AI for insurance claims & underwriting

Agentic InsuranceAI employees that read, check and route every claim

Software for insurers. AI employees read claim documents, check them against the policy, score fraud risk and send each claim down the right path. Your adjusters approve what matters.

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The problem

Insurance still runs on paperwork and hand-overs.

From the first lead to the final claim, a policy passes through many teams and systems. Every hand-over adds re-typing, waiting and room for error. Customers feel each delay, most of all when they make a claim.

A tall stack of paper files marked with coloured sticky notes

One policy, six hand-overs

  1. 01 Lead Delay
  2. 02 Sale Re-typed
  3. 03 Policy issued Bottleneck
  4. 04 Premium paid Hand-over
  5. 05 Servicing Delay
  6. 06 Claim

  • Manual, repetitive work

    Staff type the same data from forms, invoices and medical summaries into several systems.

  • Teams and systems that do not connect

    Sales, policy administration, finance and claims each hold part of the picture, so work waits at every hand-over.

  • Operating costs that keep rising

    More claims are met with more people, not with better processes. Medical costs keep rising too.

  • The claim decides loyalty

    A fast, clear claim is the moment a customer decides to stay. A slow or confusing one is when they leave.

AI employees

One AI employee for each job.

Each AI employee has one job description and its own access rights, and works only on that job. Together they cover the whole policy lifecycle. Every one of them reports to a person on your team.

01

Acquisition

Find and qualify the right prospects.

  • Prospect researcher

    • Analyses prospect data
    • Personalises digital campaigns
    • Scores leads

  • Market analyst

    • Spots market trends
    • Segments customers

  1. Acquisition

    Prospect researcher · Market analyst

    Find and qualify the right prospects.

    Prospect researcher

    • Analyses prospect data
    • Personalises digital campaigns
    • Scores leads

    Market analyst

    • Spots market trends
    • Segments customers

  2. Sales

    Product advisor · Sales assistant

    Help prospects choose and apply.

    Product advisor

    • Suggests products that fit the customer
    • Finds cross-sell and up-sell opportunities
    • Suggests product bundles

    Sales assistant

    • Answers prospects in chat straight away
    • Qualifies prospects
    • Helps them finish the application

  3. Issuance & payment

    Policy issuer · Payment manager

    Underwrite, issue the policy and collect premiums.

    Policy issuer

    • Prepares underwriting checks
    • Creates the digital policy document
    • Validates applicant data

    Payment manager

    • Processes premium payments securely
    • Flags suspicious payments
    • Sends bills on schedule

  4. Servicing

    Service agent · Account keeper

    Answer policyholders and keep records current.

    Service agent

    • Answers questions at any hour
    • Resolves first-level requests
    • Escalates to the right person

    Account keeper

    • Updates policyholder data
    • Records preferences
    • Sends notices before they are needed

  5. Claims

    Claim assessor · Claim investigator

    Assess claims and investigate the unusual ones.

    Claim assessor

    • Reads claim documents and damage photos
    • Estimates the claim amount
    • Verifies the documents

    Claim investigator

    • Detects unusual patterns
    • Gathers digital evidence
    • Recommends a decision to the adjuster

  6. Retention

    Retention analyst · Loyalty manager

    Keep policies in force and renew them.

    Retention analyst

    • Spots policies at risk of lapsing
    • Reads customer sentiment
    • Recommends retention actions

    Loyalty manager

    • Personalises rewards
    • Sends renewal offers on time
    • Analyses customer feedback

Oversight

Supervisor

An AI supervisor checks the quality of every AI employee’s work and reports it to the people responsible on your team.

Role names are examples. You choose which AI employees to start with.

How it connects

It works inside your systems, under your rules.

Agentic Insurance is software you run. Matajari delivers it and sets it up with your IT team, connected to the systems you already have.

  1. Channels

    Where requests arrive from customers, agents and staff.

    • Chat
    • Voice
    • Web
    • Email

  2. Orchestration

    Gives each task to the right AI employee and applies your rules and approval steps.

  3. Language model layer

    Reads, writes and reasons. Models can be swapped without rebuilding the rest, so you are not tied to one AI vendor.

  4. Integration layer

    Connects through secure interfaces and your workflow engine.

  5. Your core systems

    Stay the system of record.

    • Policy administration
    • Claims
    • Payments
    • Customer records

  • Sensitive data stays with you

    Health records and personal data stay in your own data centre or private cloud.

  • Heavy work can scale out

    Workloads that need more computing power, such as reading large batches of documents, can run in a cloud environment you approve.

How a claim moves

From claim to payment, with people at the gate.

Every claim follows the same path. Simple claims go straight through. Anything complex or unusual goes to an adjuster, with the groundwork already done.

  1. 01

    Claim comes in

    The customer sends photos of the invoice, medical summary and ID card by web, chat or email.

  2. 02

    Documents are read

    Text recognition (OCR) reads each page and picks out the fields that matter.

  3. 03

    Claim is checked

    Coverage, benefits and limits are checked against the policy. The claim gets a complexity score and a fraud-risk score.

  4. 04

    Decision gate

    Your rules choose the route: confidence, claim value and risk score against thresholds your team sets.

Three routes

  • Simple

    Straight through

    High confidence, low value and low risk: approved automatically. Your team still reviews a sample of these.

  • Medium

    Fast track

    Moves to the front of an adjuster’s queue, with the documents already summarised.

  • Complex or suspicious

    Manual review

    An adjuster or investigator decides, with the AI’s findings and evidence attached.

05

Decision and payment

The customer hears the outcome and approved claims are paid. Every step is on record.

The thresholds and the size of the review sample are your own settings.

What it checks

Three checks on every claim.

Before a claim reaches the decision gate, the AI reads the documents, looks for signs of fraud and checks the claim against the policy.

Reads the paperwork

Photos and scans become structured data, so nobody has to type them in.

  1. 01

    Collect

    Invoices, medical summaries, diagnosis letters and ID cards arrive as photos or scans.

  2. 02

    Recognise

    Text recognition (OCR) turns each page into text.

  3. 03

    Understand

    The layout is read to find fields such as patient name, service date, diagnosis and amount billed.

  4. 04

    Validate

    Rules and models check each field and give it a confidence score. Low scores go to a person.

Controls

People approve what matters.

AI employees prepare, check and recommend. Your people make the decisions that carry risk, and every step is on record.

A person signing a document at a desk

AI employees can

  • Read and sort incoming claims
  • Check documents, coverage and limits
  • Score risk and recommend a decision
  • Approve simple, low-value claims within the limits you set

Your people decide

  • Claims above your thresholds
  • Every decline
  • Every suspected fraud case
  • Any change to rules or thresholds

Risks designed out from the start

  • Risk

    Inconsistent explanations

    Safeguard

    Answers come only from a knowledge base you approve, and are checked against compliance rules before they go out.

  • Risk

    Wrong answers

    Safeguard

    The AI looks things up in curated sources and declines questions outside its remit instead of guessing.

  • Risk

    Wrong actions in your systems

    Safeguard

    Approval steps, a separate test environment and a full log of every action.

  • Risk

    Personal data exposure

    Safeguard

    Personal data is masked, encrypted and visible only to the roles that need it.

  • Risk

    Dependence on one AI vendor

    Safeguard

    A model layer that lets you change AI models without rebuilding.

Built-in controls

  • An audit trail of every decision and every human override
  • Role-based access and data-loss prevention
  • Monitoring of model accuracy and drift, with rollback
  • Bias checks and explanations for each recommendation
  • Consent records and data-retention rules

Built to support your obligations under

  • Law No. 27 of 2022 on Personal Data Protection (UU PDP)
  • POJK No. 4/2021 on IT risk management for non-bank financial institutions
  • POJK No. 22/2023 on consumer protection in the financial services sector

Compliance stays your responsibility as the licensed insurer. The software gives you the controls and records to show it.

Implementation

Start small. Grow claim by claim.

A phased rollout lowers risk and lets your team learn at every step. Each phase delivers something your claims team can use before the next one starts.

  1. Phase 1

    Foundation

    Business case, data inventory, target architecture and an AI governance policy.

  2. Phase 2

    Document reading

    Digital claim intake and automatic data extraction for reimbursement claims.

  3. Phase 3

    Triage and fraud scoring

    Claims routed by complexity and risk, with model monitoring from day one.

  4. Phase 4

    Automatic approval

    A rules engine approves low-risk claims, and your team reviews a sample.

  5. Phase 5

    Assistants and the wider lifecycle

    An internal knowledge assistant, medical summaries, and AI employees for sales, servicing and retention.

The data we work with

  • Policy and benefit data

    Coverage, riders, limits, waiting periods and exclusions.

  • Claim records

    Dates, claim types, amounts, status and timestamps.

  • Claim documents

    Invoices, medical summaries, diagnosis letters and ID cards.

  • Provider and medical data

    Diagnosis and procedure codes, the provider network and tariffs.

  • Past outcomes

    Which claims were approved or declined, and which were confirmed as fraud.

Your programme team

  • Business sponsor
  • Product owner
  • Architecture lead
  • Integration lead
  • Insurance specialist
  • Compliance lead
  • Quality supervisor

Where we suggest starting

Small-value health claims, with document reading first and people approving every decision until the results earn trust.

Frequently Asked Questions

Everything you need to know about Agentic Insurance.

Software that gives insurers AI employees for claims and policy work. They read claim documents, check coverage, score fraud risk and prepare decisions. Your team approves what matters.
You do. Matajari delivers the software and sets it up with your team. It runs in your environment, under your brand and your rules.
Only simple, low-risk claims within limits you set, and you can switch that off. Claims above your thresholds, every decline and every suspected fraud case go to a person.
It is not tied to one AI vendor. The language model layer can be changed without rebuilding the rest, and sensitive data stays in your environment.
Personal data is masked, encrypted and visible only to the roles that need it. Sensitive data stays in your data centre or private cloud, and every access is logged.
Claims are the usual starting point. The same AI employees can also cover acquisition, sales, policy issuance, premium payment, servicing and retention.
Usually with document reading for small-value health claims. Triage, fraud scoring and automatic approval follow, phase by phase.

See it on your own claims

Book a demo and walk through the claim flow with documents like the ones your team handles every day.

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