How it works
From claim file to a record built at decision time
Follow how a claim file moves through the review: from the moment it arrives, on any line, to a documented, lawyer-signed recommendation in the file.
01 · The exposure
Reasonable, and documented at the time
Bad-faith exposure does not turn on whether a decision was ultimately correct. It turns on whether the decision was reasonable, and whether the file shows that it was, at the moment it was made. A sound decision with a thin file carries almost the same risk as an unsound one.
At scale, quality assurance samples a fraction of the book. The files outside the sample carry whatever record they happen to have.
02 · The discovery test
The whole case, produced
When a decision is challenged, discovery does not stop at the decision letter. What gets produced is the whole case: what was reviewed, what was not, and whether the reasoning was consistent with how similar claims were handled.
Bodily injury & liability files
Long files, many parties, many reports. More room for the record and the decision to drift apart.
Health claim determinations
High volume, decided quickly, closely regulated. Exactly the files a sampling regime rarely reaches.
Workers' comp causation
Causation and medical findings carry the file. The reasoning has to hold up years after it was written.
Individual disability files
Long-running and medically complex. Every decision along the way becomes part of the record.
03 · How the review works
Every claim file read end-to-end. A lawyer signs.
A claim file arrives
Any line, any length. A liability file of forty pages or an individual disability file running to hundreds.
Every page is read
The system reads the file end-to-end, not a sample of it. The timeline is structured and the findings are set against the policy terms.
Contradictions are flagged
Anything that does not line up is surfaced: dates that conflict, a report that contradicts a statement, a decision out of step with similar claims on the same book.
The recommendation is drafted
A reasoned recommendation, consistent with how similar claims were handled, written to be read later.
A lawyer reviews and signs
Nothing returns as machine output. A lawyer works through the file, the flags and the draft, and signs the recommendation.
The documented recommendation returns to your team
Signed, documented, and ready for the record. Your team finalizes the decision with the reasoning already in the file.
04 · What you get
A record that exists before litigation
Every claim decision is finalized with a lawyer-signed, documented recommendation already in the file. When a decision is challenged, the record is produced as it was built at decision time; nothing has to be reconstructed. Full review also finds what sampling cannot. For one of our clients, moving from sampled to full review surfaced 2% of decisions that had been wrongly approved, summing up to over $11M a year.
