How an Insurer Automated Outreach Across 100K+ Calls

Customer outreach and initial claims triage were handled by staff over phone and email. With call volume in the hundreds of thousands, policyholders waited for responses, incoming claims were prioritized inconsistently, and staff spent much of their day on routine outreach and intake instead of complex cases. Claims that needed clinical input also had to be routed to state-licensed medical consultants by hand.

An AI agent that runs inbound and outbound policyholder outreach end to end and handles initial claims triage: it gathers claim details, classifies type and urgency, and hands each claim to the right state-licensed medical consultant or team. The agent is trained on the insurer's policies and claims categories and escalates anything outside its scope to a person.

The team started by defining the common outreach scenarios and claims intake questions, then trained the AI agent on the insurer's policies and claims categories. The agent was tested against real customer interactions and went live on a portion of outreach volume first. Once it held up there, coverage expanded to claims triage and the handoff to state-licensed medical consultants, until all of that work ran through the agent. The full rollout took a couple of months. Triage on ambiguous or urgent claims took the most tuning, and the team kept a human check on those decisions while the agent proved itself.

Health, life and specialty insurers, TPAs and benefits administrators running high-volume policyholder outreach and claims intake, especially where clinical claims have to reach state-licensed medical consultants quickly and every handoff needs to be consistent and on record. It works best when outreach scripts and claims categories are well defined and staff can review the edge cases the agent escalates.