InsuranceLegal & Compliance
Claims review. Coverage checked, not just read.
Cross-references every claim against the policy terms and the insured's prior claim history, surfacing coverage gaps, exclusion matches, and likely denial reasons before an adjuster starts the file — every finding cited to the policy and the claim record. Built for carriers and TPAs reviewing high claim volumes.
14 cited fields per claim. Built on Sphere AI Foundry.
claims_review — claim #CL-88214LIVE
00:00Ingest → FNOL + policy HO-3, insured J. Alvarezread
00:03Peril match → water damage, covered peril under Sec. Ipassed
00:06Exclusion check → gradual seepage exclusion, possible matchflagged
00:09Prior claims → 2 similar water losses in 18 monthsflagged
00:11Classification → Likely partial denial, 2 findingssealed
review time 9sfields cited 14/14adjuster sign-off required
Built on Sphere AI Foundry·NAIC market conduct aligned·21 years, 300+ clients
Manual coverage review doesn't scale with volume
A single coverage review means an adjuster reading the policy declarations, every endorsement, the loss notice, and the insured's prior claim file, then reasoning through exclusions and precedent by hand before writing up a recommendation. At low volume that's manageable. At hundreds of first notices of loss a week, it's the bottleneck between intake and a defensible coverage decision.
88%
faster first-pass coverage read vs. a manual file review
14
fields extracted & cited per claim
100%
of findings traceable to a policy or file citation
Claim in, cited coverage read out
Four steps, every one logged and citable back to the policy and the claim file.
01
Ingest
Reads the claim and policy directly from your systems
First notice of loss, adjuster notes, the full policy with declarations and endorsements, and the insured's prior claim history — read from your claims management system, policy admin system, or document repository. No separate upload step.
Source documents
Claim #CL-88214 — HO-3 policy, insured J. Alvarez
02
Cross-check coverage
Every peril and exclusion checked against the policy
Reported peril, effective dates, sub-limits, endorsements, and named exclusions — each checked against the specific policy language in force at the date of loss, not a generic coverage summary.
Example query
"Does the gradual-seepage exclusion apply to this water loss?"
03
Check prior history
Flags patterns across the insured's claim history
Prior claims on the same peril, same location, or same policy period are surfaced automatically — a signal adjusters otherwise have to dig for manually across separate claim files.
Cited finding
Two prior water-damage claims on this policy in the last 18 months (CL-81002, CL-84417), both closed with repair payouts under $4,000.
cited to claims history, policy #HO-3-99120404
Classify & route
One classification, one consolidated finding list
The agent returns Likely Covered, Likely Partial Denial, or Likely Denial, with a consolidated list of coverage gaps and denial reasons for adjuster sign-off before the coverage letter goes out.
Classification
Likely CoveredLikely Partial Denial ✓Likely Denial
14 fields, every one cited
What the agent extracts from every claim it reviews.
Coverage summary & classification
Policy effective-date & premium status check
Reported peril & loss description
Applicable endorsements & sub-limits
Exclusion matches, cited to policy section
Deductible & limit calculation
Prior claim history on the policy
Subrogation & third-party liability flags
Consolidated coverage-gap & denial-reason list
Adjuster review checklist & sign-off record
Typical inputs
What the agent reads, and what it connects to.
Documents
- Policy contract, declarations page, and endorsements in force at the date of loss
- First notice of loss (FNOL) and adjuster field notes
- Prior claim files on the same policy or insured
- Proof of loss, estimates, and repair invoices
- Police, fire, or independent adjuster reports where applicable
- State-specific claim-handling requirements and unfair-claims-practices rules
Systems
- Claims management system
- Policy administration system
- Document repository or imaging system
Is this the right fit?
Built for volume — not a one-off coverage question.
✓ Works best for
- Carriers and TPAs processing high volumes of first-party claims
- Teams standardizing coverage review against fixed policy forms
- Operations wanting every denial reason traceable to policy language
Too small for
- A single coverage question senior counsel can answer faster than configuring the review
- Replacing adjuster judgment or the final coverage determination
- Complex litigated claims requiring bespoke legal analysis outside standard policy language
Grounded in the policy, not a black box
Compliance-first, the same standard every Sphere agent is held to.
The agent requires the complete policy and claim file before it will return a classification, and every review sits between claim intake and the adjuster's coverage determination — never past it. A licensed adjuster confirms every finding before a coverage letter or reserve change goes out.
Findings reference the specific policy form, endorsement, and applicable state unfair-claims-practices requirements directly — see how the same audit-trail standard applies across regulated deployments in Governed AI for Insurance Carriers and Private LLM Deployment for Insurance Claims Organizations.
Prerequisites complete file
Complete policy and claim documentation required before a classification is returned.
Human review required
A licensed adjuster confirms every classification before it reaches a coverage determination — never fully autonomous.
Regulatory grounding NAIC-aligned
Findings reference specific policy language and state unfair-claims-practices requirements directly in every review.
Foundation Sphere AI Foundry
Access controls and audit trail configured here carry forward to every other agent you deploy.
Frequently asked
Does the Claims Review Agent decide whether a claim is approved or denied?
No. It performs the coverage cross-check and surfaces likely denial reasons and gaps for the adjuster to review — the adjuster makes and documents the coverage determination. Nothing is paid or denied without that sign-off.
What lines of business does the Claims Review Agent support?
Property, auto, and general liability first-party and third-party claims out of the box. Workers' compensation and specialty lines can be added during onboarding with the relevant policy language and state requirements configured in.
How does it integrate with an existing claims management system?
It reads directly from your claims management system, policy administration system, or document repository — no separate upload step required. Integration scope is confirmed during deployment planning.
Is every finding from the Claims Review Agent traceable to the policy or the file?
Yes. Every coverage gap, exclusion match, and prior-claim flag cites the specific policy endorsement, page, or file entry it came from — there is no finding without a citation back to the source.
How is this different from a generic document AI tool?
It is built specifically around a coverage cross-check against policy language and prior claim history, not a general-purpose summarizer. It runs on Sphere AI Foundry, so the access controls and audit trail configured here carry forward to other agents you deploy.
Start here
See it on your own claims
Bring three real claim files to the demo. We'll show the coverage review output live — classification, citations, and the consolidated finding list, on your own documents.
Looking for a different workflow? Browse the full Agent Catalog.
Talk to a solutions architect
Direct to a senior architect — never a sales queue. Replies within one business day.
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