DataFab / Utilities / Insurance claim handling
Governed utility · legal-expenses and written-claim insurance
The written claim, worked end to end.
Extraction vendors tag the claim and hand it on — and two in three written claims still land on a caseworker’s desk. DataFab is the layer that finishes the job: it reads the claim and every document behind it, finds what is missing, checks coverage against the policy, assesses the prospects, checks the fees, and drafts the grounded response — over the systems you already run, with a caseworker on every decision that matters.
“Extraction stops at the start. Two in three claims still reach a desk.”
The incumbent tags and extracts for a token per-case fee — and it is worth exactly that, because extraction alone cannot finish a written claim. Unstructured solicitor letters, coverage judgement and statutory fee-checking stay manual.
So a large majority of claims fall out to a caseworker — and a manually-settled case costs a large multiple of the extraction fee, fully loaded. A senior executive at a peer legal-expenses insurer puts that multiple in the tens, at the top of the range for document-heavy legal lines, and independently confirms the thesis: extraction does not complete the job. Letters, coverage judgement and fee-checking stay manual.
The economics · 02
The value is not the extraction slice. It is the fallout pool.
Every claim moved from manual to straight-through removes a manual case worth many multiples of the extraction fee. The right measure of any solution is one number: how far it shrinks the fallout rate. The break-even fee sits at many multiples of anything realistic, so the headroom is structural, not marginal.
| Scenario | Fallout falls to | Straight-through rises to | Manual workload removed | Manual-handling cost |
|---|---|---|---|---|
| Conservative | 45% | 55% | −31% | −31% |
| Base case | 35% | 65% | −46% | −46% |
| Ambitious | 25% | 75% | −62% | −62% |
Against a 65% starting fallout rate. Every ten points of fallout removed cuts the manual workload by roughly fifteen per cent. Illustrative model output from a worked example, not a quote and not a measured result.
What it does · 03
DataFab works the claim — not just reads it.
One governed pass, from intake to a decision-ready file. Where information is missing, it drafts the reach-out. Where the rules are clear, it resolves. Where judgement is needed, it prepares the judgement — coverage points matched to clauses, prospects grounded in cohorts of similar claims, fees checked against the statutory schedule — and routes the file to a caseworker with everything attached.
Reads & extracts
The claim and every document behind it — letters, forms, invoices, scans — read with a calibrated confidence on every extracted field rather than one score for the document.
Finds the gaps
Completeness is checked against what the decision actually requires, and where something is missing the reach-out is drafted for approval.
Checks coverage
Claim facts matched to the specific policy clauses and endorsements that apply. Where cover is partial, excluded or conditional, the reason is flagged and attached.
Assesses prospects
Merits and likely outcome drawn from comparable resolved cases and the clauses in play — supporting the decision, not making it.
Checks the fees
Solicitor invoices checked line by line against the statutory schedule. Over-charges, duplicates and out-of-scope items surfaced before payment, each carrying the rule it failed.
Drafts the response
The response is drafted with every statement traceable to the page and passage it came from.
Prepares & routes
A decision-ready file with everything attached — grounded, attributable, defensible. The utility prepares the decision; a caseworker makes it.
The architecture · 04
One governed layer, over your systems.
Data stays in place. A governed fabric reads your systems read-only, document intelligence and similarity services ground each claim, and the existing decisioning core is adapted — with confidence, trace and governance attached to every decision.
When the decision engine flags missing or partial information, reach-out drafts the request; the claimant’s response re-enters through intake and the case is automatically re-evaluated — no manual re-keying.
Why it can be trusted · 05
Trust is the architecture, not a promise.
Claims teams have been burned by black-box systems with a blanket accuracy figure printed on the box. This is built the other way up — every output carries its own evidence, so a caseworker can verify any statement in seconds and an auditor can replay any decision end to end.
Per-step confidence
Not one score for the document — a calibrated confidence per extracted field and per reasoning step, so review effort goes exactly where the uncertainty lives.
Source per statement
Every statement in every draft traces to the page and passage it came from. Nothing is asserted that cannot be shown.
Human in the loop by design
Coverage calls, prospects, declines and payments wait for a person. Autonomy is a dial set per step — and every gate is logged.
Read-only
A governed connector reads your policy, claims and document systems where they live. Nothing is migrated, nothing copied out.
Reason codes, not verdicts
The decision engine returns the rule chain and reason codes behind every recommendation — reviewable, contestable, explainable.
Re-evaluates on new data
When the missing document arrives, the case re-runs automatically. The file is always current, never stale.
The value, two ways · 06
A committed floor. A combined-ratio north star.
The floor · per-case efficiency · committed
Cost-competitive on day one.
- Manual workload reduced by roughly a third to two thirds, depending on the scenario
- The committed, forecastable floor — not the upside case
- The fee it replaces is a fraction of the fully-loaded manual cost it removes
- Provable on your own data during the pilot
- The efficiency case alone justifies the deployment
The north star · combined ratio · where we steer
A combined-ratio partner.
- The board runs on the combined ratio, and the loss half is twice the expense half
- Better coverage decisions and better routing move the loss ratio itself
- Directional — proven on your data, then shared in the gain
- The difference between a software vendor and an underwriting-margin partner
- It is why the pricing follows the ratio, not the case count
Directional figures are model output for illustration, not contracted. Magnitudes depend on your case mix, book and configuration.
What it unlocks · 07
The fabric, and what it unlocks.
The Knowledge Fabric is a governed foundation that reads across your systems and resolves them into one current, shared view — policies, claims, documents and history, connected through a single ontology and a golden record. Nothing is re-platformed into another silo; every process draws on the same grounded picture, so a decision made in one place stays consistent with every other.
The Knowledge & Agentic Studio sits on top of it — an environment to compose and run agencies, governed teams of agents each serving one purpose. A new process is assembled from reusable capabilities rather than built from scratch, and every decision inherits the layer’s confidence scoring, evidence trail and human-review gates. Each use case is configuration on the same foundation — defensible from day one, and faster to stand up than the last.
Intake
Written claims are read, checked for completeness and assembled into a decision-ready file. Missing information is identified and the follow-up drafted automatically. The handler receives a case that is already reasoned.
Compliance
Obligations under the applicable regime are checked against each matter as it proceeds. Breaches, gaps and required disclosures are surfaced with the rule they relate to. Every check is logged and evidenced, so an audit trail exists by default.
Coverage checking
Every claim is matched to the specific policy clauses and endorsements that apply. Where cover is partial, excluded or conditional, the reason is flagged and attached. The handler opens a coverage view that is already reasoned, not raw.
Fee checking
Solicitor invoices are checked line by line against the statutory fee schedule. Over-charges, duplicates and out-of-scope items are surfaced before payment. Each flag carries the rule it failed, so review is fast and defensible.
The same layer, reused · 08
More on the same layer.
Each reuses the same fabric, studio and governance — configuration on one foundation, not a new build.
Deadline monitor
Legal deadlines and limitation periods are tracked across the open book. The system alerts before a deadline is at risk — not after it is missed. Every deadline is tied to its source document and the obligation behind it.
Reserves
New claims are clustered with historically similar cases to inform the reserve. The recommendation arrives with the comparable set it was drawn from. Reserving becomes consistent and evidenced, not case-by-case judgement alone.
Fraud & anomaly
Claims are screened for patterns and inconsistencies against the historical book. Suspicious or contradictory cases are flagged for a person, with the anomaly explained. Nothing is auto-declined — the signal simply routes a case to review, sooner.
Prospects of success
For contested matters, the merits and likely outcome are assessed to inform coverage and routing. The view draws on comparable resolved cases and the clauses in play. It supports the decision; a person still makes the call.
Media mining
Counterparties and third parties are screened across open and licensed sources. Relevant findings — sanctions, litigation, reputational signals — are surfaced with their source. Each result is attributable, so a person can verify it before it informs a decision.
Ask the case
Any case can be questioned in natural language across the connected systems. Answers come grounded in the case record, with the evidence behind them. It turns the fabric into something a handler can simply ask.
How it lands · 09
Four gates. Prove one path deeply — not many thinly.
Quality is proven offline before a line of integration is built; the integration path and its full cost are signed off before the engineering starts; and the one legacy read-only path is proven concretely — with radical cost transparency, so no effort ever surfaces late.
Quality, offline
Extraction, coverage and drafting quality scored against a ground-truth set of decided claims — before any integration work begins. If it does not clear the bar here, nothing else starts.
Integration path priced
The path and its full cost are signed off before engineering starts. Radical cost transparency, so no effort surfaces late.
One read-only path, proven
A single legacy system connected read-only and proven concretely — the integration evidence for everything that follows.
Exit criteria met
Agreed up front, measured on your rules and your book, and signed off before scope extends.
What it needs · 10
To prove it on your book, the pilot needs:
A ground-truth case set
A representative set of decided written claims and their documents — the baseline the extraction, coverage and drafting quality is scored against.
Your rule base & policy versions
The coverage rules, policy wordings and statutory fee-schedule versions the utility must reason against — so parity is measured on your rules, not ours.
One read-only path
Read-only access to one legacy system, proven concretely — the integration evidence for everything that follows.
Your underwriting numbers
Loss ratio, average payout, coverage-error and routing costs — the data that converts the combined-ratio direction into a measured, provable case.
A scoped pilot on one line of business — quality proven offline first, integration priced transparently, exit criteria agreed up front. Weeks to the quality proof, not a platform programme.
Bottom line · the proposition
Start where extraction stops. Price on the ratio it moves.
One line of business is the beachhead; the full written-intake stream — every life-area — is the prize. The utility clears the efficiency floor from day one, and the same layer then reaches the number the board actually runs on: the combined ratio, where the loss side is twice the expense side and only a claim-understanding layer can touch it. Win the fallout, prove the loss-side impact on your data, and the vendor relationship becomes an underwriting-margin partnership.
The beachhead
One line, one legacy path, quality proven offline — value in weeks.
The platform
The same layer scales to the full written intake across every life-area.
The partnership
From per-case fee to gain-share on the combined ratio it improves.
Next step
Bring one line of business and a set of decided claims.
Quality is proven offline against your own ground truth before a line of integration is written. Exit criteria are agreed before the pilot starts.