Insuresys builds structured audit products for India's health insurance ecosystem. One product addresses fraud, waste and abuse at the insurer level. The other protects employees and gives HR the visibility they have never had.
India's health insurance sector loses a significant share of claims value to fraud, waste and abuse each year. The issue is not that these patterns are undetectable - it is that the infrastructure to act on them consistently, at scale, does not exist.
IRDAI's regulatory framework provides a clear basis for identifying overcharging and billing irregularities. The gap is in operationalising that framework across every claim, not just the few a manual auditor can review in a day.
clAImSure applies IRDAI regulations as explicit audit logic. Each claim is reviewed against coded regulatory rules. Where a flag is raised, the specific regulation behind it is cited and a recommended payable is calculated.
The product integrates with existing claims management systems via REST API and is native to the NHCX format. It extends the reach of your adjudication team without replacing their judgement - every decision, including overrides, is immutably logged.
Identifies known FWA patterns in line-item billing - the recurring practices that inflate claim values and are explicitly addressed in IRDAI health regulations.
Flags admissions and procedures that fall outside expected clinical norms for a given diagnosis - a key indicator of waste that manual review cannot assess at volume.
Accepts NHCX-format structured data, scanned documents and batch exports. Designed to sit alongside your existing infrastructure, not replace it.
Each flag references the IRDAI regulation it is based on and shows a recommended payable - not a black box score. Your adjudicator sees the logic, not just the result.
Flags are routed to your team for a final decision. Acceptances, overrides and escalations are all supported - with mandatory reason capture for overrides.
Every flag, decision and override is permanently recorded with timestamp and regulatory citation. Exportable for IRDAI inspections without manual reconstruction.
Most employees encounter their policy's limitations at the worst possible moment - already hospitalised, already handed a bill, with no knowledge of what is covered, what is excessive, and what they can challenge.
For CHROs, the picture is equally opaque. Group health premiums rise year on year. Renewal negotiations happen with no counter-data. The insurer cites claims ratios. The CHRO has nothing equivalent to push back with.
clAImBuddy works at two levels. For employees, it reviews hospital bills before they are signed - identifying overcharges, policy mismatches and disputable items, and guiding the employee through what to do next.
For the CHRO, it provides a consolidated view of group health claims activity: cost trends by hospital and diagnosis category, utilisation patterns, and an audit trail that can be used in renewal negotiations.
Employees submit hospital bills before signing. clAImBuddy identifies overcharged items, policy mismatches and disputable charges in plain, actionable language.
Translates group policy terms into clear guidance at the point of use - what is covered, what is not, and what an employee is entitled to claim before they commit to paying.
Where an overcharge is identified, clAImBuddy gives the employee the basis to dispute it - with the specific grounds clearly stated and a record of the interaction maintained.
CHROs see group claims activity over time - cost by hospital, diagnosis category trends, utilisation patterns and audit outcomes. Data that does not currently exist in one place.
Gives CHROs a documented audit record and cost trend analysis to use in insurer renewal discussions - so the conversation is not one-sided.
clAImBuddy is deployed at the corporate level and made available to employees through the HR function. No individual sign-up friction - access comes through the employer.
Most audit tools in Indian health insurance are built on statistical pattern matching. Insuresys starts from regulation - and that changes what the output can be used for.
IRDAI regulations are coded as the actual audit rules, not cited post-facto to justify a statistical flag. Every output has a regulatory basis that can be read, explained and defended.
clAImSure is audit support, not an autonomous decision engine. Every flag goes to a human decision. That decision, and its reasoning, is what gets logged - not just the system's output.
clAImSure addresses the insurer's leakage problem. clAImBuddy addresses the employee's information problem. Both sides of the same claims ecosystem, with a consistent data foundation underneath.
Data minimisation, purpose limitation and consent architecture are built into both products from the ground up - not layered on after. India's Digital Personal Data Protection Act, 2023, is treated as a product constraint, not a legal afterthought.
Neither product requires the buyer to change their claims management system. REST API integration and NHCX-native ingestion mean clAImSure fits into existing workflows. clAImBuddy deploys through the corporate HR function.
Insuresys is built with an advisory board of retired senior insurance professionals - underwriting, claims operations, TPA management and regulatory affairs. The product logic comes from the domain, not from what the technology makes easy.
| Capability | clAImSure | Statistical anomaly tools | Manual audit |
|---|---|---|---|
| IRDAI regulations coded as audit logic | ✓ Core design principle | ~ Post-facto reference only | ~ Inconsistent by auditor |
| Regulatory citation per flag | ✓ | ✕ | ~ Depends on auditor |
| Coverage across claim volume | 100% automated | 100% automated | Typically under 15% |
| Adjudicator decision log | ✓ Immutable | ~ Basic | ✕ |
| NHCX-native ingestion | ✓ | ~ Partial | ✕ |
| DPDP Act compliant by design | ✓ | ~ | Not applicable |
Insuresys exists to make health insurance claims more accurate and more transparent in India. Not by replacing the people who process them, but by giving them better tools - and giving the insured a fair position for the first time.
We start with what IRDAI says, not with what a model predicts. The regulatory framework already provides the logic needed to identify most FWA patterns in Indian health claims. Our job is to encode that logic reliably, apply it consistently, and make the output usable by a real adjudicator or CHRO - not just a data team.
Machine learning plays a supporting role where appropriate - improving extraction quality, surfacing anomaly candidates for rule review. It does not generate flags independently.
Insuresys was founded at the intersection of technology capability and insurance domain knowledge. The advisory board comprises retired senior executives from India's insurance industry - covering underwriting, claims operations, TPA management and regulatory affairs. They are active contributors to product design, not passive names on a page.
The problems clAImSure and clAImBuddy address were identified through extended conversations with people who have spent careers inside the ecosystem. The product logic reflects that, and continues to be shaped by it.
Insuresys is led by its founder, who brings a background in AI product development and financial services technology. The decision to build in health insurance FWA came from a structured analysis of where regulatory infrastructure and technology capability had the largest gap in India - and where that gap had the clearest economic consequence.
IRDAI regulations mapped and encoded. Core audit logic tested against historical claims data. FWA pattern taxonomy validated with advisory board input.
In conversations with insurers and TPAs to structure a 90-day proof-of-concept pilot. Focused on demonstrating flag accuracy and workflow integration ahead of any commercial discussion.
Live claims processing alongside the partner's existing adjudication workflow. Output measured against actual settlement decisions. Pilot designed to be self-contained with no long-term commitment required.
Full CMS integration, NHCX connectivity confirmed, adjudicator training completed. clAImBuddy corporate rollout initiated in parallel through CHRO partnerships.
To discuss a pilot or learn more, write to us at hello@insuresys.in
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