Claims AI practice library32
DesignSTR-01
Claims AI transformation thesis
Define how AI will improve claim accuracy, timeliness, consistency, customer experience, adjuster effectiveness, and cost while preserving accountable judgment.
PilotSTR-02
Claim journey and pain-point map
Map claimant and adjuster experience from loss through closure, including handoffs, waits, evidence, decisions, exceptions, communications, and controls.
OperateSTR-03
Use-case outcome and boundary
State intended users, claim types, decisions supported, exclusions, autonomy, evidence, human authority, success measures, and unacceptable outcomes.
ImproveSTR-04
Portfolio sequencing and dependency plan
Sequence claims AI initiatives using value, risk, readiness, data, platform, vendor, workforce, jurisdiction, and change dependencies.
DesignINT-01
FNOL capture and assistance
Use AI to structure loss information, identify missing details, support empathy and accessibility, and reduce rework without creating unsupported facts.
PilotINT-02
Coverage evidence support
Retrieve and organize policy, endorsements, facts, jurisdictional context, and prior decisions while preserving qualified coverage analysis.
OperateINT-03
Segmentation severity and routing
Support appropriate assignment, complexity, severity, specialization, straight-through candidates, and service levels with monitored exceptions.
ImproveINT-04
Urgency vulnerability and catastrophe handling
Recognize time-sensitive, vulnerable, displaced, injured, catastrophe, litigation, and special-handling needs and route them safely.
DesignINV-01
Evidence collection and summarization
Identify needed evidence, track provenance, summarize records, distinguish fact from inference, flag conflicts, and preserve the underlying source.
PilotINV-02
Damage and document analysis
Analyze images, estimates, invoices, medical or legal records, and other materials within validated scope and human-review requirements.
OperateINV-03
Fraud signal and referral support
Generate explainable fraud indicators for qualified investigation, avoid automatic adverse treatment, and monitor referral quality and disparities.
ImproveINV-04
Investigation plan and next-best action
Recommend proportionate tasks, experts, contacts, reserves, diary actions, or escalation while leaving accountable decisions with authorized professionals.
DesignRES-01
Liability and coverage decision support
Organize relevant facts, policy language, precedents, uncertainty, competing interpretations, and escalation triggers for expert judgment.
PilotRES-02
Severity and reserve support
Estimate ranges and drivers with uncertainty, changing facts, segmentation, actuarial alignment, overrides, and reserve adequacy monitoring.
OperateRES-03
Evaluation and negotiation support
Support valuation, comparable evidence, negotiation ranges, authority, documentation, and consistency without coercion or blind anchoring.
ImproveRES-04
Payment settlement and recovery controls
Validate payee, authority, coverage, calculations, approvals, liens, subrogation, salvage, duplicate payment, and recovery opportunities.
DesignHUM-01
Adjuster authority and accountability
Define which actions AI may perform, recommend, draft, or never take and which professional remains responsible for each claim decision.
PilotHUM-02
Review override and escalation
Provide accessible review, documented override, expert consultation, exception routing, pause, and escalation with enough evidence and authority.
OperateHUM-03
Explanation communication and recourse
Give claimants accurate, timely, understandable reasons, supporting information, next steps, correction options, human review, and appeal or complaint paths.
ImproveHUM-04
Accessibility empathy and vulnerable claimant support
Design communications and workflows for disability, language, literacy, trauma, catastrophe, financial hardship, representation, and channel constraints.
DesignTEC-01
Claims data quality and lineage
Trace policy, loss, claimant, third-party, image, text, payment, medical, legal, repair, weather, telematics, and derived data through claims decisions.
PilotTEC-02
Model and agent validation
Test performance, uncertainty, limitations, fairness, robustness, prompts, retrieval, tools, autonomy, failure modes, and deployment relevance by claim context.
OperateTEC-03
Tool access security and resilience
Control identity, permissions, secrets, prompt injection, data leakage, tool actions, logging, downtime, recovery, rollback, and safe failure.
ImproveTEC-04
Vendor service and evidence controls
Align providers on claim scope, data, performance, fairness, security, changes, incidents, audit evidence, continuity, and exit obligations.
DesignOPS-01
Production performance monitoring
Monitor accuracy, drift, latency, availability, routing, hallucination, tool failures, thresholds, alerts, investigations, and corrective actions.
PilotOPS-02
Claim quality and outcome review
Test coverage, liability, reserve, evaluation, payment, communication, timeliness, documentation, leakage, fairness, and customer outcomes.
OperateOPS-03
Workload leakage and behavior monitoring
Measure review demand, exceptions, queue shifts, rework, workarounds, overreliance, avoidance, override quality, and capacity realization.
ImproveOPS-04
Incident complaint and litigation feedback
Connect errors, complaints, appeals, litigation, regulator inquiries, vendor events, and near misses to root cause, remediation, and change control.
DesignGOV-01
Claims AI governance and change control
Set accountable ownership, risk tier, approvals, evidence, monitoring, incidents, material-change triggers, restrictions, and retirement decisions.
PilotGOV-02
Fairness compliance and jurisdiction review
Evaluate unfair claims practice, discrimination, privacy, explanation, record, licensing, accessibility, and jurisdiction-specific requirements.
OperateGOV-03
Value capacity and workforce realization
Connect AI use to quality, service, indemnity and expense outcomes, adjuster capacity, expertise, workload, adoption, and total operating cost.
ImproveGOV-04
Closed-claim learning and continuous improvement
Use closed-file review, leakage studies, complaints, recoveries, litigation, catastrophe experience, and outcome analysis to improve or retire controls and systems.