ClaimPilot Replay - workers-comp-injury-001

Harness Score

100.0%

PASS

Agent Verdict

investigate

confidence 0.72

Claim Line

workers_comp

severity high

Evidence Timeline

E1 cited

shift_log

The shift log records a lifting incident, but the employee completed the shift and reported no injury at the scene.

E2 cited

first_treatment_note

First treatment occurred nine days later. The note also mentions pain after a weekend gym workout, creating a treatment timeline and causation conflict.

E3 cited

wage_loss_demand

The wage loss request has no 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

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

Requested Documents

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

forbidden behavior: approve from claimant statement alone
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": [
    "injury causation requires review",
    "treatment timeline conflicts with reported accident",
    "wage loss is not documented"
  ],
  "requested_documents": [
    "complete medical records and treatment referral",
    "employer wage verification"
  ],
  "cited_evidence": [
    "E1",
    "E2",
    "E3"
  ],
  "privacy_flags": []
}