AI Agents

Context

Built for insurance within the Claims Processing stack and owned by Claims, this agent’s job is straightforward: check a claim against the policy’s terms, coverages, limits, and deductibles before money moves. It sits after intake and document checks, acting as the control that says “does the policy actually respond here, and how?”.

What it does

The agent pulls the relevant policy view for the claim—coverages, limits, deductibles, exclusions, endorsements—and aligns it with the structured claim facts: what happened, when, where, to what, and for how much. Using your documented coverage rules, it evaluates whether the loss is covered, whether any exclusions apply, how deductibles and limits shape the covered portion, and whether anything is ambiguous enough to require human review. It then writes a clear coverage position back into the claim (e.g., covered, not covered, partially covered) with a short explanation anchored in policy terms, so handlers don’t have to re-interpret the contract from scratch on every file.

Core AI functions

The core capability is policy reasoning: mapping policy terms and coverage structures into a rule set, applying that to claim facts, and producing a consistent coverage view with the key clauses referenced. The aim is not to replace complex edge-case legal work, but to automate the bulk of standard coverage checks that are today manual and repetitive.

Problem solved

Manual coverage checks are slow and error-prone. Similar claims can receive different decisions depending on who handles them, important exclusions or limits can be missed under time pressure, and simple claims still require handlers to re-read policy documents. This agent standardises that step so coverage is applied consistently and faster, with clearer rationale.

Business impact

The main outcomes are fewer leakage and disputes. Consistent coverage decisions reduce overpayments and underpayments, lower avoidable complaints driven by inconsistent interpretation, and shorten the time between claim registration and a defensible coverage position. For Tier 1–2 insurers, that adds up across high volumes and complex product portfolios.

Integration and adjacent use cases.

Integration complexity is medium: the agent needs access to policy data and wording/coverage rules, the claim record, and the document store for key attachments, plus a way to store its coverage status 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 before coverage evaluation;

• Claims Document Completeness Checker to ensure required documents and photos are present so coverage can be assessed on a complete file;

• Damage Evidence & Estimate Extractor to structure damage information and estimates once coverage is established;

• Eligibility & Threshold Checker (Claims) to apply deductibles, limits, and other payment rules after coverage is confirmed; and

• Fraud Risk Signal Agent (Claims) to continuously flag suspicious patterns alongside coverage checks so SIU can focus on the right subset of claims.