Life Insurance Claims Processing

Sample Life Insurance Claims Processing Workflow

Life insurance claims processing is a multi-step journey that spans document intake, eligibility checks, payout decisions, and regulatory reporting.

Each step is manual-heavy, claims adjudicators review death certificates, verify beneficiaries, assess contestability, and calculate payouts, often while switching between systems and referencing policy terms and legal documents.

The diagram below shows a typical claims processing workflow.

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This is a representative workflow. Our agentic AI can adapt to your team’s specific systems, steps, and priorities.

Each stage in this flow can be augmented with AI agents to reduce manual effort, improve speed, and ensure consistency.

Augmenting Life Insurance Claims Processing With AgentFlow

1. Initial Review and Triage

Before AgentFlow:
Claims adjudicators manually open and classify incoming files, such as death certificates, policies, medical records, and legal documents. They verify policy coverage and identify contact information for the beneficiary. This step is time-intensive, especially when forms arrive in varied formats.

With AgentFlow:
Document AI classifies documents automatically. Decision AI validates policy coverage against internal rules, while Unstructured AI extracts and verifies beneficiary contact details from messy, scanned documents.

Value:
Faster triage, fewer misfiled claims, and immediate identification of key data. Adjudicators can start meaningful review work sooner.

2. Diligence and Verification

Before AgentFlow:
Adjudicators manually check medical history, assess contestability windows, and confirm beneficiary eligibility. This often means toggling between PDFs, policy platforms, and spreadsheets.

With AgentFlow:
Conversational AI retrieves and summarizes medical records. Database AI connects to internal and external systems for historical payment data. Decision AI runs checks against contestability criteria and eligibility rules.

Value:
Adjudicators spend less time gathering information and more time validating results. Outputs are structured, consistent, and traceable.

3. Evaluation and Decision

Before AgentFlow:
Human adjudicators determine whether to approve or deny the claim and calculate the payout. They must manually reconcile policy rules, state regulations, and benefit tables.

With AgentFlow:
Decision AI applies payout logic, benefit caps, and authorization rules automatically. Edge cases get flagged for human review based on confidence thresholds.

Value:
More consistent, rule-aligned decisions. Agents accelerate the approval process while keeping humans in control of complex determinations.

4. Report Generation

Before AgentFlow:
Teams manually compile policy closure documents, tax forms, and internal audit reports. This process can take hours and may introduce inconsistencies.

With AgentFlow:
Report AI produces closure reports automatically, prefilled with details from earlier steps. Regulatory documents are generated in standard formats, ready for submission or archiving.

Value:
Faster reporting, fewer errors, and audit-ready documentation, no more chasing down data.

How AgentFlow Ensures Security, Governance, and Trust in Life Insurance Claims Processing

AgentFlow is purpose-built for regulated sectors like insurance, where data integrity, auditability, and human oversight are essential.

• Deployment that puts you in charge: AgentFlow is deployed securely inside your own infrastructure, whether in your cloud environment or on-premises. That means your data never leaves your walls. All information is fully encrypted, and access is strictly controlled, so only the right people can see or modify anything.
• Every AI action is traceable: From the first document upload to the final claims decision, every step an agent takes is logged. You get a complete, uneditable audit trail that includes who did what, when, and why. This gives compliance and audit teams full visibility, no more digging through disconnected systems.
• Governance is built in, not an afterthought: AgentFlow is designed to make sure sensitive decisions are handled responsibly. Low-confidence cases are automatically flagged for human review, and user roles define exactly what each person or agent can access or do. The system is also kept up to date with the latest industry regulations and internal policies through regular retraining and testing.
• Meets and exceeds compliance standards: AgentFlow is certified to the highest security and data standards, including SOC 2 Type II and PCI DSS 4.0. It’s also built with future certifications in mind, like ISO 27001 and GDPR Article 42. Regular third-party testing and rapid patching keep your system resilient and up to date.
• AI that learns responsibly: You’re never flying blind. AgentFlow continuously improves through human feedback and performance monitoring. You stay in the loop, and the system gets smarter over time, without ever making decisions you can’t explain.

Ready to Adapt Agentic AI to Your Workflow?

AgentFlow adapts to your unique claims process, decision logic, and compliance requirements. Every AI agent is configurable. Every action is traceable.

See how you can modernize life insurance claims with agentic workflows. Book a demo today and see AgentFlow in action.