Claims Leakage Auditor
Finds what was paid above what the policy actually required
- 8hard rules
- Things it must never do, enforced in every run
- 5handover rules
- Conditions where it stops and gives the work to a person
- 11output fields
- A structured result, not a paragraph you have to re-read
- ≤8steps per run
- Bounded work: at most 6 tool calls, enforced by the runtime
Read-only by design. This agent has no path to sending, spending, publishing or committing anything. Where that limit is the product, removing it would remove the reason to trust the output.
Overview
Claims leakage is the gap between what an insurer paid and what it was liable to pay under the policy. The industry knows the number is material and mostly cannot find it, because the causes are small and procedural rather than dramatic.
A deductible not applied. A sub-limit ignored because it sits in an endorsement rather than the main schedule. Depreciation not taken where the policy is actual cash value. A payment made without pursuing a third party who was clearly liable. A reserve set high and never revisited, distorting every downstream decision. A settlement above the handler's authority without the review that authority level exists to trigger.
None of it is fraud. Each is a handler under volume pressure making a defensible-looking decision without holding the whole policy in mind — which is the real difficulty, because a policy is a schedule plus endorsements plus wording, and the sub-limit that matters is usually in the endorsement.
The commercially serious point is that leakage is a rate, not a pile of individual errors. The pattern is worth more than any single recovery, and recovery is often impossible anyway.
This agent audits closed claims against the governing policy, reports each finding with the clause behind it, and reports the leakage rate by cause and by handling team. It reopens nothing, pays nothing, and never assesses a claimant.
Benefits
A measured leakage rate
Rather than an industry benchmark you assume applies to you.
The cause, so it can be fixed
Training, checklist or system control — each finding says which.
Recoveries identified in time
Where limitation periods have not yet expired.
What it does
Reads the endorsements, not just the schedule
The sub-limit that was missed is almost always in an endorsement rather than the main schedule.
Checks deductibles and depreciation were applied
The two most common leaks, and the two easiest to prove after the fact.
Finds recoveries never pursued
A third party clearly liable and never approached. Usually the largest single amount in the report.
Checks settlements against authority
A payment above a handler's limit without the review that the limit exists to force.
Reports the rate, not just the cases
Leakage is a recurring percentage. The pattern is worth more than any individual recovery.
Reopens nothing
It never reopens, adjusts or declines a claim. Every finding goes to a person with the file.
What this changes
What this changes about your week
- It takes over
- Auditing settled claims against the policy that actually governed them.
- Done today by
- A sample audit once a year, if at all.
- How often
- Continuous in principle, rare in practice.
- Typical manual effort
- Each claim needs the schedule plus every endorsement read against the settlement.
Why Insurance in particular. The sub-limit that was missed is almost always in an endorsement rather than the schedule. Leakage is a recurring rate rather than a pile of errors, and the pattern is worth more than any single recovery.
Runs unattended
Started by you or by an event, and it finishes on its own. Nothing waits for someone to be at a desk.
The same standard every time
The two-hundredth item is held to the bar the first one was. Consistency is the part people cannot sustain.
It cannot act on its own
Claims Leakage Auditor has no path to sending, spending or committing. That limit is why its output is safe to act on.
How it runs
This agent runs server-side through the PROMIVO runtime. Each run is logged step by step and every tool call is permission-checked before it executes.
- 1InputValidated against the agent input schema
- 2Modelclaude-opus-5 with automatic fallback
- 3Toolssearch_knowledge, extract_structured_data
- 4PermissionsRuns READ actions automatically; anything higher waits for approval
- 5OutputStructured result matching the output schema
- 6LoggingTokens, duration and every step recorded
Demo
Demo dataIllustrative sample output, abridged.
Input
{
"claims": [],
"period": "H1 2026",
"currency": "USD"
}Output
{
"escalate": true,
"findings": [
{
"paid": 41200,
"cause": "sub-limit-missed",
"claim": "CLM-77412",
"clause": "Endorsement 3, clause 2: portable equipment sub-limit of 15,000 per occurrence.",
"difference": 26200,
"recoverable": "Unlikely — settled and paid 14 months ago. The value here is the pattern, not this claim.",
"policyRequired": 15000
},
{
"paid": 88000,
"cause": "recovery-not-pursued",
"claim": "CLM-78330",
"clause": "n/a — third party recorded as at fault in the loss report.",
"difference": 88000,
"recoverable": "Possibly. The loss date is 19 months ago; check the applicable limitation period before anything else.",
"policyRequired": 88000
}
],
"disclaimer": "An audit of the insurer's own handling against its own policies. No claim has been reopened, adjusted or paid, no claimant has been assessed or contacted, no allegation of fraud is made, and no statement is made about what is legally recoverable.",
"unauditable": [
"31 claims — the governing endorsement could not be found, so they are excluded rather than passed."
],
"claimsAudited": 840,
"leakageByTeam": [
{
"note": "Concentrated in sub-limits. A checklist finding, not a training one.",
"team": "Team B",
"ratePercent": 4.8
}
],
"leakageByCause": [
{
"note": "All 47 sat in endorsements rather than the schedule.",
"cause": "sub-limit-missed",
"amount": 612000,
"claims": 47
},
{
"cause": "recovery-not-pursued",
"amount": 411000,
"claims": 12
}
],
"ambiguousWording": [
"The portable equipment definition in Endorsement 3 could exclude the item in CLM-77980. Reported rather than decided."
],
"escalationReason": "Sub-limit leakage is 47 claims across the period, three recoveries expire within 90 days, and 31 claims could not be audited because an endorsement is missing.",
"leakageRatePercent": 2.9,
"recoveriesExpiringSoon": [
"Three recoveries totalling 140,000 have limitation periods expiring within 90 days."
]
}Requirements
Integrations
No integrations required.
Before you start
- Settled claims with payments, reserves, and handler
- The governing policy documents including endorsements, in a knowledge base
- Your authority matrix
- Requires the All-Access plan or higher
Use cases
Periodic claims audit
A sample or the full population, against the policies that governed them.
After a reserving surprise
Whether payments or reserves were the cause.
Handler quality programme
Patterns by cause, to fix the process rather than the person.
Before a reinsurance renewal
Understanding your own claims cost properly.
Pricing
All-Access
Billed monthly through your PROMIVO subscription. Cancel at any time.
Runs consume your plan allowance for agent executions and tokens. See plan limits
FAQ
Does it reopen or adjust claims?
No. It has no route to a claims system. Reopening a settled claim has legal, regulatory and customer consequences that belong to a person with the full file.
Does it assess claimants?
Never. It audits the insurer's own handling against the insurer's own policy. It makes no assessment of any claimant and never suggests fraud by one.
Is this fraud detection?
No, and conflating the two is harmful. Leakage is procedural overpayment by the insurer. Fraud is an allegation about a person, requiring a different process with different safeguards.
Can it recover the money?
It identifies what may be recoverable and whether time limits allow it. Pursuing recovery is a legal and commercial decision.
Reviews
Reviews open once customers have run this agent.
Need this agent to work differently?
Tell us what to change and our team will scope a customised version for your business.
Customize this agent