AI Claim Handler Automating Insurance Processing
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Solution Overview
Problem
Manual insurance claim processing is labor-intensive, time-consuming, and costly, leading to frustration for insured individuals due to reliance on human claim adjusters, delays, and limited availability of call centers, which do not leverage flexible electronic communication methods.
Innovation Solution
An AI claim handler module using machine learning to automate insurance claim processing from first-notice-of-loss to claim closure, enabling proactive and personalized interactions through digital channels like chat, email, and IVR, reducing dependence on human adjusters and allowing 24/7 access for insured individuals.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Ease of operation
If manual claim processing by human adjusters is used, then personalized customer service and complex decision-making are improved, but processing time and operational costs increase
Solution Approach 1:
The patent segments claim processing into two distinct pathways: automated processing for straightforward claims using AI/machine learning, and human review for complex or disputed claims. This segmentation allows routine claims to be processed quickly by automated systems while reserving human adjusters for cases requiring nuanced judgment, thereby reducing overall processing time while maintaining service quality.
Solution Approach 2:
The patent introduces an AI claim handler as an intermediary between the customer and human adjusters. This intermediary automatically performs initial claim assessment, documentation collection, and routine communications, freeing human adjusters to focus on complex decision-making and difficult customer interactions, thus reducing processing time without sacrificing service quality.
2Reliability
If human claim adjusters process all claims, then complex decisions and customer empathy are improved, but labor costs and processing capacity are worsened
Solution Approach 1:
The patent implements self-service capabilities where customers can submit claims, provide documentation, and track status through automated digital channels. The AI claim handler independently processes routine claims without human intervention, allowing the system to handle high volumes of straightforward claims while maintaining decision quality through automated validation and verification processes.
Solution Approach 2:
The patent replaces the mechanical system of human adjusters handling all claims with an automated AI/ML-based processing system for routine claims. Machine learning models analyze claim data, assess damage, determine coverage, and approve payments automatically, significantly increasing productivity while maintaining reliability through consistent application of policy rules and continuous model training.
3Loss of energy
If call centers operate with limited hours, then operational costs are reduced, but customer accessibility and convenience are worsened
Solution Approach 1:
The patent enables customers to file claims, upload documentation, receive updates, and even resolve simple claims entirely through automated digital channels available 24/7. This self-service capability eliminates the need for customers to contact call centers during business hours, providing unlimited accessibility without incurring additional operational costs for extended call center hours.
Solution Approach 2:
The patent replaces the mechanical constraint of call center operating hours with an automated AI claim handler that operates continuously without interruption. The AI system processes claims and responds to customer inquiries at any time of day or night, providing 24/7 accessibility while maintaining lower operational costs compared to staffing call centers around the clock.
4Ease of operation
If multiple human adjusters handle a single claim, then customer service coverage is improved, but processing time and customer frustration increase
Solution Approach 1:
The patent introduces a single AI claim handler as a consistent intermediary that manages the entire claim process from start to finish. This AI intermediary maintains continuous communication with the customer, coordinates all necessary assessments and approvals, and provides unified service coverage without requiring handoffs between multiple human adjusters, thereby eliminating transfer-related delays and customer frustration.
Solution Approach 2:
The AI claim handler is designed with multi-functionality to perform all tasks that multiple human adjusters would normally handle: initial claim intake, documentation review, damage assessment, coverage determination, payment processing, and customer communication. This universal capability allows a single AI system to provide comprehensive service coverage equivalent to multiple human adjusters without the coordination overhead and transfer delays.
Data Source
AI summary
Example methods, apparatus, and articles of manufacture to process insurance claims using artificial intelligence are disclosed herein. An example computer-implemented method, executed by a processor, to process an insurance claim using artificial intelligence includes interacting, with the processor, electronically with at least one of an insured person, a representative of the insured person, or a representative of an insured entity to obtain information related to an insurance claim, processing, with the processor, the information with a machine learning engine to identify an action to be taken for the insurance, and performing, with the processor, the action using a backend processing module that is also used by a person to process an insurance claim.