Artificial intelligence (AI) is becoming embedded in the insurance claims lifecycle. Insurers are using AI tools to assist with claims triage, document review, fraud detection, loss assessment and coverage analysis. As a result, both insurers and insureds are finding that they need to adapt their approaches to claims preparation, evaluation and dispute resolution.
Humans remain in the loop, mostly, for now
Experience from other jurisdictions has demonstrated some of the risks associated with over-reliance on AI in insurance claims handling. These include allegations of, as well as court cases and class action suits relating to, systematically biased claims outcomes, algorithms designed or calibrated to prioritise cost reduction over fair claims assessment, and ongoing concerns regarding hallucinations and unsupported claims outcomes.
Despite advances in AI, complex claims continue to require human expertise. Large losses, business interruption claims, professional liability matters and novel coverage disputes frequently involve issues that cannot be resolved through automated analysis alone. Many insurers are implementing human in the loop protocols for complex claims that require management and input from experienced claims handlers.
For insurers, AI should be viewed as a tool that supports decision-making rather than replaces it. Meaningful human oversight remains essential, particularly where claims involve significant financial exposure or difficult questions of causation, liability or policy interpretation. The effiecincy gains offered by AI must be balanced against the need for fair and reasoned claims assessments.
Structured claims submissions
Complex insurance claims have traditionally involved large volumes of reports, correspondence, financial records and other supporting documentation. While experienced claims handlers can navigate extensive and unstructured information, AI systems generally perform best when information is organised, consistent and clearly linked to the issues relevant to cover under the policy.
As claims assessment becomes increasingly technology-assisted, both insurers and insureds will benefit from claims processes that prioritise structured information gathering, standardised documentation and clear articulation of the issues relevant to cover.
From an insurer’s perspective, claim forms should be structured to work in conjunction with their AI-enabled claims processes, so that key information is sought and obtained in a manner that is more easily and accurately processed.
For businesses, this means greater emphasis on preparing claims that are structured, evidence-based and easy to navigate.
Clear timelines, well-organised supporting documents and a logical explanation of the cause of loss, policy response and quantum are becoming increasingly important in ensuring a smooth claims process.
Claim decisions
The use of AI does not change the fundamental requirement that claims decisions must be capable of justification and supported by the facts and the policy terms. AI can assist insurers in identifying coverage issues, assessing quantum and highlighting inconsistencies within a claim.
However, complex claims often involve nuanced factual and legal questions that require judgment rather than simple pattern recognition.
Where a claim is rejected, partially declined or subject to significant adjustment, both the insurer and the insured should carefully consider the basis for the decision. This includes understanding the factual assumptions underpinning the assessment, testing whether policy wording has been interpreted correctly and requesting further explanation where necessary.
The role of brokers and advisers
The growing use of AI is also changing the role of brokers, risk advisers and claims professionals. Beyond assisting with the submission of claims, these advisers increasingly play a role in helping organisations present claims in a manner that can withstand automated scrutiny, identifying potential weaknesses in AI-assisted assessments, and facilitating engagement with insurers where claims become contentious.
As claims processes evolve, brokers and risk advisers are likely to become increasingly important in bridging the gap between AI-driven assessment and the commercial realities of complex insurance claims.
AI is becoming a permanent feature of the insurance claims landscape. The value for insurers lies in improving speed, consistency and efficiency, but those benefits will only be meaningful if they are supported by transparent reasoning, appropriate and experienced human judgment, and a continued focus on fair outcomes. For insureds and their advisers, the priority will be to ensure that claims are presented clearly and with sufficient evidence to withstand both automated and human scrutiny.
