A claims triage agent, walked through one claim
A governed claims agent prepares the file; the adjuster decides. It links photos, estimates, correspondence and the policy version to the questions that matter, and flags gaps as open questions rather than findings. Coverage, reserves, payment and any fraud referral stay with authorised staff, and every step lands in a record a regulator can read.
A water-damage claim whose estimate outruns the photos
A homeowner reports water damage in a kitchen. The file holds six photos, a contractor’s estimate and two emails describing the leak. The estimate includes replacing flooring in an adjoining room that none of the photos show.
- Agent prepares
- Control layer refuses
- Named person decides
- Person decides · Claims intake
The claim is assigned and the agent is invoked
First notice of loss is logged and assigned to an adjuster’s queue. The preparation run starts against that claim only, under the adjuster’s authority.
- Agent prepares · Claims preparation agent
It assembles the file around the issues
It retrieves the policy version in force on the date of loss, reads the estimate line by line, describes what each photo shows and pulls the dates from the correspondence. Every statement in its summary links to the document it came from.
- Agent prepares · Claims preparation agent
It raises questions, not conclusions
Two open questions: the adjoining-room flooring is not established by any photo, and the emails date the leak about two weeks before the report. It also notes the policy wording on gradual leaks for the adjuster to read. It does not say the estimate is inflated or that coverage applies or fails.
- Control layer · Control layer
The agent cannot act on the claim
Setting a reserve, deciding coverage, making a payment, denying a claim and referring it to the special investigations unit are not tools this agent holds. Any attempt is refused and logged.
- Person decides · Adjuster
The adjuster decides what happens next
The adjuster reads the gradual-leak wording, asks the contractor for photos of the adjoining room and books an inspection. Coverage is decided after the inspection, by the adjuster, with the reasoning written into the file.
- Person decides · Claims manager
Any referral is a person’s call
If the inspection raises a real concern, the decision to refer to special investigations is made by the authorised manager, who sees what supports the concern and what weakens it, because the agent kept both.
What the agent cannot do
These are not instructions in a prompt. The actions are not tools the agent holds, so a request to use one fails and the attempt is recorded. A record with refusals in it shows the boundary held.
- Decide coverage
- Set or change a reserve
- Pay or deny a claim
- Refer a claim for fraud investigation
- State an indicator as a finding
The control answers for this agent
- Who owns it?
- The head of claims for the line of business, who can pause or stop it.
- What risk tier?
- Elevated: personal data and a regulated insurance decision downstream.
- What can it reach?
- The claim file, the policy version in force, photos, estimates and correspondence for that claim. Not other claims or the policyholder’s wider history.
- Where is the hard line?
- No coverage, reserve, payment, denial or referral actions, enforced outside the prompt.
- Who decides?
- The adjuster decides coverage and next steps; an authorised manager decides any referral.
- What is kept?
- Documents retrieved, the policy version, every source link, the open questions, blocked requests and each person’s decision with its reason.
From this walkthrough to your workflow
- 1
Workflow diagnostic
A short call comparing your current process with this one: where the evidence comes from, who decides, and where the time goes. No demo, no deck.
Book a diagnostic - 2
Workflow-to-production workshop
With your process owner and your risk or compliance reviewer in the room, map the agent, its boundaries and the evidence your reviewers will need.
Insurance workflow workshop - 3
Paid production validation
One agent on your data, in your cloud, measured against a baseline and success measures agreed before work starts. Results are reported as measured, not modelled.
Claims triage, asked directly
Can an AI agent decide insurance claim coverage?
Not in a governed design. The agent prepares the file and raises questions; coverage, reserves, payment and denial stay with authorised staff. The NAIC model bulletin expects AI-supported insurance decisions to follow existing insurance law, which is far easier to show when the decision is a named person’s.
How do you stop a claims agent from overstating fraud?
Test for it. Review the agent’s outputs for language that turns an observation into a conclusion: “the photos do not show the adjoining room” is an observation, “the claimant is inflating the claim” is not the agent’s to reach. Keep referral as a human action the agent cannot invoke.
What should you measure in a claims agent pilot?
What the adjuster still has to reopen after the handoff: documents they had to find themselves, references they had to re-check, questions the agent missed. A readable summary that leaves the adjuster searching has not done the preparation.
Is this a real claim?
No. The claim on this page is invented to show the shape of the workflow. A walkthrough on your own claims process starts with a short workflow diagnostic.