Name: Ailog - RAG as a Service Platform
Availability: InStock
Rating: 4.8 (156 reviews)

Company Overview

HealthPlus is a French mutual health insurance company (mutuelle) serving 180,000 members across France. With comprehensive health, dental, and optical coverage, they handle thousands of member inquiries daily about coverage, claims, and reimbursements.

The Challenge

Call Center Overload

8,500 calls per week to the member service center
Average wait time: 12 minutes (peak times: 25+ minutes)
Call abandonment rate: 23%
Member satisfaction score: 3.2/5 (below industry average)

Repetitive Inquiries

Analysis of call patterns revealed:

Question Type	% of Calls	Complexity
Coverage verification	35%	Low
Reimbursement status	25%	Low
How to submit claims	15%	Low
Finding in-network providers	12%	Medium
Policy changes	8%	Medium
Complex claims issues	5%	High

75% of calls were low-complexity questions that could be answered from existing documentation.

The Documentation Problem

200+ page policy documents
50+ FAQ articles on the website
Members couldn't find or understand the information
Medical terminology confused non-expert members

The Solution: RAG Member Portal

HealthPlus deployed a RAG-powered assistant accessible via:

Member portal (web)
Mobile app
WhatsApp integration

Knowledge Base

All policy documents and coverage guides
Claims procedures and forms
Network provider directories
FAQ and help articles
Regulatory information (Sécurité Sociale integration)

Key Capabilities

Coverage Questions

"Am I covered for MRI scans?"
"What's my dental coverage for crowns?"
"How much will I be reimbursed for glasses?"

Claims Assistance

"How do I submit a claim for a specialist visit?"
"What documents do I need for optical reimbursement?"
"Why was my claim partially rejected?"

Member Services

"How do I add my spouse to my policy?"
"Can I upgrade my coverage?"
"Where can I find in-network dentists near me?"

Implementation

Phase 1: Knowledge Preparation (Weeks 1-2)

Simplified policy documents for plain language
Created Q&A pairs from common call transcripts
Built coverage calculator logic

Phase 2: RAG Configuration (Weeks 3-4)

French-optimized embeddings
Medical terminology handling
Personalization based on member's specific plan

Phase 3: Multi-Channel Deployment (Weeks 5-8)

Web portal integration with SSO
Mobile app widget
WhatsApp Business API integration
Human handoff for complex cases

Results After 8 Months

Call Volume Reduction

Metric	Before	After	Change
Weekly calls	8,500	2,550	-70%
Wait time	12 min	3 min	-75%
Abandonment rate	23%	5%	-78%

Member Engagement

Metric	Before	After	Change
Portal logins/month	45,000	112,000	+149%
Self-service resolution	15%	72%	+380%
Mobile app usage	22%	58%	+164%

Satisfaction Scores

Metric	Before	After	Change
Member satisfaction	3.2/5	4.5/5	+41%
NPS	18	47	+29 points
First contact resolution	45%	89%	+98%

Financial Impact

Call center cost reduction: €750,000/year
Reduced staffing needs: 12 agents → 5 agents
Additional savings from digital claims: €140,000/year
Total annual savings: €890,000

Sample Interactions

Coverage Verification

Member: "My doctor recommended an MRI for my knee. Am I covered and how much will it cost me?"

Assistant: "Based on your HealthPlus Confort plan, MRI scans are covered at 100% of the Sécurité Sociale base rate plus an additional €50 from your mutuelle coverage.

For a knee MRI (code NZQK001):

SS base: €69
Your mutuelle: additional €50
Your coverage: up to €119

Typical MRI costs: €150-300. Your out-of-pocket: approximately €30-180 depending on the facility.

Would you like me to show you in-network radiology centers near you?"

Claims Status with Personalization

Member: "What's happening with my ophthalmologist claim from last week?"

Assistant: "I found your claim #2025-0892 submitted on January 15th:

Claim Details:

Provider: Dr. Martin (ophthalmologist)
Amount: €85.00
Submitted: January 15, 2025

Status: Processing complete ✓

SS reimbursement: €20.90 (pending SS transfer)
HealthPlus reimbursement: €45.10 (paid January 18)
Total reimbursement: €66.00

The €45.10 was transferred to your bank account ending in 4521 on January 18th. The SS portion will arrive within 5 business days.

Is there anything else about this claim?"

Key Success Factors

1. Plain Language Rewriting

Policy documents were rewritten from legal language to member-friendly explanations:

Before: "Le remboursement s'effectue sur la base du tarif de convention majoré du complément mutualiste prévu au tableau des garanties."

After: "We reimburse based on the Sécurité Sociale rate plus the extra amount shown in your coverage table."

2. Personalized Responses

The assistant accesses member-specific information:

Their exact plan and coverage levels
Claim history
Remaining annual limits
Preferred providers

3. Proactive Guidance

Instead of just answering, the assistant guides:

Suggests relevant forms
Explains next steps
Offers to connect to human support for complex cases

4. Multi-Channel Consistency

Same knowledge base powers all channels:

Web portal
Mobile app
WhatsApp
(Future: voice assistant)

Technical Implementation

RAG Configuration

Documents: 500+ (policies, FAQs, procedures)
Embeddings: Multilingual with French optimization
Personalization: Member plan and history context
Retrieval: Hybrid search with coverage filtering
LLM: GPT-4 Turbo (French system prompt)
Temperature: 0.2 (factual accuracy critical)

Security & Compliance

GDPR and French health data regulations (HDS)
End-to-end encryption
SOC 2 Type II compliance
Data residency in France
No health data used for training

Integration

Core insurance system (real-time coverage data)
Claims management system
CRM for escalation and history
SS (Sécurité Sociale) data feeds

ROI Analysis

Investment

Ailog Enterprise: €500/month
Integration development: €25,000 (one-time)
Knowledge base preparation: €10,000 (one-time)
Training and change management: €5,000 (one-time)

Annual Returns

Call center savings: €750,000
Digital claims efficiency: €140,000
Improved retention (reduced churn): €50,000 (estimated)

ROI: 20x in first year (after integration costs) Payback period: 2 months

Member Testimonials

"I used to dread calling my mutuelle—always waiting forever. Now I get answers instantly on my phone, even at midnight when I was worried about my son's hospital visit."

— Sophie M., HealthPlus member

"Finally, I can understand my coverage without needing a law degree. The chatbot explains everything in normal French."

— Jean-Pierre L., HealthPlus member

Lessons Learned

Personalization is essential - Generic answers frustrate members; they want THEIR coverage information
Plain language wins - Rewrote all policy content in accessible French
WhatsApp adoption exceeded expectations - 40% of self-service now via WhatsApp
Human escalation must be seamless - One click to live agent with full context

Future Roadmap

HealthPlus is expanding:

Voice assistant integration (phone IVR)
Proactive health reminders
Claims submission via chat (photo upload)
Provider recommendation engine

Conclusion

For insurance companies, RAG self-service isn't just cost reduction—it's member experience transformation. HealthPlus's 70% call reduction and 41% satisfaction improvement show that members prefer instant, accurate self-service over waiting on hold.

The key is personalization: members don't want generic FAQ answers. They want to know about THEIR coverage, THEIR claims, THEIR options.

Ready to transform your member experience? Explore Ailog for insurance with healthcare-compliant infrastructure.

This case study is based on aggregated data from insurance implementations. Company name and some figures have been adjusted for confidentiality.

HealthPlus: 70% Call Reduction with RAG Self-Service Portal