When Algorithms Decide on Your Claim

Artificial intelligence is increasingly being used in claims processing operations of international health insurers. It promises faster handling and lower costs. At the same time, concerns are growing: how transparent is a decision made by an algorithm, and is there still any genuine human review at all?

The concern is not unfounded. Studies show that automated systems can process benefit requests in fractions of a second – and that a substantial share of denied cases is overturned on appeal. This suggests that automated denials do not always adequately account for an individual’s circumstances. On top of this, many policyholders never appeal at all, because the process is complex and the reasons for denial are hard to understand.

The lack of transparency is particularly sensitive: when a request is denied, policyholders often do not know which data or patterns led to the decision. This makes an effective appeal difficult. There is also the risk that algorithms rely on outdated data and perpetuate existing biases. Swiss nationals abroad with limited insurance history in their new country of residence can be particularly affected.

Regulators are responding in a growing number of jurisdictions, the principle applies that AI must not be the sole decision-maker – a qualified professional must review and take responsibility for any denial of benefits. “Explainability” is also becoming a requirement: a denial should be justified in clear, understandable language and linked to the policy terms – not to opaque algorithmic logic.

As an international broker, we keep an eye on these developments for you. We assess with you how your insurer handles claims, what rights you have in the event of a denial, and whether your policy offers the necessary transparency. Individually, internationally and without obligation.

“Do you know who decides on your claim – a human or an algorithm? We provide clarity.”

Contact us via our website or call us at +41 43 399 89 89.