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WORKFLOW - INSURANCE

Coverage Determination Workflow

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Quick Answer

The Coverage Determination Workflow uses AI to analyze insurance policy language, exclusions, and endorsements against claim facts to determine whether coverage applies. AI interprets policy terms, evaluates exclusions, and provides explainable coverage determinations with citations to specific policy provisions.

Definition

**Coverage Determination Workflow** automates what experienced adjusters do: reading policy language, understanding coverage grants and exclusions, applying those rules to claim facts, and documenting the rationale with policy citations.

Key Points

  • Retrieves and parses policy documents (declarations, forms, endorsements)
  • Maps claim facts to policy coverage provisions
  • Evaluates applicability of exclusions and exceptions
  • Handles coordination of benefits across multiple policies
  • Cites specific policy sections for every determination
  • Flags ambiguities for human adjuster review
  • Achieves 85-95% accuracy on standard policy forms
  • Provides confidence scores and alternative interpretations

How It Works

1

Policy Retrieval

Retrieve policy documents from policy management system: declarations page, policy forms, endorsements, exclusions.

2

Claim Facts Extraction

Extract structured facts from claim: loss type, cause of loss, date, location, parties involved, damages claimed.

3

Coverage Grant Analysis

Analyze which policy coverages might apply: liability, collision, comprehensive, property damage, bodily injury.

4

Exclusion Evaluation

Check whether exclusions apply: intentional acts, wear and tear, business use, specific perils. Evaluate exceptions to exclusions.

5

Policy Limits Check

Verify claim is within policy limits, sub-limits, and deductibles. Flag if claim exceeds coverage.

6

Coordination of Benefits

If multiple policies apply, determine primary vs. excess coverage and coordinate between policies.

7

Coverage Determination

Generate coverage decision: covered, not covered, or requires adjuster review. Include confidence score.

8

Rationale & Citations

Provide explainable rationale citing specific policy sections, exclusions evaluated, and reasoning for determination.

Decision Logic: Coverage Grant → Exclusions → Exceptions

Step 1 - Coverage Grant: Does the policy insuring agreement cover this type of loss? (e.g., "We will pay for direct physical loss to your covered auto")

Step 2 - Exclusions: Do any exclusions take coverage away? (e.g., "We do not cover loss from wear and tear")

Step 3 - Exceptions to Exclusions: Do any exceptions bring coverage back? (e.g., "But we do cover loss caused by...")

When to Escalate to Human Adjuster

  • •Ambiguous policy language requiring interpretation
  • •Novel claim scenarios not covered in training data
  • •Manuscript endorsements with non-standard language
  • •Multiple conflicting exclusions and exceptions
  • •State-specific case law heavily influences interpretation
  • •Low confidence score (<70%) on coverage determination