Claim #2024-08745 just came in. Motor TPL, customer active for 8 years. Can you classify it?
AGENT · CLAIMS TRIAGE
Claims reach the right handler, classified at the source.
Claims Triage receives the incoming claim from the carrier's management system (after FNOL), classifies it by severity, potential fraud signals, handling complexity. Routes to the right claims handler under the carrier's rules. The liquidation decision stays with the adjuster.
Claims Triage at work.
Severity: low — estimated €4,500, below the corporate value threshold. Dynamics: claim form submitted, simple counterparty, no injuries. Fraud: no signals (standard history, counterparty not on watchlist, geolocation consistent). Complexity: standard. Routing to the motor TPL handler pool. Assigned to Julia Marchetti (lowest current load).
Good. Registry OK?
Yes. The full event is in the runtime audit registry, readable for Reg. IVASS 41/2018 audit.
Why it exists.
The flow of claims in a mid-large carrier is massive. The operational problem is not the absence of systems — the claims are in the management system — it is the internal triage: who looks at every claim at opening, who classifies it by severity, who recognises potential fraud signals, who decides which claims handler to route it to.
How it works each day.
Claims Triage is the second agent of the Claims insurance squad, activated after FNOL Inbound. It receives the just-opened claim, applies the declarative classification rules (severity, fraud signals, complexity), routes the claim to the right claims handler based on the carrier's configured mapping. The claims handler receives the claim on the work channel with the classification and context ready.
The decision stays with the claims handler.
The handling decision stays with the claims handler under the carrier's procedures. The agent classifies and routes. The liquidation decision, external surveyor activation, and anti-fraud investigation opening stay with the claims handler, the surveyor, or the SIU.
Claims manager, handler, and head of anti-fraud.
Claims manager
The carrier's claims manager reclaims manual triage time and sees only the claims with recognised criticality. The claims team's capacity dimensions on the real volume of cases that require judgement, not on the total volume of incoming claims.
Claim type Auto liability
Severity Medium
Adjuster Dr. Ferrari · Northeast
Initial reserve € 4,200
Routed ✓
Claims handler
The claims handler receives pre-classified claims with context ready. They concentrate on claim handling — surveyor work, customer communication, settlement — not on initial triage. Average handling time per case goes down.
WhatsApp «I had an accident, this is Rossi»
Type Auto liability · medium
Policyholder Rossi Marco
Policy #IT-2024-04471
Case opened · CRM updated
Head of anti-fraud (SIU)
The head of anti-fraud sees, in a structured way, the claims flagged for potential fraud patterns. The SIU's capacity concentrates on the higher-risk cases, with the detail of the detected patterns ready on the work channel.
Auto liability · #2024-0847
Current reserve € 4,200
Proposed reserve € 3,850
Underwriting aligned ✓
Proposal ready · awaiting adjuster
300 claims a day, immediate triage after FNOL.
Claims Triage activates when FNOL Inbound closes the structured case.
For a multi-line carrier with 300 incoming claims per day (motor TPL, property, life, health), Claims Triage is scheduled as an immediate trigger after FNOL. A motor TPL claim enters the management system in the morning, already structured by FNOL Inbound. Claims Triage activates and extracts the data: customer active for eight years with standard claims history, estimated value €4,500, claim form submitted, counterparty identified.
Severity, fraud, complexity: three dimensions in parallel.
The agent compares against the carrier's rules: severity low (amount below the configured threshold), no fraud signals (standard history, counterparty not on watchlist, geolocation consistent), complexity standard (full claims-handler handling with no external surveyor). The classification is structured, not discretionary, and follows the declarative rules written by the claims team and the SIU.
The claims handler receives the case with context ready.
The agent routes to the motor TPL pool, assigning the claims handler with the lowest current load. The handler receives on the work channel: structured data from FNOL Inbound, Claims Triage classification, proposed next action (contact customer within 48 hours for document confirmation). The full event stays in the runtime audit registry for Reg. IVASS 41/2018 audit.
Declarative rules, versioned mapping.
The Claims Triage rules are declarative. The claims team, the anti-fraud SIU, and the head of compliance at the carrier define in a readable format the severity rules (value thresholds, complexity criteria), the potential fraud signal patterns, the classification-to-claims-handler mapping. The rules live in the carrier's repository, versioned, validated at agent startup.
Integration with the carrier's claims management system is delivered via a dedicated adapter during the project by the Exelab team. Supported systems include Guidewire ClaimCenter, Duck Creek Claims, and proprietary systems.
- Language
- TypeScript (Node.js)
- LLM model
- customer's choice: Anthropic, OpenAI, Mistral, open source models hosted internally, AWS Bedrock for a private model
- Built-in controls used
- pii-detector, credential-detector, topic-guardrail, tool-param-validator
- Native delivery channels
- Slack, Telegram, WhatsApp, OpenAI-compatible HTTP
- Claims management system integration
- dedicated adapter delivered during the project (Guidewire ClaimCenter, Duck Creek Claims, proprietary systems)
- Anti-fraud and classification rules
- declarative, versioned, written by the claims team and the SIU
- Memory
- persistent per instance, pgvector + PostgreSQL FTS on customer context and historical patterns
- Registry
- append-only, queryable with a standard SQL client (Reg. IVASS 41/2018 audit inspectable)
Frequently asked questions about the agent.
FNOL Inbound is the first agent of the Claims squad: it receives the notice from the customer, opens the structured case. Claims Triage is the second agent: it classifies the just-opened claim, routes to the right claims handler. The two agents work in sequence in the same flow.
Claims flagged with fraud signals are not blocked automatically. The agent classifies them as 'requires SIU review' and routes them to the SIU before the standard claims handler. The SIU assesses the case and decides whether to activate an anti-fraud investigation or return the claim to the standard handler. The investigation decision stays with the SIU.
No. The agent classifies and routes. The liquidation decision, external surveyor activation, and anti-fraud investigation opening stay with the claims handler, the surveyor, or the SIU under the carrier's procedures.
The typical pattern for Claims Triage at a mid-large carrier is 10-14 weeks. Discovery 2 weeks, classification and anti-fraud rule configuration 4-5 weeks, claims management system integration 3-4 weeks, hand-off to the claims team 1-2 weeks.
From a 30-minute conversation to the squad in production.
A 30-45 minute conversation to understand how Claims Triage would configure to the carrier's case. Which claims management system, which claim taxonomy, which classification and anti-fraud rules.