Authors : Rajkumar Govindaswamy Subbian

Volume/Issue : Volume 10 - 2025, Issue 2 - February

Google Scholar : https://tinyurl.com/32rb4xbw

Scribd : https://tinyurl.com/wub49uf5

DOI : https://doi.org/10.5281/zenodo.14928754

Abstract : Technology Driven Intelligent Risk & Fraud Assessment in Insurance focuses on leveraging artificial intelligence (AI), machine learning (ML), blockchain, and predictive analytics to improve risk assessment and combat fraud. The study highlights the role of AI-driven predictive analytics, deep learning algorithms, blockchain for transparency, and automation to enhance accuracy, reduce fraudulent activities, and streamline insurance workflows. The approach analyzed real-world case study demonstrated the successful integration of these technologies into Guidewire ClaimCenter and PolicyCenter, highlighting operational benefits in claims handling and fraud prevention.  Aim: The primary aim of this study is to analyze the impact of technology-driven fraud detection and intelligent risk assessment in P&C insurance. The focus areas include real-time fraud detection through AI-based automation and anomaly detection, optimizing risk assessment and claims validation with predictive analytics, leveraging blockchain-based smart contracts to secure claims payments and integrating the Guidewire ClaimCenter and PolicyCenter applications for automated claims handling.  Study Design: The study utilized LexisNexis Risk Solutions, ISO ClaimSearch (Verisk Analytics), Office of Foreign Assets Control (OFAC), Claims & Underwriting Exchange (CUE), fraud detection models, and FNOL (First Notice of Loss) AI chatbots in a Commercial Insurer to evaluate fraud and mitigate fraud. It emphasized real-time resource management in cloud environments and iterative testing to adapt to system updates. Tools like H2O.ai, Google AutoML, Selenium, and OpenAI GPT for Fraud Analysis were used to execute end-to-end tests while analyzing their impact on performance.  Place and Duration of Study:  Place: Conducted in a cloud-based environment utilizing Guidewire applications to replicate real-world operational conditions. The distributed study enabled remote collaboration among claims adjudicators across the US.  Duration: Spanned 8 months, divided into setup (2 months), iterative training and testing (5 months), and results analysis and optimization (1 month)  Methodology: The methodology employs real-time fraud detection models implemented within Guidewire ClaimCenter, using historical claims data, external fraud intelligence sources such as LexisNexis, ISO and AI-powered risk scoring systems such as H2O.ai, Google AutoML. The methodology includes data collection from structured and unstructured sources, AI-based anomaly detection, predictive analytics for fraud risk classification, and blockchain-powered identity verification to prevent fraudulent claims.  Conclusion: The study demonstrated how AI-driven fraud detection significantly improves fraud identification accuracy, reduces financial losses, and enhances operational efficiency in Property & Casualty (P&C) insurance. By integrating machine learning models, predictive analytics, and blockchain authentication within Guidewire ClaimCenter, we were able to detect fraudulent claims 60% faster, reduce manual investigations by 40%, and improve policyholder trust through faster claim settlements.

Keywords : Office of Foreign Assets Control (OFAC), Claims & Underwriting Exchange (CUE), Artificial intelligence (AI), Machine Learning (ML), Property & Casualty (P&C), FNOL (First Notice of Loss).

References :

1. Automated Claims Processing Tools: A Game-Changer for Insurers https://www.decerto.com/ post/automated-claims-processing-tools-a-game-changer-for-insurers
2. How to Automate Claims Forms Processing - https://www.datagrid.com/blog/automate-claims-forms-processing
3. Role of Automation in Insurance Industry for 2025 - https://www.ajackus.com/blog/automation-in-insurance-industry-for-2025
4. Leveraging technology in insurance to enhance risk assessment and policyholder risk reduction: https://www.oecd.org/en/publications/leveraging-technology-in-insurance-to-enhance-risk-assessment-and-policyholder-risk-reduction_2f5c18ac-en.html?
5. Transforming Fraud Detection, Risk Assessment, and Underwriting in Insurance: https://techbii.com/ai-driven-fraud-detection-in-insurance/?
6. Leveraging Data and AI for Efficient Fraud Detection in the Insurance Industry: https://theintechgroup.com/case_study/leveraging-data-and-ai-for-efficient-fraud-detection-in-the-insurance-industry/
7. Shielding the future of the insurance industry: https://legal.thomsonreuters.com/en/insights/white-papers/shielding-the-future-of-the-insurance-industry/form?gatedContent=%252Fcontent%252Fewp-marketing-websites%252Flegal%252Fgl %252Fen%252Finsights%252Fwhite-papers% 252Fshielding-the-future-of-the-insurance-industry
8. Automated Claims Processing: https://binariks.com/ blog/claims-processing-automation-insurance/
9. Integration with Guidewire ClaimCenter: https://www.expert.ai/resource/guidewire-claimcenter-claims-automation-demo-with-expert-ai/?
10. Artificial Intelligence and Machine Learning in Claims Processing: https://www.globallogic.com/wp-content/uploads/2021/02/AI-and-ML-in-Claims-Processing.pdf?
11. Using generative AI to mitigate insurance fraud: https://www.infosysbpm.com/offerings/functions/generative-ai/insights/documents/using-generative-ai-to-mitigate-insurance-fraud.pdf?
12. AI and ML in Fraud Detection: https://www.sciencetimes.com/articles/60131/20241216/ai-ml-fraud-detection.htm