Overview
Multi-agent insurance claims systems transform the claims experience from weeks to hours. Agents handle intake, document processing, fraud detection, coverage verification, and settlement calculation—accelerating legitimate claims while catching fraudulent ones.
Architecture
Claim Submission → Intake Agent → Structured Claim
↓
Document Processing Agent → Extracted Data
↓
Fraud Detection Agent → Risk Score
↓
Coverage Verification Agent → Coverage Analysis
↓
Damage Assessment Agent → Loss Estimate
↓
Settlement Calculation Agent → Settlement Offer
↓
Customer Communication Agent → Status Updates
Agent Roles
Intake Agent
- Receives claims via multiple channels
- Guides customers through submission
- Collects required information
- Creates initial claim record
Document Processing Agent
- Processes photos, documents, forms
- Extracts relevant information via OCR/vision
- Validates document authenticity
- Organizes claim file
Fraud Detection Agent
- Analyzes claim patterns
- Checks against known fraud indicators
- Scores fraud risk
- Flags suspicious claims for investigation
Coverage Verification Agent
- Reviews policy details
- Confirms coverage applicability
- Identifies exclusions or limitations
- Verifies policy status
Damage Assessment Agent
- Analyzes photos of damage
- Estimates repair/replacement costs
- Compares with historical claims
- Coordinates with adjusters when needed
Settlement Calculation Agent
- Calculates settlement amount
- Applies deductibles and limits
- Considers depreciation
- Generates settlement offer
Customer Communication Agent
- Provides status updates
- Answers customer questions
- Explains decisions
- Manages escalations
Results & ROI
Insurance companies using AI agents report:
- 50-70% reduction in claims processing time
- 25-40% reduction in operational costs
- Improved fraud detection rates
- Higher customer satisfaction scores
Key Patterns
- Guardrails Pattern: Fraud detection and compliance checking
- Human-in-the-Loop: Adjuster review for complex claims
- Tool Use Pattern: Policy systems, payment processing, vendor networks
Regulatory Compliance
Insurance AI must:
- Maintain audit trails for regulatory review
- Ensure fair claims handling
- Comply with state insurance regulations
- Protect policyholder data
- Provide explanation for claim decisions
Complex Claims Handling
For complex claims (major disasters, injuries, disputes):
- Automated triage to human adjusters
- Agent-assisted investigation
- Hybrid human-AI decision making
- Appeals process support