How do claims handlers review an AI agent’s decisions?

Read the record before the claim. Claims handlers review an agent's decisions by opening the decision record first: the verdict, the deciding bound, and the clauses and evidence used. They test the agent's reading of cover against the wording and facts, then approve, edit or decline with a reason naming both. Paid claims are sampled the same way.

Which decisions do handlers review?

Claims agents produce four kinds of decision, and each needs a different kind of review:

• Held settlements and declines, reviewed one by one before anything reaches the customer.
• Straight-through payments the agent made itself on small, clear claims, reviewed by sample for leakage and accuracy.
• Refusals, where the agent stopped because the claim fell outside its scope, such as a complex liability claim. These need a handler to pick them up.
• Drafted correspondence, reviewed for accuracy and tone.

The straight-through payments are where review is most often thin. They are fast and mostly right, so nobody looks. A small, consistent error in a calculation repeats across thousands of claims.

What are the steps?

1. Open the decision record. Read the verdict and the deciding bound. A hold under the insurer's own limits means you are the decision maker. A refusal on role scope means the claim is a type the agent is not certified for.
2. List the clauses and evidence the agent used. The policy wording comes from the policy library, a sealed source. Adjuster reports are signed. Photos and customer statements are declared. Third-party invoices may be signed or external.
3. Test cover. Read the clauses the agent relied on in full. Check exclusions and conditions against the facts, not the claim description.
4. Test the amount. Excess, limits, sub-limits, depreciation, any contribution from other insurance.
5. Check the person. Vulnerability markers, complaint history, and whether timescales and tone suit them.
6. Decide. Approve, edit or decline within your authority.
7. Write the reason. Name the clause and the fact. "Approved: covered under accidental damage, repair estimate from approved repairer."

What may the agent do, and what stays with the handler?

The hard limits are covered in what claims handlers should never let an AI agent do.

An example: a sample of paid claims

Take a motor insurer whose agent pays small windscreen claims straight through. A handler reviews a weekly random sample of 25. Most are correct. Three applied the standard excess to policies that carry a protected windscreen add-on with no excess. The record shows the agent read the excess from the main schedule and did not have the add-on endorsement in its sources.

The agent applied its sources correctly; the sources were incomplete. The handler edits the three payments to refund the excess, records the reason, and reports the gap. The agent's owner adds endorsements as a source, and the agent is re-certified on windscreen claims before its scope returns. Without the sample, the error would have reached every customer with the add-on.

Which controls make the review count?

• Declines are always reviewed by a handler.
• Straight-through payments are sampled at random, with the method recorded.
• Reasons name a clause and a fact.
• Handlers' own approvals are sampled by a senior handler.
• Approval rights follow a current reviewer credential, and pause when it lapses.

Training a team to work like this is covered in how to train the claims team to review AI agent decisions. Market detail is in AI agent training for claims handlers in insurance in France. Whether the job changes or disappears is answered in will AI agents replace claims handlers. The role map is in AI agent skills by role.