Clifford Bernard

CaseC-0015

Storm damage, paperwork to follow

An honest claim missing its documents: the right next step is to ask for them.

home claim · $5,950

What the claimant wrote

Home claim. A severe thunderstorm with high winds hit Boise, ID on 2026-01-17 and tore shingles off our roof and rear fence. There is a small leak into the attic that we have tarped. BlueLine Contractors inspected and quoted $5,950 for repairs. Neighbors had similar damage. — Tom Kowalczyk I do not have the estimate or the other paperwork yet and will send it later.

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: flagged as needing a specialist. 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 not fired: Claims with fraud indicators require investigation
    4. Code R-POLICY not fired: Claims on a policy that is not in force go to a human (denials are never automatic)
    5. Code R-TYPE-CONFIDENCE not fired: Uncertain claim type cannot be routed automatically
    6. Code R-SPECIALIST FIRED: Claims needing domain expertise are assigned to a specialist Decided here
    7. Person Disposition human_review by R-SPECIALIST

  2. W1 · Combine the small answers

    Sent to a person: flagged as needing a specialist. The right call

    The steps it went through
    1. Code Claim C-0015: $5,950, 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
    6. Code Claims on a policy that is not in force go to a human (denials are never automatic)
    7. Code Claims needing domain expertise are assigned to a specialist Decided here
    8. Person Sent to a person: R-SPECIALIST.

  3. W2 · Learn how much to trust each answer

    The customer is asked for what is missing, automatically. The right call

    The steps it went through
    1. Code Claim C-0015: $5,950, 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
    6. Code Claims on a policy that is not in force go to a human (denials are never automatic)
    7. Code Fourteen learned weights score approval at 3.6% and a request for information at 96.4%; the higher one is proposed.
    8. Code Certain enough, so it is handled with no person. Decided here
    9. Code Handled with no person: asked for the missing information.

  4. W3 · Be stricter as amounts rise

    The customer is asked for what is missing, automatically. The right call

    The steps it went through
    1. Code Claim C-0015: $5,950, 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
    6. Code Claims on a policy that is not in force go to a human (denials are never automatic)
    7. Code Fourteen learned weights score approval at 3.6% and a request for information at 96.4%; the higher one is proposed.
    8. Code Certain enough, so it is handled with no person. Decided here
    9. Code Handled with no person: asked for the missing information.

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

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

    The customer is asked for what is missing, automatically. The right call

    The steps it went through
    1. Code The fitted workflow handles this claim with no person; no lane is needed.
    2. Code Handled automatically; this claim never reaches a lane.

  2. + Grade the fraud response

    The customer is asked for what is missing, automatically. The right call

    The steps it went through
    1. Code The fitted workflow handles this claim with no person; no lane is needed.
    2. Code Handled automatically; this claim never reaches a lane.

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

    The customer is asked for what is missing, automatically. The right call

    The steps it went through
    1. Code The fitted workflow handles this claim with no person; no lane is needed.
    2. Code Handled automatically; this claim never reaches a lane.

  4. + Ask the customer one question

    The customer is asked for what is missing, automatically. The right call

    The steps it went through
    1. Code The fitted workflow handles this claim with no person; no lane is needed.
    2. Code Handled automatically; this claim never reaches a lane.

  5. + Watch after the decision

    The customer is asked for what is missing, automatically. The right call

    The steps it went through
    1. Code The fitted workflow handles this claim with no person; no lane is needed.
    2. Code Handled automatically; this claim never reaches a lane.