Insurance claims processing with an adjuster in the loop
In short
A claims agent takes first notice of loss on an inbound call or in chat, opens the claim in your system, and reads the estimates, invoices and reports that follow. It extracts the fields your process needs, checks them against the policy and your claims guidelines, flags gaps and inconsistencies, and prepares the file for an adjuster, who decides coverage and approves every payment. Built for auto, property and specialty claims teams handling high volumes of similar claims.
The problem
Claims teams handle a flood of routine work around every decision: taking the first report, chasing documents, re-keying estimates and invoices, checking the policy for limits and exclusions, and answering the same status question from the claimant again and again. Adjusters spend more time assembling files than judging them, claimants wait on hold for updates, and handling that varies from one adjuster to the next shows up in complaints and leakage. Automation that pays or denies claims on its own is not acceptable to regulators or customers. Preparing the claim so an adjuster can decide faster is.
What it moves
- Claim cycle time
- Time from first notice to a decision, by line of business.
- Adjuster time per claim
- How long an adjuster spends on a prepared file compared with assembling it.
- Status contacts handled
- How many status calls and chats are answered without pulling in an adjuster.
- Handling consistency
- Whether the same guideline is applied the same way across adjusters and offices.
How the agent works
Step 1
First notice of loss
A policyholder reports the loss on an inbound call answered by a voice agent, or in chat. The agent verifies the policy, captures what happened and opens the claim in your claims system.
Step 2
Documents arrive
Estimates, invoices, police and medical reports arrive by upload or email and are converted to text with a vision-capable model, scans and multi-page files included.
Step 3
Screen and extract
PII and prompt injection detectors flag the text before any reasoning model reads it, then dates, amounts, parties and line items are extracted into a fixed schema with the source page for each field.
Step 4
Check coverage and guidelines
The agent checks the claim against the policy's limits, deductibles and exclusions and your claims guidelines, grounded in a knowledge base, and flags gaps, duplicates and inconsistencies.
- Human review
Step 5
Adjuster decision
The prepared file, with extracted fields, source pages and flags, goes to an adjuster, who decides coverage and approves, edits or rejects any payment before it is issued.
Step 6
Status updates
Claimants ask for status by phone or chat and the agent answers from the live claim record, handing off to the adjuster when a question needs one.
Controls
Deploy on Dynamiq Cloud, or self-host in your own AWS, Azure, GCP, IBM Cloud, OpenShift or Kubernetes environment next to your claims system. For claims that carry medical or personal data, Dynamiq holds SOC 2, and signs a BAA for HIPAA workloads and a DPA under GDPR. Our engineers build the intake flow, extraction schema and coverage checks with your claims team before the agent touches a live claim.
- Rules your experts own
- Coverage, limits and fraud checks run as rules your claims leads can read and edit, with one finding per rule and saved test cases.
- An adjuster decides every claim
- The agent prepares and recommends. Coverage decisions, denials and payments always wait for a person's approval.
- Detectors before the model
- PII and prompt injection are flagged on claim documents before a reasoning model reads them, and the verdict is recorded on every run.
- Source page on every field
- Each extracted amount and date links to the page it came from, so an adjuster can check a figure in one step.
- Guidelines applied the same way
- Coverage checks run against your own guidelines in a knowledge base, so the same rule is applied the same way on every claim.
- Full audit trail
- Every run is traced and replayable, including the documents read, the guideline cited and the adjuster's decision.
Systems it connects to
- Claims administration and policy systems, over API
- Phone lines over SIP (Twilio, Telnyx or your own carrier)
- Web and app chat
- Email inboxes and uploads (Gmail, Microsoft Outlook, SharePoint)
- CRM (Salesforce, Microsoft Dynamics 365)
- Payment systems, over API, behind an approval gate
- Claims guidelines and policy wordings as a knowledge base
- Slack and Microsoft Teams for adjuster handoffs
Built with
- Voice AgentsVoice Agents answer calls on the phone, the web or your own backend, reason with an LLM, and speak back, with every turn measured.
- KnowledgeA knowledge base converts your documents into searchable context: ingestion, chunking, embedding and storage, managed for you or pointed at your own vector store.
- Guardrails and approvalsDetect PII and prompt injection before a model sees them, enforce content policies, and pause tool steps for a person to approve.
- Agent BuilderDesign an agent on a visual canvas or in the open-source Python SDK. Both compile to the same engine, so what you build ships either way.
Industries
- InsuranceAnswer policyholders by phone and chat, prepare claims and underwriting files, and keep an adjuster or underwriter approving every decision.
- HealthcarePatient intake, referral and document review, and clinical knowledge assistants, with PII and prompt injection screened before a model reads anything.
Questions and answers
Does the agent approve or deny claims?
No. It takes the first notice, prepares the file and flags issues. Coverage decisions, denials and payments always need an adjuster's approval.
Can it take first notice of loss by phone?
Yes. A voice agent answers inbound claim calls on your existing numbers, captures the loss and opens the claim, and transfers to a person when the caller needs one. Dynamiq does not place outbound calls.
Can it assess damage from photos?
Damage appraisal stays with your adjusters and the estimating tools you already use. The agent reads the documents around a claim, such as estimates, invoices and reports, and brings them into the file.
Which lines of business fit first?
High-volume lines with repeatable documents, such as auto, property and travel claims. Complex or litigated claims stay with adjusters, with the agent preparing the documents for them.
How do you handle medical and personal data in claims?
Detectors flag PII and prompt injection before a model reads claim text, the deployment can stay inside your own environment, and Dynamiq signs a BAA for HIPAA workloads and a DPA under GDPR. Detectors flag; they do not redact.
See this agent on your data.
Talk to our team. We will walk through how it works in your environment, with your systems.