Solutions / Insurance claims
Insurance and brokerage
First notice of loss to a prepared adjuster file
Every claim arrives complete, coverage-checked, scored for fraud signals and summarised, so adjusters spend their day deciding, not collecting.
Representative blueprint. The targets below are design targets we scope and measure against in a Loop Audit. They are not results from a named client.
Why claims handling is slow and expensive
- Claims come in by phone, email, app and broker, with photos, PDFs and voicemails that never match a form.
- Adjusters burn their first hours chasing missing documents and reading the policy.
- Fraud rings hide in shared phone numbers, addresses and repairers that no single adjuster sees.
- Regulatory clocks differ by jurisdiction, and one missed acknowledgement becomes a complaint.
- Claimants call to ask for status because nobody told them.
How the loop runs.
7 stages, from the moment work arrives to the moment it is proven done. Each one is observable, testable and can be paused.
Intake
Takes first notice of loss from phone transcripts, email, web forms and broker portals, in the claimant’s language, and builds one claim record.
Complete the file
Detects what is missing for this loss type, asks the claimant for it in plain language, and chases until it arrives.
Check coverage
Reads the policy and endorsements from the policy admin system and states, with clause citations, what is likely covered, excluded or unclear.
Assess signals
Reviews photos and documents for consistency, and scores fraud indicators with the reasons visible to a human.
Route
Assigns by complexity, severity, language, licence and workload. Escalates large losses and injuries immediately.
Prepare the adjuster
Delivers a one-page file summary: facts, timeline, coverage view, open questions, suggested reserve range, recommended next steps.
Keep everyone informed
Tracks regulatory deadlines and sends claimant, broker and repairer updates at the right moments.
The hard parts, and how we handle them.
Photos are evidence, not verdicts
Damage assessment supports the adjuster by flagging inconsistencies and estimating a range. It never denies, reduces or approves a claim on its own.
Fraud detection that does not punish honest people
We combine explainable rules with link analysis across claims, for example shared devices, addresses and repairers. Every flag shows its reasons, is reviewed by a person, and is tested for bias across groups before launch and on a schedule after.
Coverage reading needs citations or it is worthless
Every coverage statement quotes the clause it came from. If the model cannot find the clause, the answer is "unclear, adjuster review", not a guess.
Deadlines are jurisdiction-specific
A rules layer owns regulatory timelines per province and line of business. The model drafts the message. The calendar, not the model, decides when it is due.
What a person always decides
- Payment, denial and reserve decisions always belong to a licensed adjuster
- Fraud flags create a review task, never an automatic adverse action
- Claimant messages use approved templates for anything with legal weight
- Personal information minimised, redacted in prompts, never used to train shared models
- Fairness testing on a schedule, with results available to compliance
Connects to
- Guidewire
- Duck Creek
- Applied Epic
- Majesco
- Salesforce Financial Services Cloud
- Telephony and contact centre platforms
- Estimating and repair network platforms
Built with
- Speech-to-text and multilingual intake
- Retrieval over policy documents with clause citations
- Graph store for link analysis
- Rules engine for regulatory clocks
- Adjuster workbench integrated with your claims system
A realistic timeline.
Shadow mode first. Nothing acts on its own until its accuracy has been measured against your team’s own work.
- Weeks 1 to 3Audit of claim types, document sets, handling times and escalation rules. Pick one line of business.
- Weeks 4 to 7Intake, completeness chasing and coverage summaries running beside adjusters, with side-by-side review.
- Weeks 8 to 11Routing, fraud signals and deadline tracking live with human review on every flag.
- Week 12 onwardAdd lines of business, reserve guidance and claimant self-service.
What we design for.
Modeled targets, confirmed or corrected with your own data in a Loop Audit.
- Built for PIPEDA and provincial insurance regulator expectations
- Full decision log for market conduct review
- Canadian data residency on request