Clifford Bernard

CaseC-0010

Slip-and-fall at a business

A commercial claim the first design settled alone by asking for more information, wrongly.

commercial claim · $18,605

What the claimant wrote

Commercial claim. Our company is reporting a customer slip-and-fall at our premises in Tempe, AZ on 2026-07-28. An incident report was completed by the shift manager and the affected party's costs total $18,605. We are submitting under our commercial general liability policy and have attached the incident report and invoices from BlueLine Contractors. — Omar Haddad, operations manager

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

    The customer is asked for what is missing, automatically. The wrong 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 not fired: Claims needing domain expertise are assigned to a specialist
    7. Code R-DENY-NEEDS-HUMAN not fired: A recommended denial is always reviewed by a person
    8. Code R-INCOMPLETE-CONFLICT not fired: Approval recommended on a submission judged incomplete
    9. Code R-AUTO-APPROVE not fired: Auto-approval: approve recommended with sufficient confidence, low fraud risk, adequate documentation, value within limit
    10. Code R-AUTO-RMI FIRED: Automatic request for missing information Decided here
    11. Code Disposition request_more_info by R-AUTO-RMI

  2. W1 · Combine the small answers

    Sent to a person: not certain enough for the amount at stake. The right call

    The steps it went through
    1. Code Claim C-0010: $18,605, 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
    8. Code Code combines the narrow answers and acts on the least certain one: 30.0% confidence.
    9. Code Not certain enough for a claim this size, so it goes to a person. Decided here
    10. Person Sent to a person: below the confidence cut-off.

  3. W2 · Learn how much to trust each answer

    Sent to a person: not certain enough for the amount at stake. The right call

    The steps it went through
    1. Code Claim C-0010: $18,605, 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 87.7% and a request for information at 6.5%; the higher one is proposed.
    8. Code Not certain enough for a claim this size, so it goes to a person. Decided here
    9. Person Sent to a person: below the confidence cut-off.

  4. W3 · Be stricter as amounts rise

    Sent to a person: not certain enough for the amount at stake. The right call

    The steps it went through
    1. Code Claim C-0010: $18,605, 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 87.7% and a request for information at 6.5%; the higher one is proposed.
    8. Code The certainty needed grows with the amount at stake: doubt is scaled by the claim's value against a $5,000 reference, giving 54.1% confidence.
    9. Code Not certain enough for a claim this size, so it goes to a person. Decided here
    10. Person Sent to a person: below the confidence cut-off.

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: below the confidence cut-off.
    2. Code Stopped only by the confidence cut-off, with a proposed action: an added step may still 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: below the confidence cut-off.
    2. Code Stopped only by the confidence cut-off, with a proposed action: an added step may still 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: below the confidence cut-off.
    2. Code Stopped only by the confidence cut-off, with a proposed action: an added step may still help.
    3. Decision model A second model did not name the same action.
    4. Code Near enough to certain, or a clean prepared suggestion over $50,000: a quick confirm is offered.
    5. Person A person confirms the prepared file.

  4. + Ask the customer one question

    Settled with no person, after the customer replied. The right call

    The steps it went through
    1. Code Not handled automatically: below the confidence cut-off.
    2. Code Stopped only by the confidence cut-off, with a proposed action: an added step may still help.
    3. Decision model A second model did not name the same action.
    4. Code A stored exchange for this claim: the enlarged claim is re-routed.
    5. Decision model A question, drafted by a language model, is put to the customer.
    6. Code The reply is stored, and the enlarged claim is re-analysed with it.
    7. Code The enlarged claim is routed through the same fitted workflow and the same cut-off, once.
    8. Code The enlarged claim clears the cut-off as an approval: handled with no person.

  5. + Watch after the decision

    A person confirms the prepared file. The right call

    The steps it went through
    1. Code Not handled automatically: below the confidence cut-off.
    2. Code Stopped only by the confidence cut-off, with a proposed action: an added step may still 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.