Insurance work fails when a model is accurate in a test set and silent about why it scored a particular claim, quote, or customer. Reviewers, complaints teams, and model-risk groups need the inputs, the threshold, and the path a case took, not only a label.
What makes AI work different here
- A claim decision has to be explainable. Fair-treatment rules and internal model risk reviews usually ask why a claim was routed, denied, or fast-tracked. A score with no record of its inputs is hard to defend.
- The cost of a wrong class is uneven. Missing a valid claim and paying a claim that should have been reviewed are different failures. One accuracy number does not capture both.
- Policy wording is the source of truth. Coverage answers have to come from the actual policy, endorsement, and claim file. Open generation about what a policy says is a compliance problem, not a writing style.
- Legacy claim systems set the pace. The model is rarely the long pole. Getting a scoped, logged read of the claim system usually is.
Where we typically start
We start by naming the decision the system is allowed to make, what must stay with a person, and which documents every answer has to cite. Classification, triage, and a model-risk review are different projects, and we do not treat them as one.
Services we typically provide
Case studies from this industry
Frequently asked questions
Can a model deny a claim on its own?
We do not recommend a fully automatic denial. The usual pattern is a model that classifies and gathers the file, with a person making the decision that changes what the customer is paid.
How do you keep a coverage answer tied to the policy?
The assistant is limited to retrieved passages from the policy, endorsements, and claim notes. If the source is missing, it says so and hands the question to a person.
What does a model-risk review need from the build?
A record of training data, the decision threshold, where the score is used, and how a reviewer can see the inputs. We build that in at the start so the review has something concrete to read.