Autonomous AI Agents for Every Step of the Claims Process
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Claim resolution
Team capacity
of current OpEx
Autonomous AI Agents for Every Step of the Claims Process
Claim resolution
Team capacity
of current OpEx
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What is Agentic Claims Automation?
Claims are the highest-stakes process in insurance, yet most operations still run on fragmented tools that digitize individual steps while leaving humans to bridge every gap, chase every exception, and reconcile every system. The process stays manual. Backlogs, leakage, and inconsistency are structural, not incidental.
Otera replaces that patchwork entirely. Purpose-built AI agents execute the full claims lifecycle autonomously, from FNOL to settlement, under built-in governance with a complete audit trail. Humans set the rules. Agents run the operation. Every claim is resolved in minutes, not weeks.
AUTONOMOUS AI AGENTS
Meet Otera’s Autonomous Decision Agents for Claims Automation
Otera’s AI agents are purpose-built to run insurance operations on autopilot while keeping you fully in control with compliance and explainability at their core:
The impact
No claim can move until its data is clean. In most operations, handlers spend more time preparing submissions than making decisions, wrestling with skewed photos, mixed-language attachments, handwritten notes, and documents split across channels and days. This agent eliminates that entire bottleneck, converting any input into structured, decision-ready data in seconds.
How it works
- Reads structured and unstructured content using proprietary multi-step vision, including partially obscured fields, rotated scans, and documents where key data spans multiple pages
- Unifies inputs across PDFs, emails, images, and forms, even when one claim arrives in five formats over three days
- Maps every extracted field to policy and customer records, resolving ambiguity across source systems automatically
Why it matters
This agent removes the single largest time-tax in claims. Every minute saved upstream compounds across millions of claims into transformational OpEx reduction and dramatically faster cycle times.
The impact
Every misrouted claim doubles its handling cost. Every claim stuck in a manual sorting queue is a customer left waiting. This agent classifies and routes claims instantly using real-time signals including urgency, sentiment, policy type, region, and active catastrophic events, ensuring zero-backlog operations at any volume.
How it works
- Determines the optimal processing path within seconds of submission based on claim type, severity, channel, and policy attributes
- Elevates catastrophic-event and high-sensitivity cases for human-first handling while directing well-documented cases into autonomous flows
- Prioritizes re-submitted claims from waiting customers based on configurable business rules, so repeat contacts accelerate rather than requeue
Why it matters
This agent is the difference between an operation that scales linearly with headcount and one that absorbs any volume without degradation. During catastrophic surges, when traditional triage collapses, this agent maintains the same instant, precise routing that protects both CSAT and SLA compliance.
The impact
Coverage validation is the single largest drag on claims velocity and the primary source of financial leakage. Two handlers reading the same policy clause will not always reach the same conclusion. This agent converts policy wording into deterministic, self-enforcing rules and validates coverage instantly across all terms, limits, exclusions, and conditional requirements.
How it works
- Transforms policy documents into executable decision logic regardless of how they were originally written, formatted, or structured
- Detects eligibility conflicts, missing documentation, and special clauses, including conditional sub-limits, multi-peril overlap, and jurisdiction-specific regulatory riders
- Resolves nuanced conditions such as pre-existing exclusions and illness-linked disruptions where multiple coverage sections apply to the same event
Why it matters
This agent collapses what was a manual, judgment-dependent bottleneck into an instant, deterministic step. Interpretation drift disappears. Leakage stops at the source. Every claim receives identical, audit-ready coverage validation at a speed and consistency no human team can sustain.
The impact
Adjudication is where inconsistency costs real money. Across a portfolio of millions of claims, adjuster-by-adjuster variance in outcomes compounds into systemic leakage, compliance exposure, and unpredictable customer experience. This agent evaluates every claim against coverage rules autonomously and produces a fully traceable, audit-ready decision for every case.
How it works
- Calculates payable amounts using deterministic logic with zero variance between identical cases, regardless of volume, timing, or geography
- Resolves multi-coverage scenarios where overlapping policy sections, conditional endorsements, or cross-policy aggregation limits apply
- Produces line-by-line explainable reasoning structured for internal audit, regulatory review, and customer-facing communication
Why it matters
This agent replaces the most expensive source of inconsistency in claims operations. Every decision is identical for identical facts. Leakage from interpretation variance is eliminated. Regulators, auditors, and customers all draw from the same transparent decision trail.
The impact
Fraud imposes a dual cost: undetected fraud is direct financial leakage, while over-detection stalls legitimate claims, frustrates customers, and wastes investigator capacity. This agent, connected to your fraud data, surfaces high-confidence anomalies and behavioral irregularities continuously, often before human reviewers detect them.
How it works
- Flags duplicate submissions, emerging fraud clusters, and suspicious supplier patterns using ground-truth claims data and configurable detection rules
- Correlates signals across policies, claimants, and historical activity to identify coordinated behaviors that single-claim review would miss
- Delivers precision risk indicators that minimize false positives so analysts focus on genuine threats
Why it matters
This agent complements your existing fraud solution with a layer of pattern detection that rules-based systems cannot replicate. Fraud cases surface instantly. Legitimate claims flow without friction. Your operation stops choosing between sensitivity and speed.
The impact
Settlement defines whether a customer renews or churns. Inconsistent communication drives complaints, broker escalations, and regulatory attention, even when the underlying decision is correct. This agent executes all settlement decisions and delivers all customer and broker communications autonomously and consistently.
How it works
- Drafts settlement letters and customer updates tailored to claim type, outcome, channel, and language
- Initiates payment workflows with audit-ready logs, handling multi-currency settlements, partial payments, and multi-party splits
- Syncs every outcome across CRMs and finance systems so all systems of record reflect the same decision without manual reconciliation
Why it matters
This agent turns the most consequential moment in the claims journey into a source of competitive advantage. Every customer receives clear, empathetic, accurate communication backed by flawless execution. At portfolio scale, that consistency translates directly into higher retention, fewer complaints, and measurable CSAT uplift.
Core Agentic Skills for Claims Automation
Adaptable Across All Claim Types
Pet Claims
Settle veterinary claims autonomously, including treatment disputes and pre-existing condition exclusions.
Auto Claims
Consistent adjudication across damage, liability, and multi-party scenarios.
Home Claims
End-to-end execution from routine incidents to major losses with multiple trades.
Property Claims
Stable, governed processing from localized damage to catastrophe-driven volume surges.
Travel Claims
Instant eligibility, validation, and reimbursement across jurisdictions and policy types.
Health Claims
Complex medical billing, benefit logic, and provider disputes resolved autonomously.
Life Claims
Accurate beneficiary validation through settlement, including contested and multi-beneficiary cases.
Commercial Claims
Multi-party coordination across layered policies and complex commercial structures.
Liability Claims
Fault determination and coverage validation across disputed, multi-jurisdictional cases.
Device Protection Claims
Diagnostics, coverage enforcement, and payout execution for consumer devices.
Employee Benefits Claims
Eligibility and benefit decisions across employer-sponsored health, dental, and mobility plans.
Velocity for your Automation team, Governance for your Claims team
For your Automation team: Build fast without bottlenecks
A unified platform to design, govern, and scale autonomous workflows with full visibility. Guardrails are defined once and applied everywhere:
Before Otera
- Multi-week build and deployment cycles
- Data chaos requiring manual stitching
- Brittle automations that break on exceptions
- Human-dependent steps at every handoff
With Otera
- Configuration to production in days
- Any unstructured data, handled natively
- Resilient automation across every edge case
- End-to-end autonomous execution, humans govern
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Go live in
Autonomous Ops
Reusable Components
For your Claims team: Run autonomous claims with built-in governance
A faster, more consistent claims process that improves cycle times/CSAT and reduces leakage while freeing your team for complex cases.
Before Otera
- Tool sprawl, no unified governance
- Slow handling, low customer satisfaction
- No audit-ready oversight on decisions
- Leakage from adjuster interpretation variance
With Otera
- One governed, auditable agentic platform
- Same-hour resolution, for industry leading CSAT
- Full audit trail, every decision
- Deterministic logic, zero interpretation leakage
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CSAT
Autonomous Ops
Team Capacity
Get Unlimited Capacity at Lightspeed at a fraction of current OpEx
Run claims on autopilot while preserving governance and transparency. With Otera, you unlock top-line execution gains and bottom-line cost impact across your claims:
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10-30% higher CSAT
Same-hour settlement drives market-leading satisfaction.
Accelerated time to market
Go live in just 12 weeks.
Drastic churn reduction
Minute-level settlements eliminate attrition-driving delays.
Fraction of current OpEx
Autonomous claims remove manual processing cost.
Deterministic decision quality
Zero interpretation drift, zero leakage.
Risk reduction
Every autonomous decision is audit-ready.
The Autonomous movement has already begun
The world’s most regulated industries already use Otera for proven 90%+ end-to-end automation on mission-critical operations:
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100+ PREBUILT AGENTS
100+ Prebuilt Agents for Insurance
Deploy instantly across intake, validation, settlement, and customer communication workflows.
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Coverage Check Agent
Converts complex multi-clause policies and contracts into executable rules.
Loss Evidence Agent
Resolves conflicting adjuster, contractor, and policyholder evidence.
Medical Bill Agent
Structures multi-code billing for autonomous benefit decisions.
Claim Intake Agent
Any format, language, or quality into decision-ready data.
Auto Repair Invoice Agent
Validates every line item against regional repair norms.
Passport Agent
Cross-validates identity data across global passport formats.
Connect your existing infrastructure
Pioneering secure Agentic Automation
Trusted by leading Fortune 500 companies, Otera delivers best-in-class cyber security, data privacy and user trust with extensive encryption and infrastructure protection.
