Appeals
Find the denial conversations that generate appeals and complaints
Coach the patterns that create downstream work for your appeals and customer service teams.
Insurance · Contact Center Intelligence
The call that creates the appeal is the same call that creates the E&O claim.
Carriers run millions of FNOL intakes, coverage questions, and denial conversations a year. The intake errors, coverage misstatements, and missed escalations buried in them drive downstream rework, appeals, and exposure your QA program never sees. Spearfish surfaces them across 100% of calls.
◆ Voice · Chat · Email
◆ P&C · Specialty · Life
◆ 100% call coverage
Live · First Notice of Loss
CALL #INS-4471
A
I've got the basics down. Your policy should cover the water damage, so you're all set there.
C
Wait — so the flooding is definitely covered? Even from the storm?
A
Should be, yes. I'll get the claim submitted for you now.
C
Okay, good — I was told everything's handled.
Coverage Misstatement
Flagged 0.83
Flagged 0.83
Intake Accuracy
Gap 2 fields
Gap 2 fields
E&O Risk
Rising 0.71
Rising 0.71
The Problem
The error that costs you most happens at the start of the claim.
Traditional QA scores a 1–3% sample for tone and handle time. In insurance, the costly patterns — bad intake, coverage misstatements, missed escalations — hide in the other 97%, and don't surface until they're an appeal, a reopened claim, or an E&O exposure.
Before Spearfish
- ✕You know the FNOL was taken — not whether the intake captured the details your adjusters depend on.
- ✕An agent's off-script coverage assurance looks like a resolved call — until it resurfaces as an E&O claim.
- ✕A denial gets explained, the customer hangs up confused, and you find out when the appeal is filed.
- ✕The escalation that should have happened didn't — and your QA sample never caught it.
- ✕You grade agents on whether they said the words, not whether the customer actually understood the policy terms.
With Spearfish
- ✓Intake completeness is scored on every FNOL — the accuracy gaps that create claims rework surface immediately.
- ✓Coverage misstatements are flagged the moment they're spoken, before they become E&O exposure.
- ✓Denial conversations are audited for clarity — you coach the patterns that generate appeals and complaints.
- ✓Missed escalations are surfaced — the calls that should have escalated but didn't become a coaching program.
- ✓Comprehension is measured separately from delivery — you know when the script was said but didn't land.
Use Cases
Built for how carriers actually operate.
Four places where contextual intelligence catches the patterns creating downstream work for your claims, appeals, and customer service teams.
FNOL Intake
Audit FNOL intake for the accuracy adjusters depend on
Identify the intake errors creating extra work for claims handling.
E&O Risk
Catch coverage misstatements before they show up as E&O claims
Audit what your agents are telling customers about policy terms and surface the inconsistencies.
Comprehension
Verify customer comprehension across high-stakes interactions
Identify the calls where the script was delivered but the customer didn't actually understand.
Contextual Metrics
Intelligence your dashboards have never produced.
| Metric | Scope |
|---|---|
| FNOL Intake Completeness | First-call accuracy |
| Coverage Misstatement Flag | E&O exposure |
| Denial Clarity Score | Appeal risk |
| Missed Escalation Rate | 100% coverage |
| Customer Comprehension Rate | Per call type |
| Sentiment Trajectory | Call arc, not snapshot |
| True Resolution Rate | Outcome, not code |
Traditional analytics tell you what happened — the call lasted 11 minutes, the FNOL was logged, the denial was read aloud. Contextual intelligence tells you what actually happened: the intake was missing two fields your adjuster needs, the agent misstated coverage, and you have an appeal — and an E&O exposure — you could have prevented.
Spearfish Whitepaper — What is Contextual Intelligence?
How It Works
Deployed in days. Results from day one.
Spearfish sits on top of the contact center and claims systems you already run — without replacing anything.
Works with
Genesys
Five9
NICE
Talkdesk
Amazon Connect
⇄
Connect your stack
REST API integration with your CCaaS, CRM, and claims management systems. No rip-and-replace, no new data collection infrastructure. Connect what you already have.
✎
Define what matters in plain English
Describe what you want to measure — "Did the agent capture the loss details accurately and avoid overstating coverage?" — and Spearfish applies it to every interaction.
◈
Get intelligence across 100%
Contextual meaning extracted from every voice, chat, and email — intake completeness, coverage accuracy, denial clarity, missed escalations, and comprehension — scored against your standards.
➤
Act before it becomes rework
Coaching alerts fire on the patterns generating appeals and E&O risk — before they reach your appeals queue, your claims handlers, or a regulator.
Compliance & Risk
Defensible evidence. Not just scripts.
◊
E&O — Errors & Omissions Exposure
Coverage misstatements are the seed of an E&O claim. Spearfish audits what your agents actually tell customers about policy terms across 100% of calls, surfaces the inconsistencies, and gives you the evidence to correct them before they become a loss.
◎
Market Conduct & Unfair Claims Practices
Examiners ask about how claims and denials are handled — not whether a phrase was spoken. 100% monitoring means every denial and FNOL interaction is evaluated, flagged, and logged, available for review or a market conduct exam.
⬡
Appeals & Complaint Management
Pre-appeal signals are recognizable in the denial conversation itself. Spearfish catches the patterns that generate appeals and DOI complaints early enough to coach them out — not after the filing lands.
⚕
Data Privacy & Security
Enterprise-grade encryption for data in transit and at rest, with a full compliance framework for sensitive policyholder and claims data. Your data stays yours — Spearfish surfaces the intelligence; you own and control the underlying interactions.
Get Started
See what your claims calls are really telling you.
Connect your existing recordings and systems. Get actionable intelligence in days, not months.