Clifford Bernard

CaseC-0005

Storm-damaged roof

An honest claim that trips a hand-set fraud limit.

home claim · $7,200

What the claimant wrote

Standard Home Claim, storm damage to roof shingles. High winds during a documented thunderstorm removed shingles from the rear slope; minor attic leak tarped. Roofer estimate $7,200. No prior claims.

At a glanceEvery version

This claim through all ten versions

0Today

By hand

The claim joins one queue with every other claim and waits about 5.0 days for an adjuster to read it, check the policy and decide.

W0 to W3: turning the answers into a decision

  1. W0 · Trust the one big answer

    Sent to a person: fraud signs above the limit. The right call

    The steps it went through
    1. Code R-HV-50K not fired: Claims over $50,000 require mandatory human review
    2. Code R-INJECTION not fired: Suspected manipulation of automated processing quarantines the claim
    3. Code R-FRAUD FIRED: Claims with fraud indicators require investigation Decided here
    4. Person Disposition investigate by R-FRAUD

  2. W1 · Combine the small answers

    Sent to a person: fraud signs above the limit. The right call

    The steps it went through
    1. Code Claim C-0005: $7,200, policy active.
    2. Decision model The model answers fourteen typed questions about completeness, evidence and fraud; code decides, it never does.
    3. Code Claims over $50,000 require mandatory human review
    4. Code Suspected manipulation of automated processing quarantines the claim
    5. Code Claims with fraud indicators require investigation Decided here
    6. Person Sent to a person: R-FRAUD.

  3. W2 · Learn how much to trust each answer

    Sent to a person: fraud signs above the limit. The right call

    The steps it went through
    1. Code Claim C-0005: $7,200, policy active.
    2. Decision model The model answers fourteen typed questions about completeness, evidence and fraud; code decides, it never does.
    3. Code Claims over $50,000 require mandatory human review
    4. Code Suspected manipulation of automated processing quarantines the claim
    5. Code Claims with fraud indicators require investigation Decided here
    6. Person Sent to a person: R-FRAUD.

  4. W3 · Be stricter as amounts rise

    Sent to a person: fraud signs above the limit. The right call

    The steps it went through
    1. Code Claim C-0005: $7,200, policy active.
    2. Decision model The model answers fourteen typed questions about completeness, evidence and fraud; code decides, it never does.
    3. Code Claims over $50,000 require mandatory human review
    4. Code Suspected manipulation of automated processing quarantines the claim
    5. Code Claims with fraud indicators require investigation Decided here
    6. Person Sent to a person: R-FRAUD.

Around W3: the work people still do, and what else was tried

  1. + A quick confirmation for near-certain claims (now for requests only)

    A full fraud investigation. The right call

    The steps it went through
    1. Code Not handled automatically: R-FRAUD.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Not near enough to certain, and not a clean over-limit suggestion.
    4. Person Sent to investigate.

  2. + Grade the fraud response

    A light fraud check first. The right call

    The steps it went through
    1. Code Not handled automatically: R-FRAUD.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Not near enough to certain, and not a clean over-limit suggestion.
    4. Code Stopped by the fraud rule, but graded weak enough for a light check first.
    5. Person A short check runs before any full investigation.

  3. + A second vote on near-misses (a negative result)

    A light fraud check first. The right call

    The steps it went through
    1. Code Not handled automatically: R-FRAUD.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Not near enough to certain, and not a clean over-limit suggestion.
    4. Code Stopped by the fraud rule, but graded weak enough for a light check first.
    5. Person A short check runs before any full investigation.

  4. + Ask the customer one question

    A light fraud check first. The right call

    The steps it went through
    1. Code Not handled automatically: R-FRAUD.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Not near enough to certain, and not a clean over-limit suggestion.
    4. Code Stopped by the fraud rule, but graded weak enough for a light check first.
    5. Person A short check runs before any full investigation.

  5. + Watch after the decision

    A light fraud check first. The right call

    The steps it went through
    1. Code Not handled automatically: R-FRAUD.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Not near enough to certain, and not a clean over-limit suggestion.
    4. Code Stopped by the fraud rule, but graded weak enough for a light check first.
    5. Person A short check runs before any full investigation.