AI Agents

Context

Built for insurance within the Claims Processing stack and owned by Claims, this agent validates deductibles, sub-limits, and other payment thresholds before money goes out the door. It sits late in the flow, after coverage has been confirmed and an initial settlement amount has been calculated, acting as a final rules-based control that checks “does this payment actually respect the policy’s financial rules?”.

What it does

The agent pulls together the claim’s proposed payment amount, the underlying policy’s financial structure (deductibles, sub-limits, co-insurance, maximum payable amounts), and any product- or jurisdiction-specific thresholds. It then applies your documented rules to recalculate or verify how deductibles should be applied, how sub-limits cap different parts of the loss, and whether other thresholds (e.g., minimum payment amounts or escalation triggers) have been correctly handled. The outcome is a clear validation result written back into the claim: for example, “payment aligned with thresholds” or “payment off by X due to deductible/sub-limit rule Y,” with a short explanation that handlers can see and correct before approval.

Core AI functions

The core capability is rules plus policy validation. The agent uses structured rules derived from policy and product design to evaluate the proposed payment, check the application of deductibles and sub-limits, and flag any mismatch between calculated settlement and what the rules say should be paid. It standardises this step so that the same financial logic is applied every time, instead of being recalculated manually by each handler.

Problem solved

Misapplied deductibles and thresholds are a classic source of leakage and complaints: deductibles are sometimes skipped or mis-sized, sub-limits are overlooked or double-applied, and special thresholds are handled inconsistently under time pressure. This leads to both overpayments and underpayments, followed by rework when an error is spotted by a colleague, audit, or the customer. By turning threshold checks into a repeatable, system-driven step, the agent reduces these misapplications and the back-and-forth they create.

Business impact

The key outcome is reduced leakage and rework. Payments are more likely to align with the financial rules built into the policy and product, which cuts avoidable overpayment and reduces the number of claims that need to be adjusted after the fact. At the same time, handlers gain speed and confidence because they are no longer re-deriving deductibles and sub-limits manually, and management gets a clearer assurance that financial controls around claims are actually enforced at scale.

Integration and adjacent use cases

Integration complexity is low to medium: the agent needs access to the claim record (including proposed payment amounts), the policy’s financial parameters, and the rules used for deductibles, sub-limits, and other thresholds, plus a way to store its validation result and explanation back into the claims system.

Common combinations in this stack:

• FNOL Intake & Triaging Agent to capture First Notice of Loss cleanly and route the claim into the right workflow from day one;

• Claims Document Completeness Checker to ensure all required claim documents and photos are present so later checks are done on a complete file;

• Policy Terms & Coverage Validator (Claims) to establish whether and to what extent the loss is actually covered before any threshold validation is applied;

• Damage Evidence & Estimate Extractor to convert photos and documents into structured damage and cost information that feeds the initial settlement calculation; and

• Fraud Risk Signal Agent (Claims) to score claims for suspicious patterns from FNOL through settlement so that cases flagged as higher risk can be reviewed more closely even when thresholds and deductibles appear correctly applied.