| name | afrexai-insurance-claims |
| description | Insurance Claims Processor |
Insurance Claims Processor
Process, analyze, and optimize insurance claims. Covers property, liability, workers' comp, auto, and professional indemnity.
What This Does
Takes raw claim details and produces:
- Structured claim summary with policy coverage mapping
- Liability assessment with supporting/weakening factors
- Reserve estimate with confidence range
- Subrogation opportunity analysis
- Red flag detection (fraud indicators, coverage gaps)
- Settlement recommendation with negotiation range
- Regulatory compliance checklist by jurisdiction
Usage
Provide claim details in any format — adjuster notes, policyholder statement, incident report, photos, or free text. The agent structures everything.
Quick Claim Analysis
Analyze this claim: [paste details]
Full Processing
Process claim for:
- Policy type: [commercial general liability / property / WC / auto / PI]
- Incident date: [date]
- Reported date: [date]
- Claimant: [name/entity]
- Description: [what happened]
- Claimed amount: [if known]
- Policy limits: [if known]
- Jurisdiction: [state/country]
Claim Analysis Framework
1. Coverage Determination
- Map incident to policy provisions
- Identify applicable endorsements and exclusions
- Flag coverage disputes early
- Check occurrence vs claims-made triggers
2. Liability Assessment
Score 1-10 on insured liability exposure:
- 1-3: Strong defense position, deny or minimal settlement
- 4-6: Mixed liability, negotiate
- 7-10: Clear insured liability, reserve and settle
Factors evaluated:
- Comparative/contributory negligence (jurisdiction-specific)
- Statutory obligations
- Contractual indemnity provisions
- Prior loss history pattern
3. Reserve Estimation
Three-point estimate:
- Low: Best case with strong defense
- Mid: Most likely outcome
- High: Worst case including litigation costs
Include:
- Indemnity reserve
- Defense costs (inside/outside limits)
- Allocated loss adjustment expense (ALAE)
- Unallocated loss adjustment expense (ULAE)
4. Fraud Detection
Red flags scored by severity:
- Claim timing patterns (Monday morning, policy inception proximity)
- Prior claim frequency
- Documentation inconsistencies
- Witness availability issues
- Financial stress indicators
- Description vs damage inconsistency
5. Subrogation Analysis
- Third-party recovery potential
- Evidence preservation requirements
- Statute of limitations by jurisdiction
- Cost-benefit of pursuit
6. Settlement Strategy
- Opening position and authority range
- Mediation vs litigation cost comparison
- Jurisdiction-specific verdict ranges
- Structured settlement considerations for large claims
Industry-Specific Modules
Property Claims
- Replacement cost vs actual cash value
- Business interruption calculations (gross earnings, extra expense)
- Ordinance or law coverage triggers
- Catastrophe event coordination
Workers' Compensation
- Compensability determination
- Return-to-work timeline
- Medical treatment guidelines by state
- Permanent disability rating estimates
Professional Liability
- Discovery rule and statute of repose
- Prior acts coverage analysis
- Consent to settle provisions
- Panel counsel selection criteria
Auto/Fleet
- Comparative fault allocation
- UM/UIM stacking analysis
- Medical payment coordination
- Total loss threshold calculations
Compliance Checklist Generator
Produces jurisdiction-specific compliance timeline:
- Acknowledgment deadlines
- Investigation completion requirements
- Payment timing obligations
- Required notices and disclosures
- Bad faith exposure triggers
Output Format
Every analysis produces:
- Executive Summary — 3-line claim snapshot
- Coverage Analysis — provisions, exclusions, disputes
- Liability Score — 1-10 with reasoning
- Reserve Recommendation — low/mid/high with breakdown
- Red Flags — fraud indicators if any
- Action Items — next steps with deadlines
- Settlement Range — if applicable
Built by AfrexAI — AI agent context packs for every industry.
Get the full Insurance & Risk Management Context Pack with claims processing, underwriting automation, policy analysis, and actuarial modeling: AfrexAI Storefront
Calculate what AI agents save your claims operation: AI Revenue Calculator
