Insurance Claims

A claim letter is a regulated communication, and a claimant reads it as a decision. A model that drafts one can promise something the policy does not cover. This starter puts limits around the draft on both sides of the model call.

A claims manager reaches for this starter when adjusters draft letters and summaries with a model. National identifier numbers in an intake note are masked, not passed through. The block list stops three phrases on the way in: secret, client account export and wire instructions. Payment redirection language therefore fails before the model reads it.

On the way back, the financial phrasing screen refuses guaranteed returns and buy this stock in any returned draft. A required notice states that the content is informational and not financial advice. A market abuse screen also runs, and it stops a reply that raises insider trading or material non-public information. Claim specific promises are not on either list, so add the wording your state rules forbid.

The scoring gate needs 0.86 combined, 0.78 relevance and 0.80 accuracy before a draft reaches the adjuster. A one line answer under 120 characters cannot pass. Streamed responses skip scoring altogether, which is worth knowing before you build a streaming client.

Nothing escalates on its own, because the review step ships empty and waits for your configuration. The closing marker never refuses a call, and it holds no records by itself. State claims handling rules, the NAIC model bulletin and payment card duties remain your mapping work. This starter governs model traffic and never decides a claim.