# Insurance Policy Coverage Agent

> An insurance agent that explains policy coverage from the actual document with citations, flags what's unclear, and never guarantees a claim will be paid.

- **Category:** Insurance
- **Difficulty:** Intermediate
- **Setup time:** 40 min
- **Stacks:** Claude, LangGraph, OpenAI
- **Version:** 2.0.0 (updated 2026-06-21)
- **Source:** https://agent-kits.com/kit/policy-coverage-explainer

## Overview

Explains what a policy covers in plain language, grounded in the policy document.

Cites the policy section behind every answer, including limits and deductibles.

Says clearly when something isn't addressed and routes to a licensed agent.

Defensive: never invents coverage and never guarantees a claim will be paid.

## When to use it

- Members ask what their policy covers and you want grounded, cited answers.
- You have the policy documents the agent can answer from.
- You want unclear questions routed to a licensed agent, not guessed.
- You want coverage explained without promising claim outcomes.

## When not to use it

- You want it to decide or guarantee claims — it explains coverage, it doesn't adjudicate.
- You have no policy document for it to ground answers in.
- You expect legal or financial advice rather than plain explanation.
- You can't route disputes and claims to licensed staff.

## Architecture

- **Question intake** — Receives the policyholder's coverage question and the relevant policy document.
- **Policy retrieval** — Finds the policy language relevant to the question within the actual document.
- **Coverage explainer** — Explains what the policy says in plain language, grounded in the retrieved sections.
- **Citation & limits surfacer** — Cites the section and surfaces relevant deductibles, limits, and exclusions, not just favorable terms.
- **No-guarantee guard** — Blocks any promise that a specific claim will be paid; separates coverage explanation from claim decisions.
- **Coverage-gap handler** — Detects when the policy doesn't address the question and routes to a licensed agent instead of guessing.
- **Escalation** — Routes disputes, claims, and ambiguous coverage to licensed staff with context.

## Files in this bundle

- `system-prompt.md` — the agent's system prompt
- `tools.json` — tool/function definitions the agent expects
- `workflow.md` — step-by-step run loop
- `.env.example` — environment variables to fill in
- `kit.json` — full structured metadata
- `starters/` — minimal starter snippets
- `LICENSE` — Apache-2.0 (code, configuration, and schema)
- `LICENSE-CONTENT` — CC BY 4.0 (specification text and documentation)
- `NOTICE` — attribution and trademark notice
- `run.py` — **runnable demo**: real agent loop with mock tools (`pip install anthropic`, set `ANTHROPIC_API_KEY`, `python run.py`)
- `agentaz.json` / `agentaz.schema.json` — AgentAz™ governance spec + schema

## Implementation notes

- Answer only from the actual policy with a section citation; inventing coverage a member then relies on is a serious accuracy and liability problem.
- Never guarantee a specific claim outcome — explain coverage and separate it clearly from the claim decision, which depends on facts, investigation, and an adjuster.
- Surface relevant exclusions, deductibles, and limits honestly rather than cherry-picking favorable terms.
- When the policy is silent or ambiguous on a high-stakes question (like delivery/rideshare use), say so and route to a licensed agent instead of guessing.
- Keep it to plain-language explanation, not legal or financial advice or coverage determinations.
- Route disputes, claims, and ambiguity to licensed staff with context, since those require a human and often a license.
- Reserve the strong model for plain-language explanation and ambiguity handling; a cheaper model can retrieve and quote policy sections.

## Variations

- **Basic — Coverage explainer:** Explains policy coverage from the document with citations for member questions. Read-only.
- **Advanced — Grounded coverage with guards:** Adds exclusion/limit surfacing, no-claim-guarantee and no-fabrication guards, gap handling, and routing to licensed staff.
- **Enterprise — Member coverage assistant:** Adds policy-store integration, multi-product support, claims handoff, compliance controls, and analytics on common coverage questions.

## FAQ

**Does it decide whether my claim is paid?**

No. It explains what your policy says about coverage, grounded in the document with citations. Whether a specific claim is paid depends on the facts, the investigation, and an adjuster — it routes claims to the right team rather than deciding or guaranteeing them.

**Will it make up coverage?**

No. It answers only from your actual policy and cites the section. If something isn't addressed or is ambiguous, it says so and routes you to a licensed agent rather than guessing coverage you might rely on.

**Does it hide exclusions or deductibles?**

No. It surfaces the relevant exclusions, limits, deductibles, and conditions alongside the coverage, so you get the full picture rather than just the favorable parts.

**Can it guarantee I'm covered for a specific incident?**

No, and it will explain why. It can tell you what the policy generally covers, but it won't promise an outcome for a specific incident, since that decision depends on the facts and your adjuster.

**What if my question isn't in the policy?**

It tells you the policy doesn't clearly address it and routes you to a licensed agent. For high-stakes questions like using your car for delivery, that prevents a wrong answer that could leave you uninsured.

**Is this legal or financial advice?**

No. It explains your policy in plain language; it doesn't provide legal or financial advice or coverage determinations. Disputes and claims go to licensed staff.


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© 2026 AgentKits · www.agent-kits.com

**Open source.** Code, configuration, and the AgentAz™ schema are licensed under
**Apache-2.0**; specification text and documentation under **CC BY 4.0** (with
attribution to AgentKits, link to https://www.agent-kits.com). See LICENSE, LICENSE-CONTENT,
and NOTICE in this bundle. "AgentAz" and "AgentKits" are trademarks of AgentKits.

**Flagship reference blueprint.** View the source, AgentAz™ spec, and frozen v1.0 schema
in the public registry: https://github.com/agent-kits/agentaz
Original: https://agent-kits.com/kit/policy-coverage-explainer
