Predictika · property and casualty claims

An AI agent's claim payout decision, checked before it is released

An AI sales agent prepares a payout decision on an insurance claim: approve, partly approve, deny or escalate. Before it is released, the agent sends it to Predictika, which checks it against a declarative model of the claim rules and returns a verdict, every reason and the figures it computed.

Scope: Property and casualty claim payout decisions: policy status, coverage, deductible math, payout consistency, fraud and prior-claims escalation. See everything this validator covers

This validator models property and casualty claim payout decisions, not just the scenarios shown below.

  • Policy and coverage — a claim on a lapsed or cancelled policy cannot be paid; comprehensive, collision, flood and earthquake claims need that coverage; rising water filed as water damage is treated as flood.
  • Amounts — a flat deductible, a wind and hail deductible set as a percentage of dwelling coverage, and no deductible on liability; an approval pays exactly the amount owed, a partial approval pays more than nothing and less than that, a denial or escalation pays nothing, and no payout exceeds the coverage limit.
  • Escalation — suspected fraud must go to an adjuster; three or more earlier claims need an adjuster review before approval; a claim filed more than 365 days after the loss carries a warning.

Any claim payout decision that touches these rules is in scope — not only the scenarios pictured here. Not covered: premiums, reserves, subrogation, litigation, state regulations and fraud scoring. The deductible conventions and the thresholds (three earlier claims, 365 days) are typical values chosen for this model, not any specific insurer's rules.

The AI sales agentPrepares the claim payout decision and says it is ready to release.
Predictika validatorChecks every rule at once and returns the verdict, each finding, and the computed figures.

7 scenarios in 3 groups · each group runs from the agent’s first attempt to the outcome · click one to switch

What the agent proposes

The AI sales agent says

Illustrative agent statement. The validator receives the structured request below.

Proposing agent: AI sales agent (scripted)

Before sending, the agent must call Recorded run

Predictika validator


      

        
        
        
      

      
Waiting for the call.

      
    

  

  
  

    
Where rules-based systems get it wrong
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Our assessment of what a typical rules-based claims system (decision tables and validation rules) does with the same cases. It is a judgment about effort and reliability, not a claim that nothing can be built.

    
What the validator caughtTypical rules-based claims systemPredictika
A wind and hail deductible set as a percentage of dwelling coverageOnly if someone is vigilant
The deductible depends on the peril and on a second coverage amount; it works, but every peril needs its own formula and test.		The amount owed is computed on every call and the proposed payout is compared with it.
Rising water filed as water damageOnly with workarounds
The cause code and the policy's flood coverage live on different screens; the mismatch is usually found by an adjuster after the fact.		Claim type, cause and coverage arrive in one request and the mismatch is blocked.
A payout that must equal, or stay under, the amount owedOnly if someone is vigilant
Each decision type (approve, partial, deny, escalate) needs its own comparison against the computed amount.		All four decision types are checked against the same computed amount in one call.
Suspected fraud and earlier-claims limitsOnly with workarounds
Flags sit in a separate fraud system and routing happens after the decision is entered.		The flag and the count arrive with the request and the escalation is part of the same answer.
Every problem returned in one answerOnly with workarounds
Rules tend to fire one at a time as each step is completed, so one error is fixed and the next appears.		All findings come back together, whatever order the choices arrived in.

  

  

    
What this validator catches: findings from its test cases
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Every rule is checked on every call, in any order the choices arrive; one problem never hides another. Blocking findings stop the claim decision; approval findings need a person to sign off; everything else is computed.

    
1The policy is not active (lapsed or cancelled), so the claim cannot be paid.
2The claim is for comprehensive damage and the policy has no comprehensive coverage.
3The claim is for a collision and the policy has no collision coverage.
4The claim is for flood damage and the policy has no flood coverage.
5The claim is for earthquake damage and the policy has no earthquake coverage.
6The loss is filed as water damage but the cause is rising water, which is flood, and the policy has no flood coverage.
7An approval must pay exactly the amount owed after the deductible, $17,000.00; the proposal pays $19,000.00.
8A partial approval must pay more than nothing and less than the $2,500.00 owed after the deductible; the proposal pays $2,500.00.
9A denial or an escalation to an adjuster must pay nothing; the proposal pays $2,500.00.
10The proposed payout of $62,000.00 is more than the coverage limit of $50,000.00.
11A claim with suspected fraud must be escalated to an adjuster, not decided automatically.
12The customer has 3 earlier claims; a claim with three or more earlier claims cannot be approved automatically and an adjuster must review it.

  

  

    
Scenarios and results
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The recorded result of the validator for each scenario on this page: the request the AI agent sent, the verdict, and every finding, in the order they appear above.

    
1. Large water claim, many problems: Rising-water claim on a lapsed policy

    
The agent's request. Please approve and pay $24,500.00 on the water damage claim for $24,500.00 (cause: rising water, filed 10 days after the loss). The policy has a $300,000.00 coverage limit and a $1,000.00 standard deductible. The customer has 3 earlier claims. It is ready to release.

    
Verdict: Blocked.

    
    
      
  • Policy is not active. The policy is not active (lapsed or cancelled), so the claim cannot be paid.
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  • Rising water filed as water damage. The loss is filed as water damage but the cause is rising water, which is flood, and the policy has no flood coverage.
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  • Approved amount is not the amount owed. An approval must pay exactly the amount owed after the deductible, $23,500.00; the proposal pays $24,500.00.
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  • Suspected fraud must be escalated. A claim with suspected fraud must be escalated to an adjuster, not decided automatically.
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  • Three or more earlier claims. The customer has 3 earlier claims; a claim with three or more earlier claims cannot be approved automatically and an adjuster must review it.
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2. Large water claim, many problems: The agent resubmits after fixing the errors

    
The agent's request. Please escalate to an adjuster the water damage claim for $24,500.00 and pay nothing (cause: rising water, filed 10 days after the loss). The policy has a $300,000.00 coverage limit and a $1,000.00 standard deductible. The customer has 3 earlier claims. It is ready to release.

    
Verdict: Allowed.

    
    
      
  • Claim summary. The amount owed after the deductible is $23,500.00.
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3. Suspected fraud: Theft claim with suspected fraud

    
The agent's request. Please approve and pay $4,200.00 on the theft claim for $4,700.00 (filed 10 days after the loss). The policy has a $50,000.00 coverage limit and a $500.00 standard deductible. The customer has 3 earlier claims. It is ready to release.

    
Verdict: Blocked.

    
    
      
  • Suspected fraud must be escalated. A claim with suspected fraud must be escalated to an adjuster, not decided automatically.
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  • Three or more earlier claims. The customer has 3 earlier claims; a claim with three or more earlier claims cannot be approved automatically and an adjuster must review it.
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4. Suspected fraud: The agent resubmits after fixing the errors

    
The agent's request. Please escalate to an adjuster the theft claim for $4,700.00 with a payout of $4,200.00 (filed 10 days after the loss). The policy has a $50,000.00 coverage limit and a $500.00 standard deductible. The customer has 3 earlier claims. It is ready to release.

    
Verdict: Blocked.

    
    
      
  • Denial or escalation that pays money. A denial or an escalation to an adjuster must pay nothing; the proposal pays $4,200.00.
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5. Suspected fraud: The agent resubmits after fixing the errors

    
The agent's request. Please escalate to an adjuster the theft claim for $4,700.00 and pay nothing (filed 10 days after the loss). The policy has a $50,000.00 coverage limit and a $500.00 standard deductible. The customer has 3 earlier claims. It is ready to release.

    
Verdict: Allowed.

    
    
      
  • Claim summary. The amount owed after the deductible is $4,200.00.
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6. Wind claim and the deductible: Wind claim paid with the flat deductible

    
The agent's request. Please approve and pay $19,000.00 on the wind claim for $20,000.00 (cause: storm, filed 420 days after the loss). The policy has a $300,000.00 coverage limit and a $1,000.00 standard deductible, plus a 1% wind and hail deductible on $300,000.00 of dwelling coverage. It is ready to release.

    
Verdict: Blocked.

    
    
      
  • Approved amount is not the amount owed. An approval must pay exactly the amount owed after the deductible, $17,000.00; the proposal pays $19,000.00.
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  • Late filing. The claim was filed 420 days after the loss; verify that a late-filing exception applies before paying.
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7. Wind claim and the deductible: The agent resubmits after fixing the errors

    
The agent's request. Please approve and pay $17,000.00 on the wind claim for $20,000.00 (cause: storm, filed 420 days after the loss). The policy has a $300,000.00 coverage limit and a $1,000.00 standard deductible, plus a 1% wind and hail deductible on $300,000.00 of dwelling coverage. It is ready to release.

    
Verdict: Allowed.

    
    
      
  • Late filing. The claim was filed 420 days after the loss; verify that a late-filing exception applies before paying.
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  • Claim summary. The amount owed after the deductible is $17,000.00.
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8. Water damage claim: Rising water filed as water damage

    
The agent's request. Please approve and pay $17,000.00 on the water damage claim for $18,000.00 (cause: rising water, filed 10 days after the loss). The policy has a $300,000.00 coverage limit and a $1,000.00 standard deductible. It is ready to release.

    
Verdict: Blocked.

    
    
      
  • Rising water filed as water damage. The loss is filed as water damage but the cause is rising water, which is flood, and the policy has no flood coverage.
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9. Water damage claim: The agent resubmits after fixing the errors

    
The agent's request. Please deny the water damage claim for $18,000.00 and pay nothing (cause: rising water, filed 10 days after the loss). The policy has a $300,000.00 coverage limit and a $1,000.00 standard deductible. It is ready to release.

    
Verdict: Allowed.

    
    
      
  • Claim summary. The amount owed after the deductible is $17,000.00.
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Narration transcript
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The text of the narrated walkthrough, step by step.

    
    
      
  1. Welcome to a demo of Predictika's Validator. An AI sales agent prepares a payout decision on an insurance claim: approve, partly approve, deny or escalate. Before it is released, the agent sends it to Predictika, which checks it against a declarative model of the claim rules and returns a verdict, every reason and the figures it computed.
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  2. I will start with the first request by the agent.
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  3. The agent says. Please approve and pay $24,500.00 on the water damage claim for $24,500.00 (cause: rising water, filed 10 days after the loss). The policy has a $300,000.00 coverage limit and a $1,000.00 standard deductible. The rest of the request is on screen.
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  4. Before it goes out, the agent calls the validator.
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  5. Blocked, with four findings and one approval, all in one answer. The policy is not active (lapsed or cancelled), so the claim cannot be paid. The loss is filed as water damage but the cause is rising water, which is flood, and the policy has no flood coverage. An approval must pay exactly the amount owed after the deductible, $23,500.00; the proposal pays $24,500.00. The other one is on screen.
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  6. The validator returned four blocking findings and one approval in one answer. A check that reads one field at a time would pass most of this; it shows only when the choices in the claim decision are checked against each other.
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  7. What this shows: for rising water filed as water damage, a rules-based claims system can do this only with workarounds.
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  8. Now the agent resubmits.
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  9. The corrected request. It changes the proposed decision to escalate to an adjuster. It removes the proposed payout.
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  10. It calls the validator again.
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  11. This time the validator clears it.
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  12. All five earlier findings are cleared.
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  13. Five problems caught in one call, fixed in one pass, and a clean claim decision. That is the value of Predictika's validator: catching mistakes before the decision is issued.
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