IBM Consulting Claims-AI

Agentic AI app for claims automation

IBM’s Agentic AI solution for claims processing transforms how insurers and enterprises handle claim intake, assessment, cost estimation, and adjudication. Built with autonomous AI agents and scalable architecture, Claims AI automates end-to-end workflows while ensuring transparency, auditability, and human-in-the-loop control.

This solution can be deployed on your Microsoft Azure cloud and can be quickly configured.

The architecture and deployment plan involve GenAI assistants, containerized apps, and integration with structured data sources, which are consistent with Azure-based implementation

It can be Deployed in Microsoft Azure environment with provisioned resources

App Overview

Claims-AI supports automating complex and high-volume claims processes across property, auto, health, and commercial policy coverage.

It uses several AI agents to intelligently review policy coverage, estimate costs, generate structured reports, and identify claims requiring human review.

It can integrate with existing systems to deliver faster claims decisions, reduce processing costs, and ensure consistent, policy-aligned outcomes at scale.

Capabilities

Agents for coverage assessment Agents for policy coverage understanding and agents to evaluate claims based on damage reports, images and sensor data.

Cost Estimation Agents to estimate cost based on coverage assessment and enterprise data for cost estimates for various levels of repairs.

Online search Agentic ability to search online sources (pre-approved during configuration) for repair providers.

Report Generation Ability to act as underwriter agent to generate report for coverage, cost, and repair.

Customizability Can adapt to various policies, can connect to enterprise data sources, customize context for agents.

Security, Compliance & Privacy Built in grounding, guardrails for security and compliance.

Feature 1 – Automated Coverage Assessment

Claims-AI accelerates the coverage validation process by automating policy checks and surfacing decisions in real time.

• Uses AI to extract key data points from claims and match them against policy terms • Flags exclusions, limitations, and policy clauses relevant to the claim • Generates an automated coverage assessment report for underwriters or adjusters • Reduces cycle time and manual effort in early claim triage

Feature 2 – Multi-Agent Collaboration for Claims Review

Claims-AI coordinates specialized agents to perform complex claims tasks in parallel—ensuring speed, consistency, and accuracy.

• Involves agents like the Claims Handler, Policy Intelligence, and Cost Estimation Agent • Each agent performs a distinct function and passes structured output to the next • Supports seamless hand-offs and decision points across the claim's lifecycle • Mirrors human roles for audit-ready explainability and transparency

Feature 3 – AI-Generated Legal and Risk Summaries

AI agents synthesize key legal insights and risk factors from claim documents and external data sources.

• Extracts relevant legal language and applies internal policy interpretation models • Summarizes complex cases into readable, auditable narratives • Supports faster decision-making and improves legal review consistency • Can be extended to fraud risk signals and severity scoring

Feature 4 – Human-in-the-Loop Oversight and Auditability

Claims-AI enables transparent review with embedded checkpoints for human approval, feedback, and escalation.

• Allows adjusters or underwriters to validate, revise, or override agent recommendations • Maintains logs of human and AI decisions for audit and compliance • Ensures regulatory defensibility and reinforces trust in AI-assisted decisions • Balances automation with human expertise at critical decision points