Case reserve adequacy review on every open injury file, every quarter, with the reason behind each dollar
Reserves set right sooner, with fewer late step-ups as files develop.
See one case, screen by screen ↓It is the review of each open claim’s case reserve against what the file now shows, so the reserve reflects probable ultimate cost on the known facts. Case Reserve Adequacy Review rereads every open bodily-injury file before each reserving meeting and recommends a case reserve as a waterfall of steps, each tied to the page it came from.
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A case reserve on a bodily-injury file is set in the first days, from an ER bill and a police report. After that it moves when something forces it: a letter of representation, an MRI, a demand, a suit. Each late step-up lands as adverse development quarters after the fact that should have moved it was already in the file.
Before each quarterly reserving meeting, an adjuster carrying more than a hundred open injury files can reread only some of them end to end. The rest are reviewed by exception. A pain-management note that says “refer for surgical consultation” or a surgeon’s consult that says “candidate for fusion” sits in the medical records until the demand arrives — and California’s paid-not-billed rule or a Medicare conditional payment can move the number in a known direction that nobody priced.
Estimated split for one developing bodily-injury file at the quarterly review, by hand and with the solution.
Seven agents reread every open injury file and build the reserve waterfall; the adjuster accepts each step.
Jordan Pace was rear-ended by a Larch Ridge Distribution box truck in Sacramento in March 2024. The case reserve has stepped up four times. Here is the Q4 2026 review of that file, screen by screen, in the working solution.
All 214 open bodily-injury files in Western Casualty Claims were reread between 8 and 11 October. 46 have a recommended change and 168 hold. Marcus filters to his own nine, or to files above adjuster authority, or to files with three or more step-ups.
“46 have a recommended change; 168 hold. Reserving meeting Tue 20 Oct, 10:00.”
CA-24-018733, Jordan Pace v. Larch Ridge Distribution LLC: C5-6 disc herniation, suit filed 6 Aug 2026, limit $1,000,000, last reviewed 14 Aug 2026. The waterfall runs from today’s $185,000 case reserve through six steps to a recommended $392,800, with Marcus’s $250,000 authority drawn across it.
“Reread today 02:14 · 7 agents · 47 documents”
The file rereader goes through 47 documents added since 14 Aug — 312 pages: 21 medical, 14 bills, 6 letters, 6 litigation. The medical and future care analyst totals specials billed at $71,850 against $57,650 paid and applies California’s paid-not-billed rule. Wage loss, value and venue, litigation expense and the guideline check follow, and the bars build one by one.
Dr. Lena Moravec’s progress note of 22 Sep 2026: failed conservative care, C5-6 anterior cervical discectomy and fusion scheduled for 4 November, off work 12 to 16 weeks, then light duty. Each marked passage carries a margin note that links to its waterfall step.
Margin note: “Future surgery step: +$95,000 — scheduled, not proposed.”
The fusion is priced from the Sacramento future care cost table of 1 Jul 2026: surgeon $14,500, facility with implant $52,300, anesthesia $4,900, 24 post-op therapy visits $4,800, follow-up visits and imaging $3,100, and a $15,400 allowance for adjacent-segment care. Both sources are one click away.
“Prices only care named by a treating provider.”
Under the waterfall, the reserve history shows four step-ups in 31 months, from $15,000 to $185,000 — 26 times the opening reserve. Change 4 on 19 Nov 2025 priced the $650,000 demand. Five weeks earlier, a surgical consult had already called Jordan Pace a candidate for C5-6 fusion.
“Surgery in the records, not in the reserve · 20 months”
Marcus accepts the surgery step, then the rest. The recommended case reserve is $392,800: indemnity $335,800 and expense $57,000, 39.3% of the $1,000,000 limit. Any step he adjusts keeps his reason in the reserve note.
“Above your $250,000 authority. When every step is accepted it goes to Priya Natarajan with the reserve note.”
The reserve note is already written: the fusion now scheduled, new medical billed and reduced to amounts paid, wage loss for 16 weeks off and 6 weeks light duty, general damages from closed fusion cases in Sacramento County, defense expense through mediation with trial not reserved. It closes with when surgery was first raised and that neither earlier change reserved it.
Priya sees each step with the agent that built it and Marcus’s acceptance, the stair-steps on the file — five changes in 31 months — and the two guideline exceptions this change resolves: surgery in the medical records and not reserved since 21 Jan 2025, and no review within 30 days of the 22 Sep surgeon’s note. She approves at 10:42; the reserve posts to the claim file and the file moves to the meeting pack.
She can approve $392,800 or return it with a question.
214 files, $41.2M of case reserves carried, 46 recommended changes — 38 up, 8 down — for a net +$2,860,000, 6.9% of carried. Moves above $100,000 are listed with their trigger and approval, three go to the large-loss committee, and the file page for Jordan Pace shows the stair-steps and the reserve note. Elaine Brooks chairs.
The same file, seen by the four people who carry it into the reserving meeting — what their quarter looked like, and what it looks like now.
Seven agents reread every open injury file and build the reserve waterfall; the adjuster accepts each step.
Reads every note, diary, letter, medical record and bill added since the last review, in full, and lists each material fact with its date and page: surgery proposed or scheduled, attorney, demand, suit, wage loss, Medicare entitlement.
Totals specials billed and paid, applies the state rule for past medicals, and prices treatment the providers recommend or schedule from the cost table for the venue.
Works out lost earnings to date and expected, from wage statements and the providers’ work restrictions.
Sets the general-damages range from the carrier’s own closed files with the same injury group and county over the last five years.
Reads suit papers and defense counsel’s budget and sets the expense step.
Tests each file against the six reserving rules: surgery not reserved, suit without an expense reserve, the 30-day review clock, reserve below specials paid, Medicare conditional payments and limits demands.
Builds the waterfall from the current case reserve, one step per change the other agents found, reads the reserve history to mark facts that were in the file but not in the reserve, drafts the reserve note and routes above authority.
Accepts each step; manager approves above authority. The agents propose; a named person decides.
Adjusters and managers can ask about a file in plain words — or tell it what to set. Every answer points to its source.
Why does the fusion add $95,000 to the reserve?
Because it is no longer a possibility. Dr. Moravec’s note of 22 Sep 2026 says the C5-6 fusion is scheduled for 4 November at Capitol Valley Surgery Center. The Sacramento cost table prices a one-level cervical fusion at $95,000: surgeon $14,500, facility $52,300, anesthesia $4,900, post-op therapy $4,800, follow-up $3,100 and a $15,400 allowance for adjacent-segment care.
When did this file first mention surgery?
On 21 Jan 2025. Dr. Shah’s procedure note after the second injection says “refer for surgical consultation if relief is not sustained”. The reserve was raised 13 days later, to $85,000, without it. On 14 Oct 2025 the surgeon called Jordan Pace a “candidate for C5-6 fusion” who wished to defer; the November change priced the $650,000 demand instead. Surgery has been in the file for 20 months.
Which files are out of line with the guidelines?
19 exceptions on 18 of the 214 files, against six rules. The largest group: 5 files with no review within 30 days of a new material fact, and 4 with surgery in the medical records but not in the reserve — including Jordan Pace.
Set general damages for Jordan Pace at $45,000 and note why
Done. General damages is now +$45,000 instead of +$55,000, with the reason “venue experience differs from closed files”. The 23 closed fusion files still show a $150,000 median, so the note says your figure sits below it. The recommended reserve is now $382,800 — still above your authority, so it goes to Priya.
13 screens from the working solution, on its sample data. Pick one to see it large.
Review cadence, authority limits, state rules and cost tables are settings. Every change is saved as a new rule version with who and when.
| Setting | Default | Choose from |
|---|---|---|
| Reread every open bodily-injury file | Each quarter | Each month · Each quarter · Each half-year |
| Review after a new material fact | Within 30 days | Within 14 · 30 · 45 days |
| Recommend a change when it moves more than | $10,000 or 10% | A dollar amount you set · or 5 · 10 · 15 · 20 % |
| Casualty adjuster authority | $250,000 | $150,000 · $250,000 · $350,000 |
| Casualty claim manager authority | $500,000 | $400,000 · $500,000 · $750,000 |
| Past medicals at the amounts paid | On | On · Off |
| Closed files used for the value step | Last 5 years | Last 3 · 5 · 7 years |
| Fewest closed files to show a range | 10 files | 10 · 15 · 20 files |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample claim data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (S&P Global Market Intelligence via Insurance Journal, Apr 2026 — $7.3B of other-liability adverse development in 2025). People, companies and claims named on this page are fictional — characters and sample data in the working solution.
It is the review of each open claim’s case reserve against what the file now shows, so the reserve reflects probable ultimate cost on the known facts. Case Reserve Adequacy Review rereads every open bodily-injury file before each reserving meeting and recommends a case reserve as a waterfall of steps, each tied to the page it came from.
The reserve history shows every past change with what was known at the time, and marks any fact that was already in the file but not in the reserve. In the working solution, it shows that surgery was first raised in a pain-management note on 21 Jan 2025 and no change since has reserved it.
The medical and future care analyst prices only treatment a treating provider recommends or schedules, from your future care cost tables for the venue. It totals specials billed and paid and applies state rules such as California’s limit of past medicals to amounts paid.
No. Agents never post a reserve, change a payment or contact claimants or counsel. The adjuster accepts or adjusts each step, a claim manager approves above the adjuster’s authority, and above authority the reserve posts to the claim file only after that approval.
Yes. Every step is accepted or adjusted by the adjuster, and an adjusted step keeps its reason in the reserve note and on the audit trail. The value step shows the closed files behind its range, and with fewer than ten it is left unpriced for the adjuster.
Yes. Review cadence, the review clock after a new material fact, the threshold for recommending a change, authority limits, state rules, cost tables and the closed-file window are all settings, and each change is saved as a new rule version.
Totals by line, carried case reserves, recommended changes up and down with the net change, every move above $100,000 with its trigger and approval, where the review stands, and a file page with the stair-steps and the reserve note.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your reserving guidelines, cost tables, authority limits and a sample of open and closed files — and it goes live once every quality gate has passed. We will walk you through it on your own files first.
Thousand-page demands read in full and answered before the deadline.
1-min demoTime-Limited Demand ManagementNo policy-limits deadline missed: every demand on a clock, every condition checked.
1-min demoBodily Injury Claim ValuationSettlement authority set from comparable closed files and local verdicts.
1-min demoWe’ll run Case Reserve Adequacy Review on a sample of your own open bodily-injury files.