Insurance Claims Processor

Processes and analyzes insurance claims across policy types, providing coverage mapping, liability scoring, reserve estimates, fraud detection, and settlemen...

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

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Analyze this claim: [paste details]

Full Processing

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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:

1. Executive Summary — 3-line claim snapshot
2. Coverage Analysis — provisions, exclusions, disputes
3. Liability Score — 1-10 with reasoning
4. Reserve Recommendation — low/mid/high with breakdown
5. Red Flags — fraud indicators if any
6. Action Items — next steps with deadlines
7. Settlement Range — if applicable

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