openclaw/1kalin/afrexai-insurance-claims

Insurance Claims Processor

Process, analyze, and optimize insurance claims. Covers property, liability, workers' comp, auto, and professional indemnity.

What This Does

Takes raw claim details and produces:

• Structured claim summary with policy coverage mapping
• Liability assessment with supporting/weakening factors
• Reserve estimate with confidence range
• Subrogation opportunity analysis
• Red flag detection (fraud indicators, coverage gaps)
• Settlement recommendation with negotiation range
• Regulatory compliance checklist by jurisdiction

Usage

Provide claim details in any format — adjuster notes, policyholder statement, incident report, photos, or free text. The agent structures everything.

Quick Claim Analysis

Analyze this claim: [paste details]

Full Processing

Process claim for:
- Policy type: [commercial general liability / property / WC / auto / PI]
- Incident date: [date]
- Reported date: [date]
- Claimant: [name/entity]
- Description: [what happened]
- Claimed amount: [if known]
- Policy limits: [if known]
- Jurisdiction: [state/country]

Claim Analysis Framework

1. Coverage Determination

• Map incident to policy provisions
• Identify applicable endorsements and exclusions
• Flag coverage disputes early
• Check occurrence vs claims-made triggers

2. Liability Assessment

Score 1-10 on insured liability exposure:

• 1-3: Strong defense position, deny or minimal settlement
• 4-6: Mixed liability, negotiate
• 7-10: Clear insured liability, reserve and settle

Factors evaluated:

• Comparative/contributory negligence (jurisdiction-specific)
• Statutory obligations
• Contractual indemnity provisions
• Prior loss history pattern

3. Reserve Estimation

Three-point estimate:

• Low: Best case with strong defense
• Mid: Most likely outcome
• High: Worst case including litigation costs

Include:

• Indemnity reserve
• Defense costs (inside/outside limits)
• Allocated loss adjustment expense (ALAE)
• Unallocated loss adjustment expense (ULAE)

4. Fraud Detection

Red flags scored by severity:

• Claim timing patterns (Monday morning, policy inception proximity)
• Prior claim frequency
• Documentation inconsistencies
• Witness availability issues
• Financial stress indicators
• Description vs damage inconsistency

5. Subrogation Analysis

• Third-party recovery potential
• Evidence preservation requirements
• Statute of limitations by jurisdiction
• Cost-benefit of pursuit

6. Settlement Strategy

• Opening position and authority range
• Mediation vs litigation cost comparison
• Jurisdiction-specific verdict ranges
• Structured settlement considerations for large claims

Industry-Specific Modules

Property Claims

• Replacement cost vs actual cash value
• Business interruption calculations (gross earnings, extra expense)
• Ordinance or law coverage triggers
• Catastrophe event coordination

Workers' Compensation

• Compensability determination
• Return-to-work timeline
• Medical treatment guidelines by state
• Permanent disability rating estimates

Professional Liability

• Discovery rule and statute of repose
• Prior acts coverage analysis
• Consent to settle provisions
• Panel counsel selection criteria

Auto/Fleet

• Comparative fault allocation
• UM/UIM stacking analysis
• Medical payment coordination
• Total loss threshold calculations

Compliance Checklist Generator

Produces jurisdiction-specific compliance timeline:

• Acknowledgment deadlines
• Investigation completion requirements
• Payment timing obligations
• Required notices and disclosures
• Bad faith exposure triggers

Output Format

Every analysis produces:

1. Executive Summary — 3-line claim snapshot
2. Coverage Analysis — provisions, exclusions, disputes
3. Liability Score — 1-10 with reasoning
4. Reserve Recommendation — low/mid/high with breakdown
5. Red Flags — fraud indicators if any
6. Action Items — next steps with deadlines
7. Settlement Range — if applicable

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