Use casesFinancial institutions & fintech
Insurance claims fast-track
Simple claims wait in the same queue as hard ones, and customers wait with them.
- Kinds of AI
- ModelsSLMsAgentic AI
- Who decides
- Claims adjuster
- Connects to
- Claims, policy, and document systems
SLM · documents
- metClaim form
- metRepair estimate
- metPhotos6
Model · fraud and severity
- FraudLow bandno link to flagged repairers or parties
- SeverityClose to estimateexpected cost
Agent · route
Fast-track → the insurer's payment process (sample review applies).
- Model
- SLM
- Agent
Written limitNever decline or change an amount; those go to a claims adjuster.
DecidesClaims adjuster
1. The desk
Today
- ReadEvery first notice of loss goes to the same queue; an adjuster opens each one and reads forms, invoices, repair estimates, police or expert reports, and photos by hand.
- CheckEach document is checked against the policy by hand.
- ScoreSuspicious claims are spotted by experience, inconsistently.
- RouteSimple claims wait in the same queue as hard ones.
- DecideThe claims adjuster decides every claim, simple or hard, and customers wait in turn.
With the system
- ReadThe SLM reads the form, invoices, estimates, reports, scans, and photos into one structured claim, each field with its citation.SLM
- CheckThe insurer's coverage rules, run in code, mark the claim covered, not clearly covered, or outside the period, with the clause.Your rule
- ScoreThe fraud and severity models give a fraud band and an expected cost, with reason codes.Model
- RouteThe agent sends each claim down one path: fast-track only inside the insurer's written amount, coverage, and fraud-band rules; otherwise a claims adjuster or the special investigation unit (SIU).Agentic AI
- DecideFast-track claims are paid through the insurer's own process, with a sample reviewed; the claims adjuster decides every other claim, as before. The system never declines a claim.Person decides
What lands on the desk
Each claim arrives read, checked against its policy clause, and scored, with the route and the reason for it on one page. A clean claim goes to the insurer's own payment process under its written rules; every other claim reaches a claims adjuster already prepared.
SLM · documents
- metClaim form
- metRepair estimate
- metPhotos6
- Police reportnot required
Your rules · coverage and amount
- CoverageOwn damage covered · deductible applies · in periodpolicy §2.1, §4
- AmountEstimate within the fast-track amount
Model · fraud and severity
- FraudLow bandno link to flagged repairers or parties
- SeverityClose to estimateexpected cost
Agent · route
Fast-track → the insurer's payment process (sample review applies).
- Model
- SLM
- Agent
- Code
Written limitNever decline or change an amount; those go to a claims adjuster.
DecidesClaims adjuster
2. The system
For your technical team — skip it if you like.
How it works
In
- Claim form, invoices, repair estimates
- Expert or police reports
- Scanned documents and photos
SLM · understands
Claim reader
Reads documents, scans, and photos
Reads
- Everything under In
Out
- A structured claim
- Parties, dates, amounts, items, damage
- A citation for each
Your rules
Coverage check
The insurer's coverage rules, written in code
Reads
- The structured claim
- Policy: coverage, limits, deductible, period
Out
- Covered or not clearly covered
- In or outside the period
- With the clause
Model · estimates
Fraud and severity models
Calibrated GBM fraud score; GBM for severity and reserve
Reads
- Claim features and history
- Network links: same repairer, same parties
Out
- A fraud band
- Expected cost
- Reason codes
Agent · prepares
Routing agent
Router
Reads
- Claim, coverage, fraud band, expected cost
Out
- Fast-track: clean, covered, low fraud band
- Fast-track only under the written amount
- Claims adjuster
- Special investigation unit (SIU)
Decision
Payment process, adjuster, or SIU
Reads
- The routed claim file
Out
- Fast-track claims are paid through the insurer's own process, under its written rules
- A sample of fast-track payments is reviewed
- On the adjuster and SIU paths a person decides
- The system never declines a claim
How the agent's work is arrangedRouter
Router
Each claim takes exactly one of three fixed paths decided by written criteria; a router makes that choice explicit and logs why.
How the models are trained and tested
Your expert writes the test first. A step the test does not need is skipped, and we say why.
Show the training steps
Small language model (SLM)
Test set
200–400 past claims graded by senior adjusters (field extraction, damage description, amount).
Dataset
Claim files with final adjusted values, personal and health data removed or minimized.
Continued pre-training (CPT)Skipped
Skipped unless the line of business uses unusual vocabulary.
Supervised fine-tuning (SFT)
On the claim schema.
Reinforcement learning (RL)Skipped
Skipped: extraction is checked by rules and the test set.
Fraud and severity models
Target
Fraud: confirmed fraud or SIU outcome. Severity: the final paid amount.
Method and challenger
A gradient-boosted model against a generalized linear model (GLM) challenger; GLMs are standard in insurance.
Validation evidence
Precision at SIU capacity, and calibration of severity.
Monitoring
Monthly drift.
Where the agentic system stops
Clean claims under the insurer's written amount and coverage rules go to payment through the insurer's own process, with a sample reviewed.
Show its tools, limits, and record
- Tools and access
- Read-only claims, policy, and document systems; may request missing documents from the customer by template; writes the routing decision and the file, fast-tracking only under the insurer's written amount, coverage, and fraud-band rules, with a sample of fast-tracked claims reviewed.
- May not
- Decline a claim, reduce an amount, or accuse a customer.
- Who decides and the written limit
- Claims adjusterClean claims under the insurer's written amount and coverage rules go to payment through the insurer's own process, with a sample reviewed. The system never declines a claim; every other claim reaches a claims adjuster, prepared, and suspected fraud reaches the SIU.
- Stops when
- Any coverage doubt, document mismatch, injury, or fraud band above the threshold: the claim goes to an adjuster or the SIU.
- Record
- Every document read, rule result, score, and route.
3. Value and conditions
Where the time goes, and what your institution will measure.
Where the value comes from
- Cycle time for simple claims.
- Adjuster time freed for complex ones.
- Consistent fraud referral.
What your institution measures
- Days from notice to payment on fast-track claims
- Share of claims fast-tracked
- Sample-review error rate
- Adjuster hours per claim
- SIU hit rate
- Customer complaints
Measured in the Decision Blueprint
Baseline cycle time and claim mix by line set the starting point; your institution sets the target.
Conditions
The rules, the data, and the known error, with its guard.
- Türkiye: Insurance Law 5684 and the insurance regulator's (SEDDK) rules apply.
- Health and injury data are special-category under KVKK, Türkiye's data protection law: minimize them and keep them on your servers.
- Photo reading supports the adjuster; it never sets an amount alone.
Start here
We take a recent month of first notices of loss, sort them by line and complexity, and test the reader on your own claim documents and photos.
Similar desks
- ModelsSLMsAgentic AI
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With the systemOne file with the rating, its reasons, and the authority level.
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- ModelsSLMsAgentic AI
Early warning on the loan book
TodayThe borrower is current; other banks are already cutting its limits, and you see its quarter only at renewal.
With the systemA file, not a spreadsheet: signals checked in parallel and gathered in one place.
Watch-list committee decides
Equalize the gap.
Bring one decision. Leave knowing the first step.
A short description of the decision is enough; no confidential records.
https://eqlx.ai/use-cases/insurance-claims · Printed copy; the website is the current version.