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AI agents in insurance: claims, policies, evidence

Insurers encounter AI agents in two places: as their own agents in claims and customer service, and as their customers' agents reporting claims or concluding policies. In both cases, it must be clear who acts on whose behalf.

, Founder, Innopulse Consulting GmbH
Published

Key points

  • Insurers encounter their customers' agents and deploy their own agents in claims handling.
  • Conclusions, cancellations and claim reports need proof of representation.
  • Timestamps prove deadlines such as receipt of a cancellation.

Starting point

Insurance processes are document-heavy and rule-based, ideal for automation. At the same time, money and rights hang on every action: a claim report triggers payments, a conclusion creates a contract, a cancellation ends coverage. When agents take over these actions, the insurer must recognize whether the customer's agent really acts for her and within which limits.

Conversely, insurers deploy their own agents, for example for the initial review of claims or for goodwill decisions. Their authority must be just as clearly limited and provable.

Typical scenarios

  • Claim report by the customer's agent: the agent submits photos, invoices and a description. The insurer checks whether a mandate from the policyholder exists.
  • Comparison and conclusion: an agent compares offers and concludes household insurance up to a premium the customer has set.
  • Cancellation and switch: an agent cancels on time and switches to a cheaper offer.
  • Internal claims agent: an insurer's agent approves small claims up to a limit itself and escalates everything above it.

What must be verified

For customers' agents: whether a valid, unrevoked mandate from the policyholder exists, whether the agent is bound to it and whether the action, such as a conclusion up to a premium, lies within scope. For the insurer's own agents: whether every approval stayed within the internal authority rules and whether a decision and a receipt exist.

In disputes, it counts that the time of every action is proven independently, such as receipt of a cancellation before the deadline. A qualified timestamp makes this reliable.

In Switzerland, the Insurance Contract Act governs the contract and the Code of Obligations governs representation: if an agent acts without sufficient authority to act, it generally does not bind the customer. In the EU, the rules of the Insurance Distribution Directive (IDD) apply to distribution, for example on advice and information. Data protection law requires that agents receive only the necessary details, especially for health data.

Adoption

Insurers best start with actions governed by clear rules: cancellations and address changes by customers' agents, small claims by their own agents. For every action admitted, they define which evidence they require and verify it with KYA or their own integration of the engine.

First steps in 30 days

  1. Week 1: define the actions customers' agents may carry out, such as cancellations and address changes.
  2. Week 2: define the evidence required for them and test verification with the engine.
  3. Week 3: equip internal agents with limits from the authority rules and introduce decisions.
  4. Week 4: keep receipts and timestamps and verify first samples with KYA.

Frequently asked questions

May an AI agent conclude an insurance policy?

If the customer has authorized it to. The insurer should require evidence naming principal, agent and limits, such as a mandate with a maximum premium.

How does an insurer know a claim report is wanted by the customer?

From the policyholder's mandate, which is bound to the reporting agent and allows claim reports. Without this evidence, the report remains a statement without proven representation.

May the insurer's own agents approve claims?

Within the internal authority rules. Every approval should be checked against a mandate, signed with a decision and recorded.

What role does data protection play?

Agents should receive only the details they need. Selective disclosure allows a mandate to be presented without revealing all personal details.

How do I deal with intermediaries who use agents?

As with other representatives: the intermediary proves its authority, and its agent acts within that scope. A delegation chain makes the hand-over verifiable.

General information, not legal advice. The statutes and the circumstances of each case are decisive.

Sources

  1. Richtlinie (EU) 2016/97 (Versicherungsvertrieb, IDD): https://eur-lex.europa.eu/eli/dir/2016/97/oj
  2. Versicherungsvertragsgesetz (VVG, Schweiz): https://www.fedlex.admin.ch/eli/cc/24/719_735_717/de
  3. Obligationenrecht (OR), Art. 32 ff.: https://www.fedlex.admin.ch/eli/cc/27/317_321_377/de#art_32