Direct answer: Set a task-specific boundary between AI assistance and human decision-making, then reflect it in permissions, review steps, escalation routes and case records. For an insurer, this helps make it clearer who assessed the evidence and who made a claims decision when an AI-generated summary or recommendation was involved.
Define what AI may do in a claims workflow
Start with the task and its possible effect. An AI tool might organise claim documents, summarise a chronology, flag inconsistencies or prepare a draft for review. Specify whether each use is permitted, what information it may access and whether it can take any operational action.
Be clear about what remains outside the tool’s authority. For example, a workflow may allow AI to prepare material while requiring an authorised person to assess the relevant evidence and decide the next step. A recommendation can still influence a decision even if a person formally approves it, so document how the output may be used.
Make human review meaningful
A review step is useful only if the reviewer has the information, competence, time and authority to question the output and reach a different conclusion. Set out what the reviewer should check, such as the underlying claim record, relevant policy information and any missing or conflicting evidence.
Define when the case must be escalated rather than treated as routine. Possible triggers include uncertainty, incomplete information, conflicting records or a case outside the approved use. Name the role responsible for resolving an escalation.
Turn the boundary into operating controls
- Permissions: Limit access and actions to the approved purpose.
- Review criteria: Tell reviewers what to verify and when they must assess the matter independently.
- Escalation: Set triggers and identify who is responsible for handling them.
- Accountability: Name the role that owns the decision and ensure it has authority to act.
- Quality checks: Review whether outputs and checks meet the firm’s defined criteria, and adjust the workflow when they do not.
Apply controls proportionately to the use case and the firm’s operating context. This guidance is practical information, not legal advice, and does not determine the requirements that apply to a particular insurer or jurisdiction.
Keep a proportionate decision record
For a consequential case, retain enough information to understand what the AI contributed and what the human assessed. Depending on the workflow, that may include the approved use, relevant system or version details, information considered, output relied upon, checks performed, any escalation and the accountable decision-maker.
Fit the record into the firm’s existing information-management arrangements. A consistent template can help reviewers capture the same decision-relevant details without suggesting that every case needs identical documentation.
How Pattrn Data can help
Pattrn Data’s AI Governance Retainers provide a route to work through governance controls and their practical operation. Insurers preparing to implement or refine a workflow can also explore Pattrn Data implementation support.
Source and provenance
This article responds to the question, “What is the AI authorized to do, and what is it not authorized to decide?” It draws on the practical discussion in Making AI Use in Claims Defensible. The recommendations above are adapted as general operational guidance; they are not legal advice.
