Claim coverage verification that answers from the policy wording, and shows what would change the answer
A coverage position on day one, every answer tied to the policy wording.
See one case, screen by screen ↓It is the step where an adjuster decides whether a loss is covered under the policy the customer bought, and how much is payable. Claim Coverage Verification does the reading: it assembles the forms in force on the date of loss, draws the coverage decision from them step by step, quotes the wording behind each step and drafts the letter. The adjuster decides and signs.
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Every first-party claim needs a coverage position before the adjuster can tell the customer what will be paid. The answer sits in the exact policy the customer bought: the declarations, the edition of the policy form in force on the date of loss, the endorsements and the state amendatory endorsement. The desk adjuster opens them one by one before the first call back.
The edition matters. Ashgrove’s Hidden Water Damage endorsement changed in July 2021: the 01/18 edition capped hidden leaks at $10,000 and did not pay tear-out; the 07/21 edition pays $15,000 including tear-out. Read the wrong PDF and the number is wrong. And two adjusters can read the same wording differently — in Ashgrove’s own sample, 2 of 43 positions on the same form and facts paid full Coverage A instead of the endorsement limit, and both were reopened.
Estimated hours of work for one homeowners water claim, by hand and with the solution. In the working solution, first notice to a drafted position was 1.6 days before go-live.
Seven specialist agents assemble the forms, draw the tree and test every fact; the adjuster decides and signs.
On Friday evening, 9 October, Renata Castellano steps in front of the dishwasher and the kitchen floor gives a little. Here is what happens next, screen by screen, in the working solution.
Her coverage queue holds 14 claims, 4 ready to sign, none past a state clock. She opens the Castellano claim, PH-26-104471, at the top — homeowners, Ohio, forms AHP 03 + AHP 04 18, drafted as covered in part, $16,850 of $39,640, with 2 open questions and 13 days left on the Ohio clock.
First notice → drafted position: median 3 h 52 min over the last 30 days, was 1.6 days before go-live.
The first notice came in by phone on Saturday at 08:14 — an 11-minute call. In nine steps the agents assembled the policy, read the call, the Kessler Brothers plumber report and 14 DryPoint Restoration photos, built the tree, drafted the position, checked it against past positions and drafted the letter. Each step is on the run log with its time.
Policy assembler: “6 forms in force on 9 Oct 2026 · AHP 04 18 edition 07/21, not 01/18.”
Declarations from the 14 March 2026 renewal, the Homeowners Special Form AHP 03 (07/21) and five endorsements — Ohio amendatory, Hidden Water Damage $15,000, Water Back-Up and Sump $10,000, Personal Property Replacement Cost, Ordinance or Law 25%. Margin notes show where the position uses each passage.
Edition rule: the edition on the declarations in force on the date of loss.
The loss facts enter at the top: a slow leak of at least 3–4 weeks, hidden beneath the floor and toe-kick, unknown to the insureds until the floor went soft. The path lights through the insuring agreement and the appliance-discharge peril, turns red at the 14-day seepage exclusion, then comes back green through the Hidden Water Damage endorsement. Covered in part: $15,000 for dwelling and contents, $4,350 for mold, $0 for the dishwasher, less the $2,500 deductible.
Nadia clicks the seepage exclusion. The rail opens AHP 03 (07/21), Section I, A.2.c.(5), page 10, with the words that decided it highlighted — “constant or repeated seepage or leakage … over a period of 14 or more days” — and the facts it turned on: the plumber’s “at least 3–4 weeks” and photo 7 of 14, rings older at the centre.
“Why not: If how long it leaked were ‘under 14 days’, this step would read does not apply.”
In Why not, every fact becomes a control. Set the leak to under 14 days and the tree re-runs: the seepage exclusion drops away and the loss is covered at $35,900, $19,050 more. If an insured knew before 9 October, or the leak was in plain view, nothing is payable; water up through the floor drain would pay $7,500 under the back-up endorsement. The two facts that are uncertain become her questions to the insured and the plumber.
“What-if — not saved. Recorded position: Covered in part, $16,850.”
Earlier that morning, ahead of his co-signature, Grant asked whether the dishwasher itself is covered. The answer came from two passages: no — the policy pays for the water damage, but not for the appliance the water escaped from, and the dishwasher and its line are $1,240 on the estimate. Each passage opens in the policy or shows its step on the tree.
Answers come only from the six forms on the declarations, in the editions in force on 9 Oct 2026, and Ashgrove’s coverage guidelines.
The draft is compared with signed positions on the same form edition and fact pattern: a hidden leak of 14 or more days that nobody knew about, on AHP 03 + AHP 04 18 (07/21). It matches 41 of 43. The two outliers paid full Coverage A without the endorsement limit; quality review reopened both.
The letter explains what happened, quotes the seepage exclusion as the reason the payment is limited, names the coverage for every amount and asks the two questions that could change it. Five of six letter checks are clear; the sixth flags that the leak’s duration rests on the plumber’s estimate.
Letter checks: coverage named for every amount · reason for the limit quoted from the policy · editions in force on 9 Oct 2026 · reading grade 7.8.
Nadia signs at 09:52. The position, its path, the facts and the edition of every form are recorded with her signature. Because the payment is $22,790 less than claimed — over the $10,000 line — Grant Ellery co-signs at 09:55, and the letter and the $16,850 payment are ready to send, with the Ohio acknowledgement due by Sunday 25 October.
The same claim, seen by the four people who carry it — what their week looked like, and what it looks like now.
Seven specialist agents assemble the forms, draw the tree and test every fact; the adjuster decides and signs.
Pulls the declarations and the exact edition of every form and endorsement in force on the date of loss, including the state amendatory endorsement.
Reads the first-notice call, adjuster notes, plumber and contractor reports, photos and estimates, and writes each fact with its source and a confidence.
Turns the forms into a decision tree: insuring agreement, perils, exclusions with their exceptions, endorsements that add or remove coverage, limits and deductibles.
Walks the recorded facts through the tree, writes each step’s outcome with the quote and the fact it turned on, and computes the amounts.
For every step on and off the path, finds the single fact that would change its outcome and the dollar effect, and turns the uncertain ones into questions for the insured.
Compares each new position with past signed positions on the same form edition and fact pattern, and flags any difference.
Drafts the coverage letter or reservation of rights in plain words, every reason quoted from the policy, with the open questions and the state’s complaint rights.
Decides and signs. The agents propose; a named person decides.
Adjusters, supervisors and counsel ask in plain words — or ask what would change the answer. Every answer quotes its passage.
Why is the Castellano kitchen limited to $15,000?
Because the leak ran longer than 14 days. The plumber dates it at “at least 3–4 weeks”, so the seepage exclusion in AHP 03 A.2.c.(5) applies. The Hidden Water Damage endorsement gives coverage back because the leak was beneath the floor and nobody knew — but only to $15,000, tear-out included. Mold adds $4,350 under its own $10,000 limit.
What would make the Castellano claim fully covered?
One fact: a leak under 14 days. Then the seepage exclusion does not apply and the loss is a covered discharge — $35,900 after the deductible instead of $16,850. Today the only evidence on duration is the plumber’s “at least 3–4 weeks”; guideline W-7 says ask the insured when they first noticed.
Have we taken this position before on the same form?
Yes — 41 of 43 signed positions on AHP 03 with AHP 04 18 (07/21), a hidden leak of 14 or more days and no prior knowledge were covered in part to the endorsement limit. Two paid full Coverage A; quality review reopened both. Your draft matches the 41.
Draft the coverage letter to the Castellanos
Done — a partial coverage letter in plain words. It names the coverage for each amount, quotes the seepage exclusion and the endorsement as the basis for the $15,000 limit, and asks the two open questions. It needs your signature and Grant Ellery’s co-signature (reduction over $10,000). Ohio acknowledgement is due by Sun 25 Oct.
13 screens from the working solution, on its sample data. Pick one to see it large.
Who signs what, the state clocks and what the agents may do are settings, changed by your team and logged.
| Setting | Default | Choose from |
|---|---|---|
| Supervisor co-signs every denial | On — Grant Ellery or any claims supervisor | On · Off |
| Supervisor co-signs reductions over | $10,000 | Any amount, the difference between claimed and payable |
| Coverage counsel signs reservations of rights | On — Hannah Pruett | On · Off |
| Second look when a what-if flips the answer | On — the adjuster records why the recorded fact stands | On · Off |
| State clocks | Ohio: 15 days to acknowledge, 21 after proof of loss to accept or deny | One row per state, with its rule |
| Draft letters | On — never sent without signatures | On · Off |
| Send questions to insureds | Off — only when the adjuster presses Send | On · Off |
| Deny coverage | Never | Agents may never deny |
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 claims · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (Insurance Information Institute, homeowners losses 2019–2023 — average claim $20,062 in 2023 from $13,884 in 2019; water damage and freezing 1.50 claims per 100 policies at an average $15,400). People, companies, policies and forms named on this page are fictional — characters and sample data in the working solution.
It is the step where an adjuster decides whether a loss is covered under the policy the customer bought, and how much is payable. Claim Coverage Verification does the reading: it assembles the forms in force on the date of loss, draws the coverage decision from them step by step, quotes the wording behind each step and drafts the letter. The adjuster decides and signs.
The Policy assembler reads the declarations in force on the date of loss and fetches that exact edition of every form and endorsement from the forms library — never a later or earlier one. On the Castellano claim it used AHP 04 18 (07/21), not (01/18), and the edition rule is recorded with the position.
No. The agents may never deny coverage. Any “not covered” goes to a person, a supervisor co-signs every denial, and nothing is sent to an insured without signatures.
For each step it shows the single fact that would change the outcome, and the dollar effect. On the Castellano claim, a leak under 14 days would pay $35,900 instead of $16,850; if an insured knew before the loss, nothing would be payable. Uncertain facts become the questions the adjuster asks the insured or the trades.
Yes. The letter drafter names the coverage under which each amount is paid and quotes the clause behind every reduction or denial, in plain words, with the open questions and the state’s complaint rights. Before the adjuster signs, letter checks confirm the coverage is named for every amount, the reason is quoted from the policy, the editions are the ones in force, the words are plain and the state clock is met.
That is what the Consistency checker is for. It compares every new position with signed positions on the same form edition and fact pattern, and sends any difference to the quality reviewer. In the working solution, 247 of 254 signed positions agree with their pattern.
Yes. Who co-signs denials, the reduction amount that needs a supervisor, who signs reservations of rights, the acknowledge and decide clocks for each state, and what the agents may do are all settings.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your policy forms and editions, coverage guidelines, letter templates and a sample of signed past positions — and it goes live once every quality gate has passed. We will walk you through it on your own claims first.
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1-min demoWe’ll run Claim Coverage Verification on a sample of your own policies, forms and signed past positions.