Agentic AI for health insurers
Claim adjudication. Prior authorisation. Cashless approval. Three of the highest-volume, most reviewer-hour-heavy workflows in any health insurer’s operations. The Vihaya Engine is designed to take a meaningful share of these touchless with an audit chain regulators can reconstruct, and route the rest to your adjudicators with full context. IRDAI-context regulatory framing covered. The touchless share is tuned per pilot; Vihaya is pre-revenue and the first design-partner engagements are open.
Why this matters
Health insurance is a high-volume, document-grounded business. Adjudication operations at large insurers are reviewer-hour-heavy because most of the cost is human reviewers reading PDFs against policy wordings, hospital tariff lists, and clinical guidelines. The work is rules-heavy, document-grounded, and audit-heavy — the textbook shape for agentic decisioning.
What stops insurers automating it isn’t the AI capability — foundation models have been good enough for two years. What stops them is the absence of an audit chain dense enough for IRDAI inspection. Vihaya solves that primitive first; the model is the easy part.
Workflows in scope
Claim adjudication
Read the claim, the medical records, the policy wording, and the hospital’s tariff list. Output: approve / partial / deny / escalate with cited rationale.
Prior authorisation
Pre-procedure approval grounded in policy criteria + clinical guidelines. Touchless rate tuned per drug class during the pilot.
Cashless approval
Real-time authorisation against the cashless hospital network. Latency target: seconds, audit chain preserved.
Fraud / abuse flagging
Pattern-based detection across claim history, with citations to the prior cases that informed the flag.
Illustrative 12-week pilot plan
Illustrative weekly cadence — actual milestones will be refined with the design partner.
| Phase | Integration | Output |
|---|---|---|
| Weeks 1–2 | BAA / DPA · sandbox access · policy corpus delivery | Discovery report · golden-set scoping |
| Weeks 3–5 | Claim intake (your portal or TPA feed) | Service deployed; first eval pass |
| Weeks 6–8 | Hospital tariff list · IRDAI guideline corpus · cashless authorisation system | Golden eval set signed off by medical director |
| Weeks 9–11 | Shadow run against last quarter’s claims | Weekly variance report vs. manual decisions |
| Week 12 | Handoff | Runbook · reviewer training · go/no-go on production phase |
Health-insurance FAQ
Which kinds of Indian health insurers is Vihaya designed for?
Vihaya targets standalone health insurers, the health-insurance arms of general insurers, and TPAs (third-party administrators) who run adjudication on behalf of insurers. The engagement shape is the same across them. Vihaya has not yet signed a paid pilot with any insurer or TPA; the first design-partner engagements are open.
How does Vihaya handle multilingual claim documents?
Indian health claims arrive in English, Hindi, and major regional languages — sometimes mixed within a single document. The foundation models we route to (gpt-4o, Claude, Gemini) have meaningful coverage across these languages, with per-language quality tuned during the pilot rather than asserted up-front. The Context Mesh indexes the original-language text plus an English normalisation so retrieval works across the language barrier without losing fidelity.
Is the decision IRDAI-compliant on its own?
Vihaya provides the audit trail, citation chain, and escalation primitives the IRDAI Cyber Security Guidelines require. Compliance is an organisational property, not a vendor one — the insurer’s board-approved outsourcing policy, risk-management plan, and incident-reporting workflow all wrap Vihaya. We provide the evidence package and the right-to-audit clause; the insurer’s compliance team owns sign-off.
Can Vihaya integrate with cashless hospital networks?
Yes. The outbound adapter writes decisions back into the insurer’s cashless authorisation system (whether that’s an in-house portal or a TPA platform). Hospitals see the authorisation result in their existing workflow without a separate Vihaya login.
What about Ayushman Bharat / PMJAY claims?
Ayushman Bharat / PMJAY claims follow a different eligibility model than commercial health insurance. The same Vihaya engine handles PMJAY eligibility decisioning grounded in the scheme’s clinical packages and beneficiary criteria; this is typically a separate pilot from the commercial-claims workflow.
Want to see this in your environment?
30-minute discovery call. We follow up with a draft SOW shortly after.
Talk to us about a pilot