Straight-Through Claims-Settlement AI Agent

What this agent does

Settles the narrow band, refers everything else

Take the claim as notified — policy, loss date, cover, claimant, payee, documents and the amount claimed.

Read the policy as it stood on the loss date, including any endorsement, lapse or cancellation since.

Reason

Test the claim against the eligibility band: line, claim type, cause of loss, value and evidence required.

Compute the amount from the schedule, limits, sub-limits and excess in force — not from the sum claimed.

Check duplicates, prior claims on the same loss, sanctions on the payee, and the bank details on file.

Decide

Where every check clears and the amount sits under the ceiling, the claim pays without an adjuster.

Anything short-paid, failing a check, or over the ceiling or the daily total goes to a licensed adjuster.

Out

Pay the verified payee, apply the excess, and issue the settlement notice the policyholder receives.

Retain the policy version, the checks that cleared, the figures used and the authority it paid under.

→ Product statement

The agent pays only inside a band, a per-claim ceiling and a daily aggregate limit a named claims officer signed. It never denies, never short-pays and never closes a claim against the claimant — those belong to a licensed adjuster, on every tier and in every configuration.

Example workflow

One claim, end to end

AgentHuman

1Claim receivedA notified claim with the policy number, loss date, payee, documents and the amount claimed

2Policy read at the loss dateCover, endorsements, limits, sub-limits and excess as they stood, and whether the policy was in force

3Eligibility testedLine, claim type, cause of loss, value, evidence on file and the claim history behind it

4Quantum and screeningThe amount computed from the schedule and excess, then duplicate, fraud, sanctions and payee checks

No human action required

Stages 1 to 4 run without a person in the loop — the policy read, the eligibility test, the quantum and the screening all finish before the gate. Nothing has been paid.

5DecisionSplits on whether every check cleared and the amount sits under the ceiling

Every check cleared

Pays inside the ceiling and the daily total.

Any check failed, or over a limit

Goes to a licensed adjuster, unpaid.

Licensed adjuster

Takes the claim with the failed check named, the figures shown and the policy as read. Anything adverse to the claimant is theirs alone.

Pay · Amend · Investigate

Decided — handed back▼

6Payment released and notice sentOnly inside the per-claim ceiling, the daily total and the authority the claims officer signed

7Outcome evaluatedGate precision, overpayments, duplicates, payee failures, band drift and routing correctness, by claim type and channel

Adjuster changes

Every claim an adjuster pays differently from the computed figure is counted.

What should not run autonomously

Human approval stays in control

Outside the boundary — human approval required8 items

Declining a claim, in whole or in part.

Paying less than the claim asks for.

Applying an exclusion, condition or policy defence.

Settling a bodily-injury or liability claim.

Automation boundaryAgent acts unaided

✓Read the policy as it stood on the loss date.

✓Test the claim against the band a named officer signed.

✓Compute the amount from the schedule, limits and excess in force.

✓Run duplicate, prior-claim, sanctions and payee checks before release.

Write actions run only inside the approval boundaries agreed during implementation. Payment runs unattended only inside a band, a ceiling and a daily limit a named claims officer signed — never against the claimant. Recovery of a payment that should not have run is the carrier's, on that officer's authority, and counts against the band that allowed it.

Paying above the ceiling or the daily total.

Releasing payment after a bank-detail change.

Clearing a sanctions or fraud hit.

Changing the band, the ceiling or the limits.

Example output

One claim, annotated

Everything the agent computes is attached to the policy term and the check it came from.

Settlement output · single claimIllustrative example

Claim type

Policy at loss date

Payee

Settlement

Confidence

Deduction

Windscreen replacement

In force, unendorsed

Approved repairer

$310.00

96%

Excess only, per schedule

As receivedThe claim as notified and the policy as it stood on the loss date, endorsements and lapse status included.

Checks cleared Policy in force No duplicate on file Payee and bank verified

Why this figureFrom the schedule, sub-limit and excess in force on the loss date, not the sum claimed.

ActionPayAmendInvestigate

What the score decidesWhether it may pay unattended, not what it pays. Below the threshold an adjuster takes it.

Value

Where AI adds value

The same four claims, placed at the point in the workflow where each one applies.

Where the value landsValue 01 – 04

Every notified claimFrom FNOL and the claims queue

03Policy & band

Apply the policy that was actually in force

Cover, endorsements, limits, sub-limits and excess as they stood on the loss date — read at settlement time and stamped with the version.

01Approved path

Let the small, verified claims clear

A claim inside the band, under the ceiling and clean on every check pays without an adjuster opening it. The band is narrow by design, and it is written down.

02Human review

Send anything adverse to a person

A failed check, a short payment, a policy defence or a value over the ceiling stops the path and reaches a licensed adjuster unpaid — and still inside the statutory clock, because referring a claim does not pause it.

04Build an evidence trail

Retain the policy version read, the band and authority in force, the checks that cleared, the figures used and the adjuster's own decision — on both paths.

Integrations

Typical integrations

Five system groups connect to the same agent. Which of them are in scope is decided in discovery.

Claims & policy adminGuidewire · Duck Creek · Sapiens
Majesco · Policy and claim APIs

Payments & financeOne Inc · VPay · ACH and card rails
Payment files · ledger reconciliation

Screening & verificationSanctions and PEP lists · fraud scoring
Payee and bank-detail verification

Agent

Straight-through claims settlement

Tests eligibility
Computes quantum
Releases payment

Evidence & documentsFNOL attachments · photos and invoices
Repairer networks · claimant notices

Observability & evaluationOpenTelemetry · Langfuse
Supported monitoring/evaluation sources

Integration availability depends on the client's existing systems and API access.

Agent controls

Six layers between the model and a payment

Each control wraps the one inside it. A claim clears every layer before money moves, and nothing adverse to the claimant clears them at all.

L6 · Outermost — last line of defenceInward → L1 · closest to the model

L6Kill switchA named claims officer stops the path in one action, at any hour.Stop

L5No-adverse ruleNo denial, no short payment, no policy defence — the path only pays.Withhold

L4Value limitsA per-claim ceiling, and a daily aggregate limit on the whole path.Cap

L3Payee screeningDuplicate, prior-claim, sanctions and bank-detail checks before release.Screen

L2In-force checkCover, endorsements and excess as they stood at the loss date.Verify

L1Eligibility gateOnly the claim types, causes and values inside the signed band.Gate

Model coreProposed settlement — the band it matched, the figures computed from the policy, and confidence

L1 – L2Decide whether the claim may pay at all

L3Decides whether this payee may be paid

L4Caps one claim, and caps the day

L5 – L6Keep it to paying, and stop it dead

How Nestack evaluates it

Evaluate what was paid — and what should never have paid.

Coverage runs the whole depth of the workflow, and every layer is cut by slice.

Surface — the payment the claimant receives

Depth of coverage ▼

E1Final-output evaluationWas the amount right, and was the excess actually applied?

E2Eligibility evaluationDid every claim that paid unattended belong inside the band?

E3Tool evaluationDid it read the right policy version and pay the right payee?

E4Screening evaluationWere duplicates, prior claims and sanctions caught before release?

E5Slice evaluationHow does performance change across claim types, channels and cohorts?

E6Business outcomeOverpayment and duplicate rate, and whether referred claims still paid on time.

Floor — the payments that should not have run

Failure modes

Where each failure originates in the agent

Seven failure modes plotted against the five stages of the agent lifecycle.

Agent lifecycleDirection of processing →

01 · Policy read2 modes

SC-01

Paid on a policy not in force

Cover had lapsed or been cancelled at the loss date.

SC-02

Endorsement not read

A mid-term change to cover or excess was missed.

Stage readsCover, endorsements, limits and excess at the loss date

02 · Eligibility1 mode

SC-03

Stale data cleared the gate

The band matched on figures already out of date.

Stage testsWhether the claim belongs in the band that was signed

03 · Quantum & checks2 modes

SC-04

Excess or sub-limit skipped

Quantum taken from the wrong schedule or limit.

SC-05

Duplicate of a settled claim

The same loss already paid through another channel.

Stage computesThe amount, plus duplicate and sanctions checks

04 · Payment & notice1 mode

SC-06

Wrong payee after a change

Bank details changed shortly before release.

Stage releasesThe money that leaves and the notice that follows it

05 · Band / Version1 mode

SC-07

Band widens without notice

A rule change admits a category nobody approved.

Stage tracksRule, threshold and model changes to the band itself

Sev-1 · money leaves and does not come back Sev-2 · a real claim is paid the wrong amount Sev-3 · paid twice, and recovery is possible

See the complete Insurance failure-mode catalogue →

Affected slices

The band is only as narrow as its worst cohort

A band built from claim history, channel and geography decides who is paid in minutes and who waits for an adjuster. A few cohorts carry most of the wrong payments. Nestack reports performance by slice, not only in total.

Slice performance — reported separately, not only in aggregateIllustrative example

Slice	Failure rate	Lift	Status
Policies endorsed mid-term	6.4%	3.2×	Review
Payees with changed bank details	4.4%	2.2×	Review
Claims just under the ceiling	3.5%	1.8×	Watch
Repeat routine claims	1.4%	0.7×	Normal

Bar: wrong-payment lift vs. repeat routine-claim baseline · scale 0–4.0× · tick marks the 2.0× review threshold 2 of 4 slices over threshold

Evidence-linked improvement

Every wrong payment narrows the band

Money paid on a claim rarely comes back — absent fraud or an express recovery clause, a settlement stands. So each cycle changes what the band admits next.

Improvement cycle · five stagesSwitchback — the path turns at Improve and returns at Learn

01Detect

Overpayment, duplicate or payee-failure rate moves in one slice.

02Diagnose

Traced to the policy read, the gate, the quantum or a band change.

03Improve

The rule, threshold or ceiling is changed, re-signed by the claims officer and version-linked.

04Verify

Re-run against held-out claims, including every payment that had to be chased.

05Learn

The wrong payment becomes a regression case and a gate the band must pass.

Learn → DetectThe return edge. Every cycle re-reads the band itself — a rule change that widened it without a signature is rolled back before the next claim pays.

Typical build scope

Twelve workstreams across six weeks

The build scope read against the delivery timeline. Week structure follows the six-week plan — discovery, band and policy reads, quantum and screening, evaluation, payment integration, then production validation and handover.

Workstream Week 1Week 2Week 3Week 4Week 5Week 6

01Workflow discovery and automation-boundary definition.

02Eligibility band, ceiling and daily-limit sign-off.

03Claims and policy-admin API assessment.

04Policy-at-loss-date and endorsement reads.

05Quantum from schedule, limits and excess.

06Duplicate and prior-claim detection.

07Fraud and sanctions screening before release.

08Payee and bank-detail verification.

09Gate-precision and overpayment evaluation.

10Payment integration, limits and the stop control.

11Settlement notices and finance reconciliation.

12Deployment, documentation and Agent Care handover.

12 workstreams · 6 weeks · bar shows the weeks a workstream is active — several run in parallel Final scope and sequence confirmed in discovery

Engagement tiers

What each tier includes

Rows are the capabilities named in each tier's scope. Higher tiers include everything below them.

Capability✓ in scope · — not at this tier PilotOne claim type, shadow only ProductionOne line, live payments AdvancedMulti-line / multi-entity

Introduced at Pilot

Eligibility band and gate✓✓✓

Policy-at-loss-date reads✓✓✓

Quantum from schedule and excess✓✓✓

Shadow mode — proposes, pays nothing✓✓✓

Baseline evaluation✓✓✓

Introduced at Production

Duplicate and prior-claim checks—✓✓

Sanctions and payee verification—✓✓

Live payment inside a signed limit—✓✓

Daily aggregate cap and stop control—✓✓

Introduced at Advanced

Multi-line and multi-entity bands——✓

Enterprise controls and audit packs——✓

Build price From $5,000 From $8,000 Custom quote

Final build priceConfirmed after discovery based on the lines and claim types in scope, the claims and payment systems involved, screening sources, claim volume, the authority and limits agreed, and deployment requirements.

Separate from buildBuild pricing is separate from recurring Agent Care, which covers managed monitoring, evaluations, incidents and verified improvements after launch.

What we need from you

What you bring, and what we build with it

Each input maps to a piece of build scope and a week in the delivery timeline.

You bringWe build with it

01The lines and claim types you would pay without an adjuster → Workflow discovery and automation-boundary definitionWeek 1

02A signed per-claim ceiling and daily aggregate limit → Eligibility band, ceiling and daily-limit configurationWeek 1

03Access to claims and policy admin, endorsements included → Policy-at-loss-date reads and in-force checksWeek 2

04Your schedules, sub-limits and excess rules → Quantum computed from the limits actually in forceWeek 3

05Screening sources and your payee-verification rules → Duplicate, prior-claim, sanctions and bank-detail checksWeek 3

06Claims you paid wrongly, and the ones you had to chase → Evaluation suite, regression cases and failure-mode testingWeek 4

07The named officer who holds the authority and the stop control → Payment integration, limits and the stop controlWeeks 5–6

Nothing else is required Deployment, documentation and Agent Care handover are ours.

Delivery timeline

Four phases across six weeks

Phases are drawn over the weeks they actually occupy. Nothing is paid before week 6 — the path runs in shadow until the limits are proven on live claims.

Phase W1W2W3W4W5W6

Discovery W1

Build W2 – W3

Evaluate W4 – W5

Pilot & Launch W5 – W6

Week focus W1Claim types, the band, the ceiling and who signs it W2Policy-at-loss-date reads and endorsement handling W3Quantum, duplicate, sanctions and payee verification W4Evaluation suite, gate precision and failure-mode testing W5Payment integration, limits and the stop control, in shadow W6First live payments inside the signed limits, then handover

Reading the bandBars span only the weeks their work is named in. Shadow running in week 5 is real — the path proposes and releases nothing.

At the end of W6Live payments have run inside the signed ceiling and daily limit, and every adverse decision in that period was an adjuster's.

DurationSix-week plan shown · typical delivery 4–6 weeks depending on scope confirmed in discovery.

Next step · Insurance AI agent

Draw the band before you automate the payment.

Show us the claim types you would pay without an adjuster, the systems that hold the policy and the money, and who signs the authority. We'll draw the band, set the ceiling, the daily limit and the stop control, and show you everything that falls outside it.

Discuss this agent →

Nestack Agents · Straight-through claims settlementAGT-INS-08 · Agent Care available after launch