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.

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