Microsoft Scenario Library Financial Services Insurance – Claim settlement agent

Available with: Microsoft Copilot Studio

Financial Services scenario: Insurance – Claim settlement agent

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Scenario

Use Copilot Studio to create a claim settlement agent

Accelerates claim resolution by pre-filling forms, triaging cases based on complexity and risk, and automating simple decisions to improve speed, accuracy, and fraud detection.

1. Extract structured claim data

Pulls data from incoming emails, call transcripts, and CRM entries to pre-fill claim forms.

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AI Agent

Benefit: Pre-fills claim form to eliminate manual intake delays and errors.

Scores each claim to determine priority and route appropriately.

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AI Agent

Benefit: Scores each claim to accelerate simple claims and ensures high-risk ones are prioritized.

Matches claim data against policy terms, past claims, vendor systems, and health databases.

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AI Agent

Benefit: Cross-checks supporting data to ensure accuracy and verifies coverage before payout.

Analyzes claim patterns for fraud indicators or policy misuse.

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AI Agent

Benefit: Detects risk signal to reduce false claims and supports regulatory compliance.

Auto-approves, escalates, or routes claims with summaries, risk indicators, and suggested actions.

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AI Agent

Benefit: Routes claim with summaries to streamline team handoffs and improves decision speed.

Stores claim outcome, agent actions, and feedback for future tuning.

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AI Agent

Benefit: Stores claim outcome, agent actions, and feedback to support continuous learning and audit transparency.

KPIs

Opportunity to impact key functional area KPIs

Generate insights and content within the everyday flow of work, expedite investigations, and communicate more effectively to prevent and remediate compliance issues.
Speed data analysis and reporting
  • Quickly analyze trends
  • Generate informative charts
  • Create strategy presentations

Improve productivity by leveraging automation to quickly prioritize and accomplish daily tasks, optimize processes, and save time and effort on daily tasks.
Boost productivity
  • Rapidly research customer interactions
  • Create first drafts faster
  • Check for similar issues and resolutions
  • Quickly send follow-up communications

Differentiate customer interactions from competitors to help increase market share; Reduce the time for comprehensive portfolio evaluation with change recommendations reflecting market dynamics; Build trust and confidence among clients leading to increased number of active investors. 
Improve customer meetings
  • Research company information
  • Learn how to pitch the product
  • Organize information from past interactions
  • Completely focus during the meeting

Streamline operations for faster resolution of customer issues, providing tools for decision-making and strategy development. This can lead to higher customer satisfaction, increased customer lifetime value, and maximized customer investment portfolio.
Improve customer satisfaction
  • Diagnose a problem quickly using
    external and internal databases
  • Automated analysis using customer data and knowledge base
  • Quicker and more accurate draft responses
    based on historical resolution data
  • Proactive and personalized follow-up communications

1Access Microsoft 365 Copilot Chat at m365copilot.com, or the Microsoft 365 Copilot Chat mobile app and set toggle to “Web”.

2Access Microsoft 365 Copilot Chat at m365copilot.com, the Microsoft 365 Copilot Chat mobile app, or the Microsoft 365 Copilot Chat app in Teams, and set toggle to “Work”.

3AI Agents allow Copilot to access your organization-specific apps. In the past this would have required an API call to get data from a system of record.

The content in this example scenario is for demonstration purposes only. You should evaluate how Copilot aligns with your organization’s business processes, regulatory requirements, and responsible AI principles.