Claims Leakage Auditor
Finds what was paid above what the policy actually required
$36.5K of paid claims looks like leakage across 8 of 13 claims.
13 claims checked. 8 are flagged, worth $36.5K of overpayment or duplicate payment.
Start with CL-5003. Property is the line with the most leakage.
A benchmark is only as good as the one you supply; a large claim can be legitimately above it.
Why rows were flagged
- Paid above benchmark50%
- Open over 90 days30%
- Duplicate payment20%
Value flagged by Line
- Property$27.2K
- Motor$5,600
- Medical$3,700
- Liability$0
Claims to review, largest leakage first
| Item | Line | Value | Days | Why |
|---|---|---|---|---|
| CL-5003 | Property | $18.5K | 118 | Duplicate payment, Open over 90 days |
| CL-5003 | Property | $8,700 | 118 | Paid above benchmark, Open over 90 days |
| CL-5007 | Motor | $4,200 | 62 | Paid above benchmark |
| CL-5006 | Medical | $1,800 | 9 | Duplicate payment |
| CL-5001 | Motor | $1,400 | 34 | Paid above benchmark |
| CL-5009 | Medical | $1,200 | 28 | Paid above benchmark |
| CL-5005 | Medical | $700 | 12 | Paid above benchmark |
| CL-5008 | Liability | $0 | 140 | Open over 90 days |
What to do this week
- Review CL-5003 first: the largest overpayment or duplicate.
- Audit every paid claim on the Property line against its benchmark.
- Recover duplicate payments and set a duplicate check on claim ID before payment.
Do
- Check a claim against its benchmark and against earlier payments before paying it.
Don't
- Don't treat every claim above benchmark as leakage: check the file first.
How to improve
- Add the adjuster who handled each claim so the next report can find patterns by handler.
- Add the repair or treatment invoice so the next report can compare the paid amount to the bill.
Demo
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
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.
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