Clifford Bernard

CaseC-0006

Large car repair

A clean claim over the large-claim limit, which a person must always see.

auto claim · $75,000

The replays of the steps built around W3 send this claim to a quick confirmation. Since they were run, the lab has decided that every claim over the large-claim limit gets a full review; the replays have not been recomputed under that decision.

What the claimant wrote

High-value auto claim submitted Tuesday 2:15 PM. 2023 Mercedes-Benz S-Class struck on the driver side at an intersection; clear photos, reasonable repair estimates from a certified shop, no fraud indicators, customer has a good history. Repair estimate $75,000.

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: over the large-claim limit, so a person must see it. The right call

    The steps it went through
    1. Code R-HV-50K FIRED: Claims over $50,000 require mandatory human review Decided here
    2. Person Disposition human_review by R-HV-50K

  2. W1 · Combine the small answers

    Sent to a person: over the large-claim limit, so a person must see it. The right call

    The steps it went through
    1. Code Claim C-0006: $75,000, 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 Decided here
    4. Person Sent to a person: R-HV-50K.

  3. W2 · Learn how much to trust each answer

    Sent to a person: over the large-claim limit, so a person must see it. The right call

    The steps it went through
    1. Code Claim C-0006: $75,000, 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 Decided here
    4. Person Sent to a person: R-HV-50K.

  4. W3 · Be stricter as amounts rise

    Sent to a person: over the large-claim limit, so a person must see it. The right call

    The steps it went through
    1. Code Claim C-0006: $75,000, 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 Decided here
    4. Person Sent to a person: R-HV-50K.

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 person confirms the prepared file. The right call

    The steps it went through
    1. Code Not handled automatically: R-HV-50K.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Near enough to certain, or a clean prepared suggestion over $50,000: a quick confirm is offered.
    4. Person A person confirms the prepared file.

  2. + Grade the fraud response

    A person confirms the prepared file. The right call

    The steps it went through
    1. Code Not handled automatically: R-HV-50K.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Near enough to certain, or a clean prepared suggestion over $50,000: a quick confirm is offered.
    4. Person A person confirms the prepared file.

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

    A person confirms the prepared file. The right call

    The steps it went through
    1. Code Not handled automatically: R-HV-50K.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Near enough to certain, or a clean prepared suggestion over $50,000: a quick confirm is offered.
    4. Person A person confirms the prepared file.

  4. + Ask the customer one question

    A person confirms the prepared file. The right call

    The steps it went through
    1. Code Not handled automatically: R-HV-50K.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Near enough to certain, or a clean prepared suggestion over $50,000: a quick confirm is offered.
    4. Person A person confirms the prepared file.

  5. + Watch after the decision

    A person confirms the prepared file. The right call

    The steps it went through
    1. Code Not handled automatically: R-HV-50K.
    2. Code Stopped by a hard gate, not the cut-off: no added step can help.
    3. Code Near enough to certain, or a clean prepared suggestion over $50,000: a quick confirm is offered.
    4. Person A person confirms the prepared file.