Building an Insurance Claims Agent with Copilot Studio and Dataverse

Insurance claims processing is the textbook use case for AI agents: high volume, structured workflow, clear rules, and significant time savings. Here is how to build one with Copilot Studio and Dataverse.

The Architecture

• Trigger — New claim submitted via web form, email, or agent chat.
• Intake agent — Extracts claim details: policy number, incident type, date, description, and supporting documents.
• Validation — Looks up the policy in Dataverse. Checks coverage, deductibles, and policy status. Flags mismatches.
• Assessment — For photo claims (auto damage, property damage), vision AI assesses severity. For text-based claims, NLP extracts key facts.
• Routing — Based on claim value and complexity, routes to auto-approve (simple, low-value), standard adjuster, or senior adjuster with HITL approval.

The Dataverse Layer

Tables for Customers, Policies, Claims, Transactions, and Adjuster Roster. The agent reads from all of these and creates/updates Claims records as it processes. Relationships between tables let the agent navigate from a customer to their policies to their claim history.

The Business Impact

Typical results: 60% reduction in processing time for simple claims, 30% for complex ones. Adjusters focus on claims that need human judgment instead of data entry. Customer satisfaction improves because claims move faster.