Automated claims assessment flow
Automated claims assessment flow
Automate standard cases and reserve expert time for genuinely complex claims.
Problem
Insurance claims involve heavy document review and manual data entry. Most claims are straightforward: complete documents, clear coverage, and unambiguous amounts. Yet every claim follows the same human-intensive process. That limits adjuster capacity, lengthens resolution times, and increases data-entry errors.
Solution with Orbis Studio
Customers submit claim documents (policy copy, damage photos, reports) through the Insurance System component. The Agent analyzes documents and produces a structured pre-assessment: policy number, loss date, claimed amount, coverage status, and similar fields.
The flow then branches. Standard claims—covered, complete documentation, no anomalies—route to automated processing steps. Claims with missing documents, coverage disputes, or anomalies go to adjusters through HITL Gate. Adjusters receive a pre-assessment summary and enter their decision; the flow continues from there.
Every step is logged for audit.
Business outcomes
- Most standard claims complete without human intervention; adjuster capacity shifts to complex cases.
- Data-entry errors decrease because information is extracted from documents automatically.
- Consistent checks apply to every claim; coverage and completeness use the same criteria.
- Customers can track claim status in real time.
- Decision rationale and timestamps are recorded for audit and compliance.
Technical details
Orbis Studio components
| Component | Role |
|---|---|
| Insurance System | Receives claim submissions and attached documents |
| Agent | Document analysis, field extraction, pre-assessment report |
| HITL Gate | Adjuster approval for exception cases |
| If-Else | Routes standard vs. exception claims |
| Chat Output | Status notifications to customers |
Flow architecture
HITL Gate configuration
Actions table:
| Action ID | Label |
|---|---|
approve | Approve |
reject | Return |
escalate | Escalate to senior adjuster |
input_schema defines the form shown to adjusters. Suggested fields:
_15{_15 "type": "object",_15 "properties": {_15 "decision_rationale": {_15 "type": "string",_15 "title": "Decision rationale",_15 "description": "Explain why you approve, return, or escalate this claim."_15 },_15 "missing_documents": {_15 "type": "string",_15 "title": "Missing or incorrect documents",_15 "description": "List any missing or inconsistent documents, if applicable."_15 }_15 }_15}
Example agent system prompt
_12You are an insurance claims assessment assistant. From uploaded documents, extract:_12- Policy number_12- Date of loss_12- Claimed amount_12- Loss description_12_12Then evaluate:_12- Are documents complete?_12- Is the claimed loss covered?_12- Are there any anomalies?_12_12Present results as a structured summary.
Integration points
- Documents from customer portals attach to the flow via the Insurance System component
filesparameter. - A tool connected to the agent can call the policy core system API for verification.
- HITL Gate decisions can be sent to external systems through the Orbis Studio API.