Has your claim been flagged as suspicious by an algorithm or AI system? A risk signal is not the same as proven fraud. Ask which specific facts the insurer relies on for its decision and what human assessment has taken place. The legal consequences may not be concealed behind a general reference to a system.
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Written by Onur Arslan, attorney at Arslan Advocaten. Do you have questions about your own situation? Get in touch.
Selection, analysis and decision are separate steps
An algorithm can select claims for further investigation, flag unusual patterns or summarise information. That does not mean the system also rejects the payout on its own. Ask, therefore, about the role automation played in your file: which signal arose, how was it checked and who took the final decision?
A similarity between claims can be entirely innocent. People may use the same garage, doctor or claims representative without any fraud being involved. The relevant individual facts must be investigated. Incorrect source data can also affect a risk score.
Explanation and access
The GDPR grants rights to information and access. Special rules and exceptions apply to decisions based solely on automated processing that produce legal effects or similarly significant effects. Not every AI-assisted action automatically falls within that category. See GDPR, Articles 13–15 and 22.
Ask which personal data were used, which sources they come from and how errors can be corrected. A request for an understandable explanation is not the same as an unlimited right to all the source code. The explanation must, however, be useful enough to allow you to understand and challenge the processing and the decision.
A human must genuinely assess the case
A name alone beneath an automatically generated rejection says little about the substantive review. Ask which objections and counter-evidence the claims handler took into account. A human assessment must be meaningful and not merely a formality.
Present demonstrable errors in a targeted way: an incorrect vehicle link, a mix-up of persons, a duplicate claim that had already been corrected, or a wrong date. Then ask for a reassessment of both the risk classification and the measures based on it.
Fraud, payout and registration
A system score does not replace the substantiation of intentional deception. Nor does every discrepancy provide sufficient grounds for registration in the External Reference Register (EVR). Ask for separate reasons for additional investigation, rejection, recovery of payments and registration. The applicable statutory and protocol requirements continue to apply when technology is used.
In personal injury cases, technical signals must also be distinguished from medical causation. A text model that points out differences between reports cannot, as a matter of course, determine their medical significance. A targeted assessment by the right expert remains necessary.
Frequently asked questions
May an insurer use AI?
Technology is not prohibited in itself. Its use must comply with the applicable rules and may not replace a proper individual assessment.
Am I entitled to the exact risk score?
That depends on the data and the processing. Ask for your personal data and the understandable information needed to assess the decision.
Does a high risk score prove fraud?
No. A risk selection must be followed by an investigation into specific facts.
What can Arslan do?
We can ask targeted questions about the processing and challenge the rejection or registration on the basis of the individual facts.
Read also about requesting investigation reports and the burden of proof in insurance fraud.
Have an insurance decision based on algorithmic signals assessed.
This page provides general information and is not legal advice on your own situation. No rights can be derived from its content.
