Claims. Underwriting.
Member Services.
Insurance operations have unique compliance requirements, domain terminology, and decision complexity. We build AI that understands all three.
The Operational Challenge
Document Processing Bottleneck
Claims, policies, medical records all require manual review.
Knowledge Fragmentation
Policy information scattered across legacy systems.
Response Inconsistency
Different agents give different answers to the same question.
Compliance Burden
Regulatory requirements demand traceable, auditable decisions.
Insurance-Specific Architecture
Five coordinated layers handle every query from intake to response, with domain-specific routing and compliance-ready audit trails.
flowchart TB
subgraph Input[Channels]
Agent[Agent Desktop]
Portal[Member Portal]
Phone[Phone/IVR]
end
subgraph L1[Intent & Routing]
Intent[Intent Classification]
Steer[Steering Agent]
end
subgraph L2[Domain Selection]
Domain{Domain?}
Claims[Claims]
UW[Underwriting]
Service[Service]
Compliance[Compliance]
end
subgraph L3[Processing]
Retrieve[Document Retrieval]
Expert[Expert Reasoning]
end
subgraph L4[Quality]
Conf[Confidence Check]
Valid[Validation]
end
subgraph L5[Output]
Respond[Grounded Response]
Cite[Policy Citations]
Escalate[Human Escalation]
end
Agent --> Intent
Portal --> Intent
Phone --> Intent
Intent --> Steer --> Domain
Domain --> Claims --> Retrieve
Domain --> UW --> Expert
Domain --> Service --> Retrieve
Domain --> Compliance --> Expert
Retrieve --> Conf
Expert --> Conf
Conf --> Valid
Valid -->|Pass| Respond --> Cite
Valid -->|Fail| Escalate
Insurance Use Cases
Claims Summarization
Automatically extract key details from claim documents, summarize relevant history, and provide decision support with supporting evidence.
Underwriting Assistant
Analyze medical records, calculate risk indicators, and provide underwriting recommendations aligned with your guidelines.
Member Service Agent
Answer policy questions, process routine updates, and handle inquiries 24/7 with consistent, policy-grounded responses.
Document Classification
Automatically classify incoming documents, extract entities, and route to appropriate workflows without manual triage.
Compliance Monitoring
Check communications against regulatory requirements, flag potential issues, and maintain complete audit trails.
Fraud Detection
Pattern recognition across claims data to identify anomalies and flag potentially fraudulent submissions for review.
Domain Expert Models
Each insurance domain gets a specialized model trained on your terminology, decision patterns, and institutional knowledge.
| Domain | Training Data | Capabilities |
|---|---|---|
| Claims | Historical decisions, denial reasons, appeals | Adjudication reasoning, status explanations |
| Underwriting | Risk assessments, medical guidelines | Risk scoring, eligibility determination |
| Member Services | Interaction logs, policy documents | Policy Q&A, empathetic responses |
| Compliance | State regulations, NAIC guidelines | Regulation lookup, compliance checking |
Ready for Insurance AI That Works?
We've built detailed architectures for insurance operations. Let's discuss how they map to your specific workflows.