Clifford Bernard

CaseC-0018

Burglary

An honest claim just under the bar, where a second model's agreement could settle it.

home claim · $8,725

What the claimant wrote

Home claim. Our house in Fresno, CA was burgled on 2026-05-14 while we were away. The back door was forced. Stolen: two bicycles and power tools. We filed a police report the same day and have receipts for most items. Total loss is $8,725. — Ruth Adeyemi 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-0018: $8,725, 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

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

    The steps it went through
    1. Code Claim C-0018: $8,725, 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 15.3% and a request for information at 79.0%; 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-0018: $8,725, 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 15.3% and a request for information at 79.0%; 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.

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)

    Settled with no person, after a second model agreed. 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 named the same action, and the claim clears the fitted floor.
    4. Code A second model agreed and the claim clears the floor: handled with no person.

  4. + Ask the customer one question

    Settled with no person, after a second model agreed. 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 named the same action, and the claim clears the fitted floor.
    4. Code A second model agreed and the claim clears the floor: 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.