Claims and AI – Reimagining the Experience with Intelligent Automation

At this past year’s Global InsurTech conference, Sedgwick’s Chief Claims Officer, Max Koonce, took the stage to share his perspective on how artificial intelligence is transforming the insurance industry. In a session titled “Claims and AI – Reimagining the Experience with Intelligent Automation,” Max explored the evolution of automation in claims, the opportunities and challenges of AI and Sedgwick’s vision for blending intelligent technology with the human touch. Here’s a summary of the key insights and takeaways from his presentation.

Q: The insurance industry has been on an automation journey for decades. How should we define “AI” in today’s claims context, and how is it different from previous technological innovations?

A: AI in insurance is the application of intelligent systems that analyze data, learn from patterns and make decisions or recommendations. Unlike earlier tech, like the personal computer, which enabled basic automation, AI moves beyond trend analysis and reporting. It evaluates, analyzes and guides users on what data means, what’s missing, and what’s critical to address. In claims, this means faster, more accurate administration, improved customer service, enhanced fraud detection and smarter workflows.

Q: What are the “low hanging fruit” for AI in claims — areas where it can quickly bring value?

A: Several areas are already seeing impact:

• Medical summarizations in workers’ comp: AI quickly distills complex medical records for examiners.
• Demand packet summarizations in general liability and auto: AI helps sort and summarize legal documents.
• Customer service: AI generates claim summaries for clients, capturing all critical information to date.
• Fraud detection: AI analyzes photos in auto property damage claims for anomalies.
• Workflows: AI provides guidance to examiners, streamlining routine tasks and highlighting next steps.

Q: What obstacles or pain points do you encounter when implementing AI-driven solutions?

A: There are two main challenges:

• Return on Investment: AI is not cheap. It must deliver efficiency, effectiveness and improved outcomes to justify the investment.
• Regulatory concerns: There’s ongoing debate about how AI should be regulated. Clients want assurance that AI won’t expose them to risk, especially regarding bias or discrimination. Lawsuits have questioned whether AI creates disparate impacts. At Sedgwick, we use AI for guidance and direction, not for final decision-making, ensuring human oversight remains central.

Q: How will technology and automation change claims roles over the next 5–10 years? What advice do you have for new claims professionals?

A: While some roles will decline (like typists or basic data entry), new roles — such as data scientists and AI specialists — are emerging. Claims management will always need a human element to address the personal side of claims. Automation will allow examiners and adjusters to focus more on empathy and complex decision-making. For new professionals, AI offers the chance to “level up” faster: technology can help bridge the experience gap as seasoned experts retire, allowing newer examiners to learn and advance more quickly than traditional methods allowed.

Q: How important is “explainability” or “transparency” in AI applications for claims?

A: It’s critical. Clients need to understand what AI does, how it works and its expected impact. Most companies now have internal AI governance processes to ensure transparency and accountability. Explainable AI builds trust and helps organizations meet regulatory requirements.

Q: With so many vendors offering AI solutions, how do you decide whether to build in-house or buy from a vendor?

A: Sedgwick’s approach is to build in-house, supported by select partners. This ensures control over the platform and helps address client concerns about data privacy and security. Building internally allows for customization and alignment with company values and processes.

Q: What does the AI-powered claims experience of 2030 look like, and how can insurers build toward it now?

A: While much of this was covered in closing remarks, the vision is clear: AI will automate routine tasks, empower examiners with actionable insights and enhance the customer experience. Insurers should focus on integrating AI thoughtfully, maintaining human oversight and prioritizing transparency and continuous learning.

Conclusion:
AI is reimagining the claims experience, making it faster, smarter and more customer-centric. The journey requires balancing innovation with oversight, investing in talent and ensuring transparency. As Max Koonce emphasized, the opportunity to “level up” is here, and the future of claims will be shaped by those who embrace intelligent automation while keeping the human touch at the center.