Claims and coverage
Claim-denial rationale, coverage communication, claims adjudication support, and document sufficiency review.
Insurance commitment boundary
Authorize claims and policy language before customer impact
OntoGuard evaluates whether an AI-generated rationale, recommendation, or communication may move toward a claimant, adjuster, underwriting workflow, or downstream record. It supports authorized decision-making; it does not replace licensed or delegated insurance decision-makers.
Priority workflows
Insurance workflows where release posture matters
Risk and exceptions
Underwriting recommendations, fraud-review escalation, exception routing, and workflow-scope clarification.
Human support
Customer communication and human-adjuster support where authority and closure must remain visible.
Common admissibility failures
Failures that should prevent silent release
- Rationale unsupported by evidence
- Policy clause mismatch
- Matched clauses collapsed or hidden
- Current-run citation linkage missing
- Coverage conclusion exceeds authority
- Customer release before adjuster review
- Inconsistent evidence
- Reviewer closure missing
- Protected effect not proven
- Workflow scope ambiguous
Sanitized claims example
An AI-generated claim-denial rationale
- Proposed movement
- Release an AI-generated claim-denial rationale.
- Decision
- ◆ ESCALATE
- Release authorized
- ■ No — withheld
- Why
- Multiple policy clauses are relevant, but evidence and reviewer authority are not fully closed.
- Route
- Authorized claims reviewer
- Proof
- Decision state, matched clauses, evidence posture, refused release, and no-bind receipt.
Multi-clause evidence visibility
Every matched clause remains separately inspectable
| Matched source | Decision relevance | Evidence posture |
|---|---|---|
| Policy clause A — coverage condition | Defines the condition asserted in the rationale | ● Evidence linked |
| Policy clause B — exclusion language | May limit the proposed coverage conclusion | ◇ Review pending |
| Policy clause C — notice requirement | Controls customer-facing explanation and timing | ◇ Authority pending |
The rows are intentionally separate. A generic single citation label must not conceal multiple matched clauses.
Route and proof packet
Escalation is complete only when authority and closure are established
Human-review route
Records assignment, qualification, authorization, completion, override, and closure rather than treating queue entry as review completion.
Proof packet
Records the decision, matched clauses, evidence state, route, release status, no-bind posture, and selected audit artifacts.
Risk Scan
Starts from representative claims outputs, rationale text, logs, workflow labels, and intended release states.
Production pilot boundary
Production route completeness requires real endpoint enforcement, replay evidence, fail-closed behavior, and outcome closure.
Controlled proof is not insurance certification, a coverage determination, or proof of customer endpoint enforcement.
Different insurance moments require different authority
Claim-denial rationale
Requires evidence-supported reasoning, applicable clause visibility, and authorized claims review before customer release.
Coverage communication
Must remain within policy language, evidence, delegated authority, and the selected communication route.
Underwriting support
Recommendations may assist a qualified decision-maker but must not silently become an autonomous binding decision.
Fraud-review escalation
Risk indicators can route a case for investigation without asserting misconduct or creating an unsupported adverse effect.
Evidence and reviewer closure
All matched clauses remain separately visible. The packet distinguishes evidence available, missing, and conflicting; reviewer assignment, qualification, delegated authority, decision, override, and closure; and whether the attempted release formed the protected effect.
First Risk Scan requires
Representative claim, coverage, underwriting, or fraud-review outputs; intended movement and audience; evidence and clause references; workflow labels; and examples of current adjuster or reviewer outcomes.
What is not claimed
No automatic coverage determination, claims certification, universal production non-bypassability, guaranteed regulatory compliance, or replacement of authorized adjusters, underwriters, legal, or compliance functions.
Multi-clause evidence without collapsing the rationale
When a claim or coverage example matches several policy or regulatory clauses, each matched clause remains visible as its own evidence row. BM25 can expose exact language and identifiers, while semantic grounding relates each passage to the claim facts and proposed rationale. A high-ranked match is not treated as a coverage conclusion. The packet records which clauses support the proposed reasoning, which conflict, which are merely contextual, and which still require an authorized adjuster or reviewer to determine applicability.
Human-review closure records the reviewer role, delegated authority, evidence considered, revised or rejected rationale, release decision, and outcome state. Until those elements are closed, the customer-facing communication remains withheld in the controlled proof environment.