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Artificial Intelligence in Insurance claims

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Insurance policies protect people and organisations from financial losses during the most upsetting times of their lives. According to studies, the majority of consumers believe that insurance companies will do everything possible  to avoid paying claims.

What AI can do in Insurance claims

In most cases, this isn’t true. There are numerous good reasons why an insurance company would reject a claim. The most common reasons for this are-

  • The claim is for something that isn’t truly covered by the policy,
  • It was filed too soon after the loss.
  • It lacked key details.
  • The policy wasn’t in effect when the loss occurred. Rarely, carriers could reject a claim.

The primary objective of the insurance sector is to support clients and ensure that they receive compensation for valid claims for which they are qualified for payment. The manual reliance on claims management processes is not free of bias, and not all claims that should be approved are approved. New technology can help here. More automation in claims processing means that rules, rather than human judgement, are used.

There will always be circumstances where a certain amount of human judgement is necessary to choose the best course of action for a claim. However, implementing automated rules based on artificial intelligence (AI) can lead to higher levels of consistency. This is because AI (most of the time) follows rules and does not make value judgments like humans do.

Health Insurance claim process using Artificial Intelligence

Health care and insurance are among the aspects of American life that people despise the most. Recent developments in AI may change this infamously unfriendly to consumers section of the insurance industry.


New technology solutions can use AI to collect data from various sources to complete the pre-approval process for health insurance companies. AI-powered technology might help insurers gather and quality-control all the information they need to pre-approve medical services and prescription pharmaceuticals rather than relying on overburdened office staff as healthcare providers.  AI also eliminates the back-and-forth between customers, providers, and insurers, intelligently pulling the right information from the right sources to deliver accurate and complete pre-approval requests.

Verify coverage and reduce denials

AI can sort through a variety of extremely complicated insurance documentation, much like the pre-approval method, to identify which treatments and procedures qualify for planning. There are even new software tools that promise to discover coverage that policyholders and healthcare providers didn’t even know existed. AI can’t change your policy or magically entitle you to coverage you don’t have. But it understands the terms of your plan and knows what you’re claiming and what you’re doing. They might be far better at showcasing their skills than individuals are. Using AI tools for this purpose can reduce the number of denied health insurance claims, ultimately helping consumers and providers.

Cost estimate

AI can help solve one of the biggest pain points in the healthcare system – lack of price transparency for consumers. By accessing data from insurers and healthcare providers, AI tools are able to identify different scenarios to generate cost estimates.

 Overall, the addition and adoption of AI in medical billing has the potential to make the process more user-friendly for everyday people needing medical care.

Artificial Intelligence and Human Bias in Claims Processing

It’s a well-known fact that people have unconscious and unspoken biases. We all have beliefs that influence our behaviour, even if we don’t know it. Decisions are subject to influence. We are not implying,  that claim adjusters will consciously give higher values to claims based on the insured’s sex, race, or other protected class. However, there are so many implicit biases in every decision we make every day that it is impossible to eliminate them.

By discouraging people from analysing particular insurance claims, AI may be able to more equitably assess who is at responsibility and the value of those claims. AI can expedite the claims process, at least for the majority of instances that are frequent and everyday, leading to quicker approvals and pay-outs to clients.

 Artificial intelligence isn’t perfect, but it’s still helpful

AI is not a remedy for all the challenges facing the insurance industry and its customers. However, it is true that artificial intelligence can process more complex data than humans would like. And at speeds we can only dream of. This processing power means AI can spot trends and make predictions. This will improve both the speed and accuracy of the claims process, ultimately improving the lives of consumers who rely on insurance for day-to-day protection and just need a claim. If it is damaged, it will be paid quickly.

About Apoorva: 

Apoorva is a technology services company that assists software products with ideation, developing prototypes, programming, creating a digital marketing presence and accelerating sales through direct contact. Over 150 for-profit and non-profit organizations, such as Xcel Energy, PeopleCare Health Services, Frontier Airlines and Centers for Spiritual Living have trusted Apoorva to build software. 

Apoorva was founded in 2001, has more than 50 employees, and uses proprietary and proven methodologies to bring technology products to the market. Contact us / Visit for more information.

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