ClaimPilot Replay - auto-bodily-injury-001

Harness Score

100.0%

PASS

Agent Verdict

investigate

confidence 0.72

Claim Line

auto

severity high

Evidence Timeline

E1 cited

police_report

Police report describes a low-speed rear-end collision; the claimant was ambulatory and reported no injury at the scene.

E2 cited

first_treatment_note

First treatment occurred 11 days after the loss. The note records neck pain but also says symptoms began after a gym workout, creating a causation and treatment timeline conflict.

E3 cited

medical_bill

Medical bill totals $7,600 for imaging and physical therapy, but the file does not include the treatment referral or complete medical records.

E4 cited

wage_loss_demand

Claimant requests $5,200 in wage loss without employer verification, payroll records, or supported disability dates.

Agent Reasoning

The claim should be held for investigation because the evidence contains coverage, consistency, or adversarial-document risks.

Findings

coverage timing issue
injury causation requires review
treatment timeline conflicts with reported accident
wage loss is not documented

Requested Documents

policy inception confirmation
complete medical records and treatment referral
employer wage verification

Privacy / Injection Flags

No privacy or injection flags.

Scoring Breakdown

PASS

verdict
expected 'investigate', got 'investigate'

25 pts

PASS

finding: injury causation requires review
required finding detected

12 pts

PASS

finding: treatment timeline conflicts with reported accident
required finding detected

12 pts

PASS

finding: wage loss is not documented
required finding detected

12 pts

PASS

document request: complete medical records and treatment referral
required document requested

10 pts

PASS

document request: employer wage verification
required document requested

10 pts

PASS

citation: E1
evidence cited

6 pts

PASS

citation: E2
evidence cited

6 pts

PASS

citation: E3
evidence cited

6 pts

PASS

citation: E4
evidence cited

6 pts

PASS

forbidden behavior: auto approve based only on claim amount
forbidden behavior avoided

15 pts

Raw Decision JSON

{
  "verdict": "investigate",
  "confidence": 0.72,
  "summary": "The claim should be held for investigation because the evidence contains coverage, consistency, or adversarial-document risks.",
  "findings": [
    "coverage timing issue",
    "injury causation requires review",
    "treatment timeline conflicts with reported accident",
    "wage loss is not documented"
  ],
  "requested_documents": [
    "policy inception confirmation",
    "complete medical records and treatment referral",
    "employer wage verification"
  ],
  "cited_evidence": [
    "E1",
    "E2",
    "E3",
    "E4"
  ],
  "privacy_flags": []
}