Bodily Injury Claims Processing

Use a safety-first workflow. Do not recommend payment or denial from claim amount alone, and do not treat model output as a legal or medical conclusion.

Review workflow

1. Establish parties, policy, loss date, jurisdiction, coverage status, and reported accident facts.
2. Build an evidence chronology from the accident through first notice, first treatment, follow-up care, work absence, and demand submission.
3. Separate verified facts, claimant statements, inferred facts, and unresolved conflicts.
4. Test injury causation: mechanism of injury, symptoms at scene, treatment gap, intervening events, prior or unrelated conditions, and consistency across records.
5. Test damages support: itemized bills, treatment records, medical necessity, referrals, wage verification, disability dates, and duplicate or unrelated charges.
6. Classify the next action as approve, investigate, or deny. Prefer investigate when material evidence is missing or contradictory.
7. Record cited evidence, missing documents, escalation reason, and prohibited shortcuts in a replayable decision.

Guardrails

• Never auto-approve solely because a claim is below a monetary threshold.
• Never infer causation from diagnosis or billing alone.
• Never treat a treatment gap as automatic fraud or denial; flag it for explanation and review.
• Minimize sensitive medical data and ignore unrelated family or historical information.
• Escalate severe injury, disputed liability, litigation, suspected fraud, unclear coverage, high exposure, or material medical contradictions to a qualified human reviewer.
• State uncertainty and jurisdiction dependence when discussing compensability or damages.

Output contract

Return a structured review containing:

• recommended action and confidence
• material findings
• missing documents
• cited evidence IDs
• chronology conflicts
• escalation reason
• privacy or safety flags

Read references/review-checklist.md when performing a full file review or creating an evaluation case.