Vertical 03 · Insurance

Claims-fraud and adjuster-explainability AI
with signed, replay-by-claim evidence

The NAIC AI Model Bulletin (adopted December 2023; state implementation 2024 onward) and the patchwork of state-DOI variations make insurance one of the most operationally demanding AI-governance environments. Carriers need claims-fraud AI, adjuster-explainability outputs, and long-horizon reconstruction of the AI decision path — all with claimant identifiers protected and a long-tail evidence trail.

Request a consultation→ Trust architecture
Primary frameworksNAIC AI Bulletin · State DOI
BuyerCCO · Chief Claims Officer
Tier defaultTier 1 (gateway)
Retention windowEngagement-scoped per LoB
Reinsurance arbitrationSigned per-session evidence (cross-session cryptographic replay on roadmap)
Production timeline~6 weeks (typical)
The core problem

Fraud detection wants every data point — compliance wants every data point protected

A modern fraud-detection workflow wants medical-records context, EUO transcripts, prior-claim history, and SIU notes — all of which contain claimant identifiers, PHI, and adjuster mental impressions. The NAIC AI Model Bulletin holds carriers accountable for AI explainability and consumer-facing transparency. State DOI variations layer additional jurisdictional requirements. The result: fraud AI runs on demographics and rules, and the deeper context stays unprotected and unused.

Unprotected baseline
Risk
workflowfraud_review.case_summary
claimant identifiersexposed if sent raw
NAIC explainabilitynarrative only
replay-by-claimnot reconstructable
reinsurance arbitrationmemory-of-AI only
With VeilEngine

Adjuster-explainability that holds in arbitration eight years from now

VeilEngine’s insurance vertical pack is designed to protect claimant identifiers, PHI elements, and adjuster mental-impression markers at the boundary. Every fraud-review, adjuster narrative, and explainability output gets a signed receipt. Retention is designed so a per-session signed evidence chain can be kept for years aligned to your line-of-business statute of limitations; a full cross-session transparency log with multi-year replay is on the roadmap.

  • Long-tail evidence retention — per-session signed evidence designed to be kept for windows aligned to your LoB statute of limitations; a hash-linked cross-session log is on the roadmap
  • NAIC-aligned explainability — every AI-touched decision attests to inputs, policy version, and model used
  • State DOI matrix — jurisdiction-aware controls scoped during the engagement; state-by-state overlay coverage is built per engagement
  • Reconstruction of the AI decision path — the receipt records a hash of inputs, the model, and policy controls per request; full long-horizon replay across sessions is roadmap and engagement-scoped
Receipt // rcpt_ins_2f8b · Illustrative receipt
Signed
workflowfraud_review.tier3
vertical packinsurance (per engagement)
providerClaude Opus
protection tierTier 1 · gateway
claimant ID in payload0 raw
explainability fieldsrecorded
retention windowengagement-scoped
DOI jurisdictionscoped per engagement
attestationsigned (per-request)
sha256:b7c4e9a1f3...
Insurance workflows in scope

Workflows your CCO and Chief Claims Officer sign off on together

Claims-fraud tier-3 review

Synthesis of case text and structured claim data (medicals, EUO, prior claims, SIU notes). Document/file inputs are handled under disclosure controls; non-text payloads are block-default at the gateway. Tier 1. Illustrative — ~90s TUA vs. ~4 hours manual.

Adjuster narrative drafting

Loss-event summarization and coverage analysis with claimant identifiers protected. Tier 1.

Explainability-on-demand

Consumer-facing explanation of an AI-touched decision, NAIC-aligned. The signed receipt records the decision context (inputs by hash, model, policy version); cross-session replay-by-claim is on the roadmap.

Subrogation discovery

Third-party-recovery candidate identification across claim corpus with protected identifiers. Tier 1.

Reinsurance arbitration replay

Reconstruction of the recorded decision path (input hash, model, policy version) within the engagement-scoped retention window. Per-session evidence is offline auditor-verifiable; full cross-session replay is roadmap.

Custom workflow

Bring the LoB-specific workflow your CCO has blocked. We scope during the regulatory audit.

FAQ

Insurance AI governance, answered

Yes, when the workflow protects claimant identifiers and produces evidence of the control path. The insurance pack is designed for fraud review, adjuster narrative drafting, and explainability support where the carrier needs useful AI output plus a record that can survive a state DOI exam or later claim dispute.
The NAIC bulletin expects insurers to govern AI systems according to their risk and consumer impact. Vertical Edge AI maps that governance into operating evidence: AI use case, policy version, approval gate, model route, protected data classes, and the receipt trail that shows what happened on a specific claim workflow.
It means the carrier can reconstruct the recorded decision path for a specific claim later: which workflow ran, which inputs were protected (by hash/class), which model served the request, and which policy controls were active. Output retention and long-horizon cross-session replay are engagement-scoped / roadmap. That matters when a regulator, reinsurer, or claimant asks why an AI-assisted decision happened.
No. The first-fit workflows are decision-support and evidence workflows: fraud triage, adjuster narrative drafting, explainability packets, subrogation discovery, and reconstruction. Human review, policy authority, and carrier-specific controls stay in the workflow.
The vertical pack carries jurisdiction-aware controls scoped during the engagement. Your operating states determine which transparency, retention, explainability, and consumer-impact controls apply, where a state has adopted them, for a given workflow, and the receipt records the policy version applied at request time. State-by-state DOI overlay coverage is built per engagement.
Insurance engagement

Bring the fraud workflow your CCO has blocked

We start with a discovery regulatory audit alongside your CCO, Chief Claims Officer, and SIU lead. You receive a preliminary exposure map and a replay-by-claim plan as the diagnostic deliverable — yours to keep regardless of next steps.

Request a consultation→