Tier-1 Insurer Claims Triage
A tier-1 insurer automated first-pass claims triage with governed agents — human-in-the-loop for complex cases, policy-grounded decisions, and production go-live in 11 weeks with FDEE monitoring through catastrophe surge volumes.
A tier-1 insurer automated first-pass claims triage with governed agents — human-in-the-loop for complex cases, policy-grounded decisions, and production go-live in 11 weeks with FDEE monitoring through catastrophe surge volumes.
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Challenge
First-pass claims triage consumed adjuster capacity — FNOL backlogs grew during surge events while a prior chatbot pilot lacked policy grounding and failed compliance review.
The insurer needed agents that cite policy provisions, flag fraud indicators, and escalate ambiguous cases — not generic summarisation over unsecured document uploads.
Production deployment — not proof-of-concept
Governed agents with full audit trails
Embedded FDE delivery model
Operational accountability through go-live
Approach
Embedded FDEs connected policy admin, document stores, and FNOL channels via MCP. Knowledge graph structured coverage rules and exclusions for explainable retrieval.
Triage agent scored severity, reserve estimates, and fraud referral with confidence thresholds — sub-threshold cases routed to adjusters with full agent reasoning attached.
FDEEs red-teamed adversarial FNOL inputs and monitored quality 24/7 through catastrophe season.
Results
45% reduction in first-pass triage handling time. 3× surge capacity during catastrophe with 99.9% uptime. Full audit trail for every triage decision. Client reference available under NDA.
Production outcomes, not pilot metrics.
First-pass triage handling time.
Discovery to production go-live.
Surge FNOL capacity during catastrophe.
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Frequently asked questions
- Can Derisk360 provide references?
- Selected references are available on request during discovery calls.
- What industries are represented?
- Banking, insurance, financial services, and regulated enterprises globally.
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