Fraud and severity thresholds live in code, so claims leadership cannot adjust them without a release.
Claims and underwriting
Let the claims agent settle the routine claims
Routine collision claims settle without sitting in a queue. A claim with a high fraud score stops before payout, and a third claim this year goes to an adjuster with the history attached.
Connecting the agent? See the developer guide for Insurance: P&C, Life & Annuity
A fraud rule that needed one more fact
The claims leader wants more automatic settlements. Here is how a new rule gets there.
Claims vice president
Wants the agent settling more collision claims so adjusters can spend their time on injury and total-loss files.
Governance engineer
Adds a rule: claims of $10,000 or more with two prior claims in 12 months go to an adjuster.
Developer
Gets a fix request because the agent was not sending the prior-claim count, and adds it.
Adjuster
Receives held claims in the Inbox with the amount, the history, and the rule, and settles or refers each one.
Built-in handoff
The prior-claim count becomes a developer fix request
Claims system developer
The developer who connected the claims agent gets a fix request for the prior-claim count. It closes when the data arrives, and compliance is asked to check the rule again.
See the six role portals and how work moves between themWhy claims automation stays small
Most carriers can automate a claim decision. Fewer can show a regulator how each one was made.
Adjusters get escalations with no context and redo the agent’s work.
A market-conduct question means pulling files from the claims system, the model log, and email.
Claims and underwriting decisions to start with
Pick one line of business and one decision the team already makes by rule.
Claims settlement
The agent proposes a payout. Carrier rules on fraud score, claim history, and coverage limits decide whether it pays, waits, or stops.
Underwriting and pricing
Keep the risk factors and model version with each quote, so an eligibility question has an answer.
Fraud referrals
Send a referred claim to special investigations with the signals that triggered the referral.
For the teams who approve go-live
Compliance
Carrier rules sit outside the agent, versioned, with a record of every change and who approved it.
Life and health pricing
AI used for life and health insurance pricing is high-risk under the EU AI Act, with obligations from December 2, 2027.
Special investigations
Referrals arrive with the fraud signals and the rule that stopped the payout.
Bring one line of business
Start with collision claims or another high-volume line, and the thresholds your claims team already uses.