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Insurance Claim Handling

vr.wm-act-045 · wm-act-045-insurance-claim-handling

Represent one governed insurance-claim-handling case that coordinates notification, investigation, coverage and amount assessment, reasoned decision, settlement handoffs, communications, review and closure without becoming the insurance claim or the systems it coordinates.

World Models Activities and processes ACT.INS
Bundle → Layer → Finding → QuestionsClassifiersWhat it isWhy it existsDistinguishing featuresWhat robots and AI may and may not doMoral aspectsOwnersLinks to other meta-modelsIdentity and identifiersDirect propertiesRecognitionCapabilities and actionsHazards and failure modesStandards and interfacesContext of useSources

Bundle → Layer → Finding → Questions Filled

6 bundles · 12 layers · 24 findings · 72 questions

Handling case identity, boundary and authority Groups governed context for handling case identity, boundary and authority.

Case profile, identity, lineage and jurisdiction

Groups claim-handling context for case profile, identity, lineage and jurisdiction.

Handling case type, scope, insurance line, jurisdiction and boundary

Records handling case type, scope, insurance line, jurisdiction and boundary as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish handling case type, scope, insurance line, jurisdiction and boundary? classification
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support handling case type, scope, insurance line, jurisdiction and boundary? temporal
  3. How may handling case type, scope, insurance line, jurisdiction and boundary be validated, challenged, corrected, related, retained or disposed without losing history? lifecycle

Case identifier, source, version, predecessor, successor and lineage

Records case identifier, source, version, predecessor, successor and lineage as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish case identifier, source, version, predecessor, successor and lineage? identity
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support case identifier, source, version, predecessor, successor and lineage? composition
  3. How may case identifier, source, version, predecessor, successor and lineage be validated, challenged, corrected, related, retained or disposed without losing history? event

Mandate, participants, delegation, conflicts and outsourcing

Groups claim-handling context for mandate, participants, delegation, conflicts and outsourcing.

Insurer, handler, adjuster, expert, claimant, representative, role and authority

Records insurer, handler, adjuster, expert, claimant, representative, role and authority as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish insurer, handler, adjuster, expert, claimant, representative, role and authority? authority
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support insurer, handler, adjuster, expert, claimant, representative, role and authority? evidence
  3. How may insurer, handler, adjuster, expert, claimant, representative, role and authority be validated, challenged, corrected, related, retained or disposed without losing history? retention

Delegation, assignment, outsourcing, conflict, competence, capacity and oversight

Records delegation, assignment, outsourcing, conflict, competence, capacity and oversight as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish delegation, assignment, outsourcing, conflict, competence, capacity and oversight? ownership
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support delegation, assignment, outsourcing, conflict, competence, capacity and oversight? interoperability
  3. How may delegation, assignment, outsourcing, conflict, competence, capacity and oversight be validated, challenged, corrected, related, retained or disposed without losing history? security
Notification, intake, triage and coverage framing Groups governed context for notification, intake, triage and coverage framing.

Notification receipt, acknowledgement, guidance and routing

Groups claim-handling context for notification receipt, acknowledgement, guidance and routing.

Notification channel, received time, submitter, loss reference and duplicate check

Records notification channel, received time, submitter, loss reference and duplicate check as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish notification channel, received time, submitter, loss reference and duplicate check? event
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support notification channel, received time, submitter, loss reference and duplicate check? quality
  3. How may notification channel, received time, submitter, loss reference and duplicate check be validated, challenged, corrected, related, retained or disposed without losing history? validation

Acknowledgement, guidance, required information, language, accessibility and routing

Records acknowledgement, guidance, required information, language, accessibility and routing as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish acknowledgement, guidance, required information, language, accessibility and routing? process
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support acknowledgement, guidance, required information, language, accessibility and routing? state
  3. How may acknowledgement, guidance, required information, language, accessibility and routing be validated, challenged, corrected, related, retained or disposed without losing history? privacy

Claim, policy, coverage, party and priority binding

Groups claim-handling context for claim, policy, coverage, party and priority binding.

Claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference

Records claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference? relationship
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference? measurement
  3. How may claim, policy, insured, claimant, beneficiary, loss, exposure and coverage reference be validated, challenged, corrected, related, retained or disposed without losing history? access

Completeness, admissibility, triage, severity, vulnerability, catastrophe and service target

Records completeness, admissibility, triage, severity, vulnerability, catastrophe and service target as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish completeness, admissibility, triage, severity, vulnerability, catastrophe and service target? requirement
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support completeness, admissibility, triage, severity, vulnerability, catastrophe and service target? lifecycle
  3. How may completeness, admissibility, triage, severity, vulnerability, catastrophe and service target be validated, challenged, corrected, related, retained or disposed without losing history? exception
Evidence, investigation and assessment Groups governed context for evidence, investigation and assessment.

Evidence requests, receipt, custody, quality and expert input

Groups claim-handling context for evidence requests, receipt, custody, quality and expert input.

Information request, purpose, scope, deadline, burden, response and escalation

Records information request, purpose, scope, deadline, burden, response and escalation as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish information request, purpose, scope, deadline, burden, response and escalation? process
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support information request, purpose, scope, deadline, burden, response and escalation? event
  3. How may information request, purpose, scope, deadline, burden, response and escalation be validated, challenged, corrected, related, retained or disposed without losing history? identity

Evidence source, receipt, custody, integrity, quality, challenge and expert opinion

Records evidence source, receipt, custody, integrity, quality, challenge and expert opinion as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish evidence source, receipt, custody, integrity, quality, challenge and expert opinion? evidence
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support evidence source, receipt, custody, integrity, quality, challenge and expert opinion? retention
  3. How may evidence source, receipt, custody, integrity, quality, challenge and expert opinion be validated, challenged, corrected, related, retained or disposed without losing history? authority

Coverage, liability, causation, damage, benefit and fraud assessment

Groups claim-handling context for coverage, liability, causation, damage, benefit and fraud assessment.

Policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis

Records policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis? decision
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis? security
  3. How may policy term, in-force, coverage, exclusion, condition, limit, deductible and coordination analysis be validated, challenged, corrected, related, retained or disposed without losing history? relationship

Liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator

Records liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator? measurement
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator? validation
  3. How may liability, causation, damage, benefit, adjustment, estimate, uncertainty and fraud indicator be validated, challenged, corrected, related, retained or disposed without losing history? provenance
Decisions, settlement and financial handoffs Groups governed context for decisions, settlement and financial handoffs.

Reserves, authority limits and reasoned decisions

Groups claim-handling context for reserves, authority limits and reasoned decisions.

Estimate, reserve external reference, authority limit, review and change rationale

Records estimate, reserve external reference, authority limit, review and change rationale as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish estimate, reserve external reference, authority limit, review and change rationale? provenance
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support estimate, reserve external reference, authority limit, review and change rationale? privacy
  3. How may estimate, reserve external reference, authority limit, review and change rationale be validated, challenged, corrected, related, retained or disposed without losing history? process

Coverage, liability, benefit, item adjudication, acceptance, partial denial and reason

Records coverage, liability, benefit, item adjudication, acceptance, partial denial and reason as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish coverage, liability, benefit, item adjudication, acceptance, partial denial and reason? decision
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support coverage, liability, benefit, item adjudication, acceptance, partial denial and reason? access
  3. How may coverage, liability, benefit, item adjudication, acceptance, partial denial and reason be validated, challenged, corrected, related, retained or disposed without losing history? decision

Offers, negotiation, settlement, payment and recovery instructions

Groups claim-handling context for offers, negotiation, settlement, payment and recovery instructions.

Reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms

Records reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms? lifecycle
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms? exception
  3. How may reasoned offer, counteroffer, negotiation, acceptance, release and settlement terms be validated, challenged, corrected, related, retained or disposed without losing history? temporal

Payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference

Records payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference? relationship
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference? identity
  3. How may payment instruction, payee, allocation, currency, tax, interest, offset and clearing reference be validated, challenged, corrected, related, retained or disposed without losing history? composition
Communications, disputes, fraud and recoveries Groups governed context for communications, disputes, fraud and recoveries.

Status communications, deadlines, complaints and reviews

Groups claim-handling context for status communications, deadlines, complaints and reviews.

Status update, request, response, reason, language, channel, delivery and deadline

Records status update, request, response, reason, language, channel, delivery and deadline as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish status update, request, response, reason, language, channel, delivery and deadline? temporal
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support status update, request, response, reason, language, channel, delivery and deadline? authority
  3. How may status update, request, response, reason, language, channel, delivery and deadline be validated, challenged, corrected, related, retained or disposed without losing history? evidence

Internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference

Records internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference? relationship
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference? relationship
  3. How may internal review, complaint, ombudsman, arbitration, litigation, appeal and remedy reference be validated, challenged, corrected, related, retained or disposed without losing history? interoperability

Fraud referral, subrogation, salvage and third-party recovery

Groups claim-handling context for fraud referral, subrogation, salvage and third-party recovery.

Fraud indicator, referral, authority, restriction, outcome reference and non-prejudice

Records fraud indicator, referral, authority, restriction, outcome reference and non-prejudice as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish fraud indicator, referral, authority, restriction, outcome reference and non-prejudice? security
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support fraud indicator, referral, authority, restriction, outcome reference and non-prejudice? provenance
  3. How may fraud indicator, referral, authority, restriction, outcome reference and non-prejudice be validated, challenged, corrected, related, retained or disposed without losing history? quality

Subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference

Records subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference? relationship
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference? process
  3. How may subrogation, salvage, contribution, reinsurance, recovery right, handoff and proceeds reference be validated, challenged, corrected, related, retained or disposed without losing history? state
Lifecycle, quality, provenance, retention, interoperability and agents Groups governed context for lifecycle, quality, provenance, retention, interoperability and agents.

Lifecycle events, reopening, quality and fairness observation

Groups claim-handling context for lifecycle events, reopening, quality and fairness observation.

Notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event

Records notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event? event
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event? decision
  3. How may notified, registered, triaged, investigating, decided, settled, closed, reopened and corrected event be validated, challenged, corrected, related, retained or disposed without losing history? measurement

Timeliness, fairness, consistency, explanation, burden, complaint and outcome observation

Records timeliness, fairness, consistency, explanation, burden, complaint and outcome observation as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish timeliness, fairness, consistency, explanation, burden, complaint and outcome observation? quality
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support timeliness, fairness, consistency, explanation, burden, complaint and outcome observation? temporal
  3. How may timeliness, fairness, consistency, explanation, burden, complaint and outcome observation be validated, challenged, corrected, related, retained or disposed without losing history? lifecycle

Provenance, privacy, retention, projection and safe agent operations

Groups claim-handling context for provenance, privacy, retention, projection and safe agent operations.

Actor, tool, source, method, derivation, event time, knowledge time, access and audit reference

Records actor, tool, source, method, derivation, event time, knowledge time, access and audit reference as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish actor, tool, source, method, derivation, event time, knowledge time, access and audit reference? provenance
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support actor, tool, source, method, derivation, event time, knowledge time, access and audit reference? composition
  3. How may actor, tool, source, method, derivation, event time, knowledge time, access and audit reference be validated, challenged, corrected, related, retained or disposed without losing history? event

Retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability

Records retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability as source-qualified claim-handling context while preserving external master ownership and separating request, assessment, decision, instruction and execution.

  1. What stable identities, classes, values and explicit unknowns establish retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability? retention
  2. Which authority, source, method, evidence, event time, knowledge time, confidence and limits support retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability? evidence
  3. How may retention, hold, redaction, mapping loss, idempotency, dry-run, post-check and contestability be validated, challenged, corrected, related, retained or disposed without losing history? retention

Classifiers Filled

Family
World Models
Category
Activities and processes
Entry kind
aggregate
Navigation path
NAV.ACT.INS
Domain
ACT.INS
Industry
Cross-industry
Tags
insuranceclaimhandlingact.ins

What it is Filled

Owns handling-case identity and lineage, mandate, assignment, intake, acknowledgement, triage, authoritative claim and policy bindings, evidence requests and use, investigation activity, assessment assertions, decision and offer records, settlement and financial handoffs, status communications, review and dispute links, fraud and recovery referrals, closure, reopening, quality, provenance, access, retention and interoperability. Insurance Claim, Policy, Loss, Party, Evidence, Fraud, Complaint, Legal, Payment, Reserve, Communication, Audit and Record masters remain external.

In scope

  • Handling-case identity, authority, intake, acknowledgement, guidance, triage, assignments, claim and policy bindings
  • Evidence requests and use, investigation, coverage, liability, causation, benefit and amount assessments, fraud indicators and controlled referral
  • Reasoned decisions, offers, settlements, payment and recovery handoffs, communications, reviews, closure, reopening, provenance, privacy, retention and interoperability

Out of scope

  • Independent insurance claim, policy, coverage, loss, party, asset, damage, injury, evidence, expert, fraud, complaint, legal case, payment, reserve, communication, audit or record master lifecycles
  • Treating notification as acceptance, policy existence as coverage, investigation as proof, reserve as offer, decision as payment, suspicion as fraud or closure as erased rights
  • Providing legal or medical judgment, executing payments, operating insurer systems, determining universally applicable deadlines or autonomously deciding or settling claims

Why it exists Filled

Represent one governed insurance-claim-handling case that coordinates notification, investigation, coverage and amount assessment, reasoned decision, settlement handoffs, communications, review and closure without becoming the insurance claim or the systems it coordinates.

Distinguishing features Filled

  • Models the insurer's handling work on a claim, not the claim, policy or loss event.
  • Keeps coverage, liability, benefit, reserve, offer, settlement and payment as separate decisions.
  • Routes suspected fraud to a separate case instead of deciding it inside handling.
  • Records reasons for decisions and review routes for claimants.

What robots and AI may and may not do Filled

Must not

  • Accept or deny coverage without an authorised handler.
  • Accuse a claimant of fraud or flag them publicly.
  • Request medical or personal data beyond what the claim needs.
  • Delay acknowledgement or decisions past regulatory deadlines.
  • Issue payments directly.

Only with a human decision

  • Coverage and liability decisions.
  • Fraud referrals.
  • Settlement offers and complaint handling.

May

  • Acknowledge and triage incoming notifications.
  • Request missing documents and track replies.
  • Prepare a coverage assessment draft citing policy terms.
  • Send status updates to claimants.

Moral aspects Filled

  • Claimants are often in distress after a loss; delays and unclear reasons cause harm.
  • Health and injury data are sensitive and must be minimal and protected.
  • Automated fraud scoring can discriminate and wrongly deny valid claims.

Who is affected

  • Claimants and beneficiaries
  • Injured third parties
  • Claims handlers and experts

Owners Filled

Steward

Dimension owner and insurance-claim-handling mandate

Roles

Claim handling owner
Own case scope, mandate, service and lifecycle.
Claim handler or adjuster
Own assigned intake, investigation, assessment and communications within authority.
Coverage and legal reviewer
Own policy interpretation and reasoned exception review.
Medical, engineering or valuation expert
Own source-qualified expert observations without deciding the claim outside delegation.
Settlement authority
Own decision and settlement approvals within recorded limits.
Fraud referral steward
Own restricted indicator review and independent referral.
Complaint and dispute reviewer
Own impartial review, escalation and redress handoffs.
Privacy, records and assurance steward
Own protected views, holds, retention, disclosure and auditability.

Links to other meta-models Filled

composes

  • WM-ECO-036 Insurance Claim - Candidate composition preserving claim identity and handling-case separation; no approved edge exists.

references

  • WM-ECO-003 Insurance Policy and policy, coverage, loss, party, asset, injury and damage models - Bind authoritative contract and subject facts while their masters retain identity and lifecycle.
  • Evidence, Expert, Fraud Case, Complaint, Ombudsman, Arbitration, Court Case, Communication, Audit and Record models - Bind investigation evidence, referrals, redress and accountable communication without lifecycle cascade.
  • Reserve, Payment, Accounting Entry, Reinsurance, Subrogation, Salvage and Recovery models - Issue bounded instructions and record receipts while external financial and rights masters own execution and proceeds.

aligned

  • IAIS ICP, NAIC claim-conduct models, FCA ICOBS, EU motor and distribution directives, HL7 FHIR and ACORD P&C - Project version-pinned conduct, regulatory and exchange views with declared jurisdiction, maturity and information loss.

neighbor

  • WM-ECO-036 Insurance Claim candidate composer - The claim master owns the claim identifier and substantive policy-loss-demand assertions. This aggregate owns one handling process, its work, decisions and handoffs. The ledger relation is candidate, not approved.
  • WM-ECO-003 Insurance Policy and Coverage - The policy master owns contract, insured risk, coverage terms and policy lifecycle. The handling case records source-qualified interpretations and decision-time snapshots without rewriting the contract.
  • Evidence, Expert, Damage, Injury and Loss Event - External masters own source observations and subject facts. This case records requests, custody references, validation, use and resulting assessments.
  • Fraud Case, Complaint, Ombudsman, Arbitration and Court Case - This process may create a controlled referral or bind an external review outcome; it does not decide fraud or absorb independent redress and adjudication lifecycles.
  • Reserve, Payment, Accounting, Reinsurance, Subrogation and Salvage - This model owns estimates, approval and handoff assertions needed to explain handling. External financial and recovery masters own booking, execution, clearing, rights and proceeds.

parent

  • WM-ECO-036

What else AI and robots need to interact with it Filled

Identity and identifiers required Filled

  • Authoritative master-system handling-case identifier qualified by insurer, source and profile.
  • Governed globally resolvable handling-case IRI.
  • Dimension UUID when neither preceding identifier exists.

Direct properties not applicable Not applicable

Not applicable

Institutional or informational subject: no invented physical properties.

Recognition optional Filled

  • A handling case has a claim number, a policy reference, a claimant, a loss date and a handler.
  • It is confused with the claim, the policy, the loss event or a fraud case.

Capabilities and actions required Filled

  • Register handling case: Governed operation to register handling case with attributable evidence and no hidden master-system mutation.
  • Acknowledge and triage notification: Governed operation to acknowledge and triage notification with attributable evidence and no hidden master-system mutation.
  • Bind claim, policy, loss and parties: Governed operation to bind claim, policy, loss and parties with attributable evidence and no hidden master-system mutation.
  • Plan and conduct investigation: Governed operation to plan and conduct investigation with attributable evidence and no hidden master-system mutation.
  • Assess coverage, liability and benefit: Governed operation to assess coverage, liability and benefit with attributable evidence and no hidden master-system mutation.
  • Refer suspected fraud: Governed operation to refer suspected fraud with attributable evidence and no hidden master-system mutation.
  • Issue reasoned decision or offer: Governed operation to issue reasoned decision or offer with attributable evidence and no hidden master-system mutation.
  • Settle and initiate financial handoffs: Governed operation to settle and initiate financial handoffs with attributable evidence and no hidden master-system mutation.
  • Review, dispute, reopen or correct: Governed operation to review, dispute, reopen or correct with attributable evidence and no hidden master-system mutation.
  • Close, project, retain and audit: Governed operation to close, project, retain and audit with attributable evidence and no hidden master-system mutation.

Hazards and failure modes required Filled

  • Wrongful denial leaving people without support.
  • Data leaks of health or financial information.
  • Missed regulatory deadlines leading to penalties.

Standards and interfaces required Filled

  • ACORD data standards.
  • ISO 20022 for settlement payments.

Context of use required Filled

  • Deadlines, reasonableness, settlement duties, disclosure, interest, limitation and appeal rights depend on jurisdiction and policy class.
  • NAIC models are United States model texts rather than automatically applicable state law; FCA and EU sources are regional profiles.
  • Health claim exchanges and patient-facing projections vary by trading-partner agreement, jurisdiction and FHIR implementation guide.

Sources Filled

  1. Insurance Core Principles and Common Framework for the Supervision of Internationally Active Insurance Groups - International Association of Insurance Supervisors
  2. Unfair Claims Settlement Practices Act - National Association of Insurance Commissioners
  3. Unfair Property/Casualty Claims Settlement Practices Model Regulation - National Association of Insurance Commissioners
  4. Market Conduct Record Retention and Production Model Regulation - National Association of Insurance Commissioners
  5. ICOBS 8 Claims handling - Financial Conduct Authority
  6. Guidelines on Complaints-Handling by Insurance Undertakings - European Insurance and Occupational Pensions Authority
  7. Directive 2009/103/EC relating to insurance against civil liability in respect of the use of motor vehicles - European Union
  8. Directive (EU) 2016/97 on insurance distribution - European Union
  9. Enterprise Act 2016, Part 5: Late Payment of Insurance Claims - United Kingdom Legislation
  10. FHIR R5 Claim - Health Level Seven International
  11. FHIR R5 ClaimResponse - Health Level Seven International
  12. FHIR R5 ExplanationOfBenefit - Health Level Seven International
  13. ACORD Property and Casualty Data Standards - Association for Cooperative Operations Research and Development
  14. Regulation (EU) 2016/679 General Data Protection Regulation - European Union
  15. PROV-O: The PROV Ontology - World Wide Web Consortium
  16. Date and Time on the Internet: Timestamps - Internet Engineering Task Force

Open questions

  • Approve or reject the WM-ECO-036 composition and define claim-to-handling-case cardinality, reopening and multi-insurer coordination semantics.
  • Create line-of-business profiles with specialized evidence, benefit, authority, reserve, settlement and recovery rules.
  • Create jurisdiction profiles for deadlines, reasoned decisions, interest, limitation, privacy, complaints, redress, retention and catastrophe duties.
  • Test full licensed ACORD mappings and selected FHIR implementation guides without treating either as universal semantics.
  • Obtain supplemental Claude or Grok review and resolve any material challenge before canonical promotion.
  • Claude and Grok each timed out on one bounded attempt; no independent external result was admitted.
  • WM-ECO-036 COMPOSE WM-ACT-045 is a candidate relation, not an approved edge.
  • Life, health, disability, workers compensation, property, motor, liability, travel, cyber, marine, reinsurance and catastrophe handling require separate profiles.
  • ACORD evidence is limited to public overview material and HL7 FHIR R5 financial resources are Trial Use; no full ACORD or universal FHIR conformance is claimed.

Machine files

Card as JSON Specification AGENTS.md Source Card backlog vercy.card/1

Provenance

world-models research · reviewable-draft

Built from: models/wm-act-045-insurance-claim-handling/spec.yaml, ver-cy/world-models/card-supplements/wm-act-045-insurance-claim-handling.json