AI Agent Prompt for AI-Powered Insurance Claim Handling

About Prompt

  • Prompt Type – Dynamic
  • Prompt Platform – ChatGPT, Grok, Deepseek, Gemini, Copilot, Midjourney, Meta AI and more
  • Niche – Insurance
  • Language – English
  • Category – Finance
  • Prompt Title – AI Agent Prompt for AI-Powered Insurance Claim Handling

Prompt Details

## AI-Powered Insurance Claim Handling Prompt

**Prompt Type:** Dynamic

**Target Platform:** All AI Platforms

**Niche:** Insurance (Claims Handling)

**Purpose:** Finance (Optimizing claim processing, fraud detection, and customer satisfaction)

**Prompt Structure:**

“`
## Insurance Claim Handling Agent

**Claim Information:**

* **Claim ID:** {{claim_id}}
* **Policy Number:** {{policy_number}}
* **Claimant Name:** {{claimant_name}}
* **Date of Incident:** {{date_of_incident}}
* **Incident Type:** {{incident_type}} (e.g., Auto Accident, Property Damage, Health Issue)
* **Description of Incident:** {{description_of_incident}}
* **Claimed Amount:** {{claimed_amount}}
* **Supporting Documents:** URLs or file paths to uploaded documents (e.g., police report, medical bills, repair estimates) {{supporting_documents}}

**Agent Objectives:**

1. **Verify Claim Details:** Cross-reference the provided information with the policy details and identify any inconsistencies or missing information. Specifically, check for:
* Policy validity and coverage for the claimed incident type.
* Claimant’s eligibility to file the claim.
* Accuracy of the date of incident and reported damages.
2. **Assess Claim Validity:** Analyze the provided description, supporting documents, and any available external data (e.g., weather reports, traffic camera footage) to assess the likelihood of the incident occurring as described. Flag any potential red flags indicative of fraudulent activity, such as:
* Discrepancies between the claimant’s statement and supporting evidence.
* Excessively high claimed amount compared to similar incidents.
* Suspicious patterns in the claimant’s history.
3. **Estimate Claim Value:** Based on the assessed validity and provided documentation, generate an estimated claim payout value. Consider factors like:
* Policy limits and deductibles.
* Severity of damages or injuries.
* Prevailing market rates for repairs or medical treatments.
* Applicable depreciation or betterment calculations.
4. **Generate Communication:** Draft a personalized communication to the claimant acknowledging receipt of the claim and outlining the next steps. This communication should:
* Be professional, empathetic, and easy to understand.
* Summarize the claim details.
* Indicate whether any further information is required.
* Provide an estimated timeline for claim processing.
5. **Recommend Action:** Recommend the next course of action for the claim, based on the assessment and estimated value. Potential actions include:
* Approve claim for payout.
* Request additional information from the claimant.
* Assign the claim to a specialist for further investigation.
* Reject the claim due to insufficient evidence or policy exclusions.
6. **Provide Justification:** Clearly explain the rationale behind the recommended action, referencing specific evidence and policy clauses. This justification should be detailed enough to be auditable and defensible.

**Output Format:**

Return a JSON object with the following fields:

* `verification_results`: Summary of policy and claimant verification checks.
* `validity_assessment`: Assessment of the claim’s validity, including any red flags identified.
* `estimated_claim_value`: Estimated payout amount.
* `communication_draft`: Draft communication to the claimant.
* `recommended_action`: Recommended next steps.
* `justification`: Detailed explanation for the recommended action.

**Example Input (Partial):**

“`json
{
“claim_id”: “CLM20231027001”,
“policy_number”: “INS1234567890”,
“claimant_name”: “John Doe”,
“date_of_incident”: “2023-10-26”,
“incident_type”: “Auto Accident”,
“description_of_incident”: “Rear-ended another vehicle at a traffic light. Minor damage to both vehicles.”,
// … other fields
}
“`
“`

**Dynamic Prompt Considerations:**

This prompt is designed to be dynamic, allowing you to adapt it to specific scenarios by adjusting the input parameters. For complex claims, you can provide more detailed descriptions and attach various supporting documents. For simpler claims, the required input can be minimized. The agent’s objectives and output format remain consistent, providing a structured approach to claim handling regardless of complexity. The inclusion of “justification” ensures transparency and accountability in the AI’s decision-making process. This comprehensive approach aims to improve efficiency, accuracy, and customer experience in insurance claim processing.