
Mor Segal
VP R&D at Five Sigma
Mor brings over a decade of experience in software development, specializing in high-scale, big data, and AI solutions. With a strong background in building and leading teams, Mor drives innovation in claims management technology.
10 MINUTE READ
Artificial intelligence (AI) is moving to take center stage in modern claims management. From automating routine tasks to analyzing data at unprecedented scales, AI is changing how insurance claims are handled, automating many parts of the claims lifecycle, and in some cases even facilitating straight-through-processing (STP).
But the real power lies in integrating AI with human expertise, creating a process that is effective, adaptable, and customer-focused. This synergy is reshaping how insurers approach claims management, with tangible benefits like accuracy, efficiency, and customer satisfaction.
AI’s Limitation in Claims Management
AI has become invaluable for processing vast datasets, identifying patterns, and executing repetitive tasks quickly and accurately. It can predict claims outcomes, detect potential fraud, and even optimize workflows by identifying bottlenecks.
Yet for all its amazing qualities, AI might struggle with nuance. It can only grasp context or make logical and ethical judgments to a certain extent. For instance, a system using AI technology for its claims management may flag an unusual pattern as fraud, but it takes human insight to discern whether the anomaly is legitimate or a red herring. For instance, an AI model might flag multiple claims submitted within a short time frame as potential fraud. However, a human adjuster might recognize that the pattern is due to legitimate circumstances, such as a natural disaster affecting multiple properties owned by the claimant, rather than fraudulent intent.
Moreover, AI lacks the emotional intelligence required to navigate sensitive situations, such as dealing with claimants who have experienced personal loss.
The Human Advantage: Where Claim Experience Meets Intuition
While AI is adept at crunching numbers and automating processes, human adjusters excel in areas that require contextual understanding and empathy. Claims are rarely black and white. A seasoned adjuster can interpret the gray areas—reading between the lines of a policy, understanding regional tendencies, or addressing the unique needs of claimants.
Human adjusters bring invaluable critical thinking to claims that involve multiple stakeholders, conflicting accounts, or ambiguous policy coverage. For example, in a multi-vehicle accident where liability is shared across multiple parties, AI can analyze the data and suggest possible scenarios based on historical claims. However, it takes an experienced adjuster to interpret nuances such as conflicting witness statements, local traffic laws, or potential subrogation opportunities.
Perhaps most importantly, humans offer the emotional intelligence AI lacks. Sure, people like to use AI models like ChatGPT to fish for compliments. ChatGPT is great at telling you what you want to hear. But somewhere between the third and fourth compliment it becomes meaningless. While AI can generate responses that sound reassuring, human interactions go beyond surface-level answers, addressing emotions, concerns, and expectations in a way that builds trust and confidence.
Whether it’s calming a distraught claimant or building rapport during negotiations, the ability to connect on a human level is irreplaceable in fostering trust and satisfaction.
The Benefits of Collaboration: Human and AI Handling Claims Together
The real innovation in claims management comes from blending human intuition with AI-driven insights. This collaboration ensures that each side enhances the other’s strengths while compensating for their respective weaknesses.
- Improved Accuracy: AI minimizes manual errors by handling routine tasks, while adjusters validate and refine the results to ensure they align with real-world complexities.
- Increased Efficiency: By automating repetitive processes like data entry, document analysis, and initial claim triage, AI frees up adjusters to focus on higher-value tasks that require their judgment.
- Better Customer Experiences: AI enables rapid responses and real-time updates, while adjusters provide the empathy and understanding claimants need during challenging times.
- Continuous Learning: With each handled claim, the system continues to improve. AI learns from outcomes, while human feedback fine-tunes the algorithms for even better performance over time.
Clive AI: The Human Claims Adjuster’s Best Friend
Clive™, the insurance industry’s first AI claims adjuster, represents the perfect synergy between advanced AI and human expertise, modernizing the way claims are handled. Rather than replacing human adjusters, Clive enhances their capabilities, freeing their time with automation, guiding them with actionable insights, and letting them focus on areas requiring more human skills, such as customer service and complex decision making.
Working on top of any Claims Management System (CMS), Clive brings a new level of efficiency, cost reduction, and accuracy to claims operations. By automating administrative and manual processes and offering data-backed recommendations, Clive allows insurers to focus their efforts where they matter most—on complex, high-value claims that require human judgment and empathy.
Developed by insurance experts for insurance professionals, Clive understands the intricacies of claims handling, policy interpretations, and compliance requirements. Clive acts as an experienced adjuster—recognizing subtle claims nuances, adapting to evolving circumstances, and ensuring every action aligns with company protocols and regulatory frameworks.
Adjusters who oversee claims handled by Clive experience significant improvements in efficiency and accuracy, achieving better outcomes and greater job satisfaction. Clive’s support allows them to showcase improved handling results, faster resolution times, and fewer errors.
Chief Claims Officers and team leaders also benefit from Clive’s capabilities, gaining greater visibility into claim operations, allowing for better resource allocation, performance tracking, and compliance adherence. Clive provides valuable analytics and reporting that empower leadership to make informed strategic decisions, helping insurers stay ahead.
Here’s what Clive can do:
Claims Analysis at Every Step
Clive continuously analyzes incoming claim data with AI precision, providing adjusters with real-time, data-driven insights. Instead of spending hours sifting through documentation, adjusters and claims leaders receive instant document summaries, highlighted potential red flags, and suggested next steps. This dynamic analysis allows adjusters to make informed decisions quickly and focus on strategic aspects of claim resolution.
Actionable Claim Planning for Streamlined Workflows
Clive generates step-by-step action plans based on the insurer’s Standard Operating Procedures (SOPs) and his deep expertise in claims management. Adjusters no longer need to manually outline the next steps; Clive offers a clear roadmap for claim progression, recommending whether actions should be automated or handled manually. Clive acts as a reliable guide, ensuring every claim is handled in the most effective and compliant manner, reducing adjusters’ workloads.
Interactive Assistance Through Conversational AI
Adjusters can interact with Clive via a friendly chat interface to get immediate answers to any claim-related queries. Whether it’s policy details, coverage clarifications, or procedural guidance, Clive provides instant, context-aware responses. His ability to resonate responses ensures adjusters fully understand the claim status and compliance requirements. Clive provides quick and easy access to claim data without endless searches, acting as an on-demand claim expert.
Automated Execution: Clive Doesn’t Just Advise, He Acts
Whether it’s automating FNOL data entry, analyzing and paying invoices in a click of a button, or assisting with claimant communications, Clive drives speed and accuracy across the claims process. Adjusters can choose to have Clive take action or manually review tasks before execution. Additionally, when enabled, Clive can apply Straight-Through Processing (STP), automating simple claims from FNOL to resolution without manual intervention.
Built-in Quality Assurance and Compliance Monitoring
Clive continuously monitors claims handled by adjusters, cross-checking actions against SOPs and compliance requirements. He catches potential errors before they escalate, ensuring consistency in claim handling and reducing the risk of regulatory fines. Clive’s proactive quality assurance saves adjusters valuable time and helps insurers maintain compliance effortlessly.
Conclusion: Modern Claims Management Requires Both AI and Humans
The near future of claims management is not about choosing between AI and human expertise—it’s about combining them. Together, they create a process that is faster and better than either could achieve on its own. Insurers that embrace this hybrid approach will set the standard for what claims management can become.