AI Policy Enforcement for Insurance Claims and Underwriting
Insurance carriers use Corules to gate claims adjudication and underwriting decisions. Legitimate claims auto-approve within seconds. Fraud signals trigger escalation with full context preserved for investigators — not silent rejection. Every decision is logged for state insurance department examination.
Le problème
Insurance carriers use Corules to gate claims adjudication and underwriting decisions. Legitimate claims auto-approve within seconds. Fraud signals trigger escalation with full context preserved for investigators — not silent rejection. Every decision is logged for state insurance department examination.
Contexte réglementaire
State insurance codes require prompt payment of covered claims (typically 30 days from notice). Claims denials require specific written reasons. Adverse underwriting decisions (non-renewal, cancellation) require state-mandated notice periods and reason codes. AI use in claims and underwriting is increasingly regulated at state level.
Types de décisions clés
- First notice of loss triage and severity classification
- Claims approval within adjuster authority limits
- Fraud signal escalation to SIU
- Policy coverage verification and exclusion application
- Subrogation opportunity identification
Cas d'usage associés
Frequently Asked Questions
Why does a suspicious claim escalate instead of being denied automatically?
State insurance codes prohibit unfair claim settlement practices. Auto-denying a claim based on a fraud score — without human review — creates regulatory and litigation exposure. Escalation preserves the human judgment required.
Can payout authority limits vary by adjuster license level?
Yes. Authority matrix parameters are keyed by adjuster tier and claim type. State-required payment timelines are enforced as policy constraints.