agent runs throughout claim handling to ensure every acknowledgment, investigation step, decision, and payment conforms to the statutory timelines and product SLAs for the relevant jurisdiction.

What it does

The agent reconstructs the live claim timeline from FNOL, case notes, system events, and correspondence, then calculates due-by dates for required milestones (acknowledge, request information, determine liability, issue payment). It applies permitted clock pauses (awaiting documents, SIU/legal/medical holds), tracks restarts with citation to rule and evidence, and flags impending or actual breaches with a short rationale (“decision due in 3 days per §…; paused 7 days pending discharge summary”). It also drafts compliant customer communications—acknowledgments, information requests, delay notices, and decision/payment letters—using approved templates, each linked to the event that started or paused the clock.

Core AI functions

Jurisdiction/product rule evaluation (deadlines, pause conditions, mandated notices); timeline reconstruction from workflow/DMS events; due-date computation with pause/resume logic; breach/near-breach detection with reason codes; and template-driven drafting that embeds source lineage and rule citations.

Problem solved

Deadline control is often inconsistent across products and regions; pauses aren’t evidenced cleanly; and letters are assembled ad hoc—leading to late decisions, regulatory exposure, and rework during audits or complaints.

Business impact

Claims move on time and on record: fewer breaches and escalations, faster clean audits, lower complaint volume tied to timeliness, and consistent, regulator-ready communications—each step backed by click-through evidence.

Integration and adjacent use cases

Integration complexity: Low to medium. The agent reads events, notes, and documents from your claims workflow and DMS, writes timeline status, breach/near-breach flags, and auto-drafted notices back to the case, and logs citations and evidence—no core changes required.

It is commonly paired within this stack with:

• Policy language regulatory check agent (align coverage determinations with policy wording and jurisdictional rules),

• Audit trail completeness verifier (ensure every step and pause carries source evidence),

• Customer communication consistency agent (synchronize content, tone, and mandatory disclosures across messages), and

• Regulated document filing assistant (assemble and submit required filings with the same timeline evidence).