TPD Disability Claims Screening Automated: Medical, Policy and Financial Logic in One Pass

// the problem

TPD claims processing is slow by design, not by medical necessity. Heterogeneous medical certificates and disability assessments require interpretation beyond OCR — percentages must be understood in clinical context. Policy rules are local, conditional, and buried in PDF annexes — definitions of "Total" vs. "Partial" vary by jurisdiction and product. Financial decisions wait for external rulings, locking up significant capital reserves unnecessarily. Claimants are left in the dark during the most stressful moment of their lives. Notice of Loss, Disability Certificate, Medical History, Policy Annexes, and Financial Exposure each live in different silos with no single unified view.

// what CLU does

CLU's GRID Framework (Observe → Analyze → Decide → Act) resolves the 4-layer complexity stack simultaneously. Medical assessment and policy logic happen in parallel — the agent swarm cross-references all evidence against policy conditions in one unified pass. Actuarial agents model reserve requirements based on real evidence, freeing locked capital without waiting for external rulings. An Empathetic Communication Agent generates clear status updates with transparent explanations for every decision. Adjusters receive edge cases with full context pre-loaded: the system handles routine, humans handle judgment.

// the agents, in order

1. 1
   Intake Agent

   Ingests Notice of Loss, Disability Certificate, Medical History, and Policy Annexes into a unified claim profile — zero siloed data, all evidence in one view
2. 2
   Medical Analysis Agent

   Interprets disability percentages and medical certificates contextually — cross-references against clinical norms and jurisdiction-specific definitions of Total vs. Partial disability
3. 3
   Policy Logic Agent

   Applies jurisdiction-specific and product-specific rules from policy annexes in parallel with medical analysis — resolves the 4-layer complexity stack in one pass
4. 4
   Reserve Intelligence Agent

   Models reserve requirements based on real evidence from the unified claim profile — frees locked capital without waiting for external rulings
5. 5
   Communication Agent

   Generates clear, empathetic status updates for claimants at every milestone — transparent explanations for every decision, reducing anxiety and complaints
6. 6
   Escalation Agent

   Delivers complex edge cases to adjusters with full context pre-loaded — humans review judgment calls, not administrative intake data

// systems it talks to

• Medical Certificate Parser
• Policy Rules Engine (TML)
• Actuarial Reserve Model
• Claims System API
• Customer Comms API
• Audit Trail DB

// more cases in P&C Insurance

• P&C Claims Intake and Triage Automated: FNOL to Adjuster Queue in Under 30 Minutes98% of claims routed in under 30 minutes. Zero manual triage. Adjusters focus exclusively on complex, high-value cases.
• Policy Renewal Retention Automated 90 Days Out: Stop Losing 15–25% of the BookCarriers stop losing 15–25% of their book to reactive outreach. Every retention touchpoint runs on schedule, 90 days out, with no manual reporting.
• P&C Claims Vendor Coordination Automated: Inspectors, Adjusters and Contractors in 6 Days Instead of 18Complete third-party vendor lifecycle orchestrated autonomously — from assignment to invoice approval. Vendor cycle compressed from 18 days to 6 days with zero email/phone relay.
• Florida P&C Claims Deadline Compliance: 14/30/90-Day Statutory Tracking Without Blind SpotsEvery open claim is a ticking compliance clock. CLU intercepts before breach — autonomously monitoring every claim against Florida's 14/30/90-day statutory deadlines with zero blind spots.
• Liability Underwriting Submissions Automated: Broker Emails to Quote 70% Faster9-agent swarm orchestrates every submission from data-sludge intake to broker-ready quote — 100% appetite consistency, 80% less operational effort.
• Third-Party Contract Risk Review with DORA and GDPR Compliance Checks at Ingestion6-agent swarm extracts risk from PDFs, auto-flags DORA gaps, redlines against Golden Standard, and models financial exposure — contracts are no longer static storage.
• Travel Insurance Claims Straight-Through Processing: Auto-Settlement in Hours, Not DaysNeural Grid STP resolves multi-format claims (PDFs, images, multi-currency) with >95% confidence auto-settlement — customers never repeat information.
• Motor Claims Lifecycle Automated from FNOL to Subrogation, with 30–40% Less FraudBefore · During · After — Risk DNA profiling, autonomous FNOL decisioning, subrogation recovery, and lifecycle intelligence orchestrated as one continuous loop.
• Health Insurance Policy Retention: Churn Signals Detected Before the Renewal Window Opens6-agent Smart Policy Engine compares plans dynamically, personalizes offers by usage and churn risk, and engages customers conversationally — before they stop renewing.
• Kinesiology Claims Fraud Detection: False Licenses, Session Inflation and Rings Caught Before PaymentCLU + Aictive: Gatekeeper, Enforcer, and Watchdog layers detect false licenses, session inflation, and organized rings — pre-payment, not post-investigation.