AI System for Preparing Insurance Claim Documents for Initial Review

The problem

When the claim notification, policy, photographs, incident report and invoices are held in different sources, staff must manually align the fields before preparing a list of missing documents and inconsistencies.

The claims specialist must compare every suggestion in the missing-document and inconsistency list with the source record; incomplete or conflicting evidence must not replace the final decision.

If several incidents in the same file are not referred for separate review, a valid claim could be rejected; the record must not progress without a human decision.

What we set out to improve

• Time taken for the draft missing-document and inconsistency list and its supporting evidence to reach the claims specialist for review
• How records referred for human review because several incidents appear in the same file are resolved
• Number of suggestions corrected after identifying the risk of rejecting a valid claim

How the system works

1. 01 Retrieve the claim notification, policy, photographs, incident report and invoices from authorised sources
2. 02 Verify field and document versions
3. 03 Prepare the missing-document and inconsistency list with supporting evidence
4. 04 Check for exceptions: several incidents appear in the same file
5. 05 Have the claims specialist accept, correct or reject the suggestion
6. 06 Decision gate: claim acceptance, rejection and compensation
7. 07 Record the decision and source separately

Methods we used

• A source-identified data schema for claim notifications, policies, photographs, incident reports and invoices
• A structure that separates deterministic rules from AI suggestions
• A screen showing the missing-document and inconsistency list alongside its supporting evidence
• A human review queue for several incidents appearing in the same file
• A record identifier that prevents duplicate processing

Where people stay involved

Data and security

Claim notifications, policies, photographs, incident reports and invoices should be processed using only the fields required. Role-based access should be applied, and unnecessary identity, health, financial and internal organisational data should not be sent to the model. Source retrieval, the AI suggestion and the claims specialist's decision should be recorded separately.

Who this suits

Frequently asked questions