Claim Payout Estimator Agent
Automatically compute claim payouts using policy rules compliance
Description
Challenge:
Manual claim payout calculations are time-consuming and prone to errors, leading to disputes, delayed settlements, and inconsistent application of policy terms. Ensuring compliance with coverage rules, deductibles, co-pay, sub-limits, and regulations adds further complexity.
How It Works:
The Claim Payout Estimator Agent computes settlement amounts for validated claims by applying policy coverage rules, financial limits, deductibles, co-pays, sub-limits, exclusions, waiting periods, and regulatory mandates. It produces structured payout results in JSON or Excel and generates customer-friendly summaries for transparency. The agent can simulate “what-if” scenarios, helping adjusters, underwriters, and customer service teams project payouts under varying rules. Integration with claims, settlement, and payment systems enables near real-time payout decisions while maintaining an auditable trail.
Benefits:
90–95% automation in payout calculations
Reduces settlement disputes by 60–70%
Payout time cut from hours to seconds
Real-time customer communication of payouts
Ensures 100% compliance with regulatory payout rules
Transparent and auditable calculation process
Features
Provides automated, rule-compliant, and transparent payout estimation for claims, combining policy logic, financial calculations, and regulatory checks.
Features & Capabilities:
Input Intake: Receive structured claim data post-validation
Policy Retrieval: Fetch coverage rules, sub-limits, and exclusions
Deductible Application: Apply applicable deductibles before co-pay
Coverage & Adjustment Calculation: Apply eligible costs, co-pay percentages, sub-limits, exclusions, and waiting periods
Final Payout Computation: Calculate net payable amount with regulatory compliance
Customer Summary: Generate payout explanation for transparency
Scenario Simulation: Estimate payouts under alternative policy scenarios
Output & Routing: Structured JSON/Excel results sent to settlement/payment workflows
Operating Blueprint
Knowledge Sources:
Policy coverage Repository coverage rules, Benefit schedules)
Deductibles & Co-pay Tables
Historical Claims & Settlement data
Regulatory Payout Guidelines
Currency & financial Calculation rules
Business Rules:
Deductible Application → Always subtract deductible first
Co-pay Handling → Apply policy-specific percentage
Sub-limit Validation → Ensure per-treatment or per-condition limits are respected
Exclusion Enforcement → Reject non-covered costs
Waiting Period → Deny payout for conditions within waiting periods
Regulatory Compliance → Adjust payouts per jurisdictional rules
Multi-Currency Handling → Normalize to policy currency
Maximum Coverage → Cap at sum insured
Tool Workflow:
Intake → policy Retrieval → Deductible & coverage Calculation
Adjustment Application → Final Payout Computation → compliance Check
Output Generation → JSON/Excel → Routing to Claims/payment System'
Audit Logging → Record each step for transparency
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