Published

Insurance Claim

vr.wm-eco-036 · wm-eco-036-insurance-claim

Represent one governed insurance claim as the identity-bearing request and substantive assertion aggregate that invokes an insurance policy, statutory scheme or compensation basis after a loss or qualifying circumstance, without becoming the handling workflow or external systems that assess and resolve it.

World Models Society, people and institutions SOC.ECO.INS

Bundle → Layer → Finding → Questions Classifiers What it is Why it exists Distinguishing features What robots and AI may and may not do Moral aspects Owners Links to other meta-models Identity and identifiers Direct properties Recognition Capabilities and actions Hazards and failure modes Standards and interfaces Context of use Sources

Bundle → Layer → Finding → Questions Filled

6 bundles · 12 layers · 24 findings · 72 questions

Claim identity, basis and parties Establish the identity-bearing request, its insurance basis and participant roles without absorbing policy or party masters

Claim identity, class, version and lineage

Groups governed assertions about claim identity, class, version and lineage for an insurance claim.

Claim identifier, business identifier, master system, version and successor

Records claim identifier, business identifier, master system, version and successor as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claim identifier, business identifier, master system, version and successor? identity
Who asserted, submitted, owns, stewards, validates, contests or may access claim identifier, business identifier, master system, version and successor, under what authority and purpose? ownership
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claim identifier, business identifier, master system, version and successor? quality

Claim use, insurance line, loss class, jurisdiction, priority and status

Records claim use, insurance line, loss class, jurisdiction, priority and status as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claim use, insurance line, loss class, jurisdiction, priority and status? classification
Who asserted, submitted, owns, stewards, validates, contests or may access claim use, insurance line, loss class, jurisdiction, priority and status, under what authority and purpose? authority
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claim use, insurance line, loss class, jurisdiction, priority and status? validation

Insurance basis and party roles

Groups governed assertions about insurance basis and party roles for an insurance claim.

Policy, scheme, coverage, benefit, focality, order and coordination

Records policy, scheme, coverage, benefit, focality, order and coordination as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish policy, scheme, coverage, benefit, focality, order and coordination? relationship
Who asserted, submitted, owns, stewards, validates, contests or may access policy, scheme, coverage, benefit, focality, order and coordination, under what authority and purpose? requirement
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify policy, scheme, coverage, benefit, focality, order and coordination? security

Claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative

Records claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative? authority
Who asserted, submitted, owns, stewards, validates, contests or may access claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative, under what authority and purpose? constraint
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative? privacy

Occurrence, insured subject and claim assertions Record what is alleged to have happened and what loss or benefit is claimed while retaining external occurrence, subject and evidence authority

Occurrence, loss, peril, cause and context

Groups governed assertions about occurrence, loss, peril, cause and context for an insurance claim.

Occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference

Records occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference? relationship
Who asserted, submitted, owns, stewards, validates, contests or may access occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference, under what authority and purpose? process
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference? retention

Occurrence, discovery, notification, location, jurisdiction and knowledge time

Records occurrence, discovery, notification, location, jurisdiction and knowledge time as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish occurrence, discovery, notification, location, jurisdiction and knowledge time? temporal
Who asserted, submitted, owns, stewards, validates, contests or may access occurrence, discovery, notification, location, jurisdiction and knowledge time, under what authority and purpose? event
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify occurrence, discovery, notification, location, jurisdiction and knowledge time? access

Insured subject, damage, injury, expense and benefit

Groups governed assertions about insured subject, damage, injury, expense and benefit for an insurance claim.

Insured interest, asset, person, service, exposure, condition and pre-loss state reference

Records insured interest, asset, person, service, exposure, condition and pre-loss state reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish insured interest, asset, person, service, exposure, condition and pre-loss state reference? composition
Who asserted, submitted, owns, stewards, validates, contests or may access insured interest, asset, person, service, exposure, condition and pre-loss state reference, under what authority and purpose? measurement
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify insured interest, asset, person, service, exposure, condition and pre-loss state reference? exception

Damage, injury, illness, expense, service, loss of use and requested benefit assertion

Records damage, injury, illness, expense, service, loss of use and requested benefit assertion as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish damage, injury, illness, expense, service, loss of use and requested benefit assertion? evidence
Who asserted, submitted, owns, stewards, validates, contests or may access damage, injury, illness, expense, service, loss of use and requested benefit assertion, under what authority and purpose? evidence
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify damage, injury, illness, expense, service, loss of use and requested benefit assertion? interoperability

Claim lines, quantities and amounts Preserve item-level requested benefits and separately qualified monetary assertions

Claim line, service, product, damage and period

Groups governed assertions about claim line, service, product, damage and period for an insurance claim.

Claim line sequence, group, detail, subdetail, code, description and reference

Records claim line sequence, group, detail, subdetail, code, description and reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claim line sequence, group, detail, subdetail, code, description and reference? composition
Who asserted, submitted, owns, stewards, validates, contests or may access claim line sequence, group, detail, subdetail, code, description and reference, under what authority and purpose? quality
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claim line sequence, group, detail, subdetail, code, description and reference? decision

Quantity, unit, service date, billable period, place, provider and recipient

Records quantity, unit, service date, billable period, place, provider and recipient as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish quantity, unit, service date, billable period, place, provider and recipient? measurement
Who asserted, submitted, owns, stewards, validates, contests or may access quantity, unit, service date, billable period, place, provider and recipient, under what authority and purpose? validation
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify quantity, unit, service date, billable period, place, provider and recipient? identity

Claimed values, deductibles, limits and allocation

Groups governed assertions about claimed values, deductibles, limits and allocation for an insurance claim.

Claimed amount, currency, unit price, factor, tax, net and total

Records claimed amount, currency, unit price, factor, tax, net and total as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claimed amount, currency, unit price, factor, tax, net and total? measurement
Who asserted, submitted, owns, stewards, validates, contests or may access claimed amount, currency, unit price, factor, tax, net and total, under what authority and purpose? security
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claimed amount, currency, unit price, factor, tax, net and total? classification

Deductible, copayment, coinsurance, limit, excess, other coverage and allocation

Records deductible, copayment, coinsurance, limit, excess, other coverage and allocation as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish deductible, copayment, coinsurance, limit, excess, other coverage and allocation? constraint
Who asserted, submitted, owns, stewards, validates, contests or may access deductible, copayment, coinsurance, limit, excess, other coverage and allocation, under what authority and purpose? privacy
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify deductible, copayment, coinsurance, limit, excess, other coverage and allocation? composition

Presentation, evidence and claim relationships Distinguish how a claim is presented and supported from handling decisions and external source records

Notice, presentation, completeness and validation

Groups governed assertions about notice, presentation, completeness and validation for an insurance claim.

Notice, presentation, submitter, channel, received time, language and accessibility

Records notice, presentation, submitter, channel, received time, language and accessibility as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish notice, presentation, submitter, channel, received time, language and accessibility? event
Who asserted, submitted, owns, stewards, validates, contests or may access notice, presentation, submitter, channel, received time, language and accessibility, under what authority and purpose? retention
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify notice, presentation, submitter, channel, received time, language and accessibility? relationship

Required information, completeness, admissibility, format validation, error and correction

Records required information, completeness, admissibility, format validation, error and correction as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish required information, completeness, admissibility, format validation, error and correction? validation
Who asserted, submitted, owns, stewards, validates, contests or may access required information, completeness, admissibility, format validation, error and correction, under what authority and purpose? access
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify required information, completeness, admissibility, format validation, error and correction? state

Supporting information, evidence and related claims

Groups governed assertions about supporting information, evidence and related claims for an insurance claim.

Supporting information, document, image, observation, statement, source and evidence reference

Records supporting information, document, image, observation, statement, source and evidence reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish supporting information, document, image, observation, statement, source and evidence reference? evidence
Who asserted, submitted, owns, stewards, validates, contests or may access supporting information, document, image, observation, statement, source and evidence reference, under what authority and purpose? exception
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify supporting information, document, image, observation, statement, source and evidence reference? lifecycle

Related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim

Records related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim? relationship
Who asserted, submitted, owns, stewards, validates, contests or may access related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim, under what authority and purpose? interoperability
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim? temporal

Positions, outcomes and claim lifecycle Link competing positions and external outcomes while keeping claim-owned amendment and continuity semantics

Party positions, decisions, settlement and payment references

Groups governed assertions about party positions, decisions, settlement and payment references for an insurance claim.

Claimant allegation, insurer coverage, liability, causation, valuation and benefit position

Records claimant allegation, insurer coverage, liability, causation, valuation and benefit position as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claimant allegation, insurer coverage, liability, causation, valuation and benefit position? decision
Who asserted, submitted, owns, stewards, validates, contests or may access claimant allegation, insurer coverage, liability, causation, valuation and benefit position, under what authority and purpose? decision
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claimant allegation, insurer coverage, liability, causation, valuation and benefit position? provenance

Reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference

Records reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference? relationship
Who asserted, submitted, owns, stewards, validates, contests or may access reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference, under what authority and purpose? identity
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference? ownership

Amendment, withdrawal, closure, reopening and contestation

Groups governed assertions about amendment, withdrawal, closure, reopening and contestation for an insurance claim.

Draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error

Records draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error? lifecycle
Who asserted, submitted, owns, stewards, validates, contests or may access draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error, under what authority and purpose? classification
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error? authority

Correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference

Records correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference? exception
Who asserted, submitted, owns, stewards, validates, contests or may access correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference, under what authority and purpose? composition
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference? requirement

Governance, privacy, retention and interoperability Make claim data attributable, protected, durable and projectable without confusing transport with semantic identity

Provenance, quality, access and retention

Groups governed assertions about provenance, quality, access and retention for an insurance claim.

Source, actor, assertion, method, confidence, conflict, event time and knowledge time

Records source, actor, assertion, method, confidence, conflict, event time and knowledge time as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish source, actor, assertion, method, confidence, conflict, event time and knowledge time? provenance
Who asserted, submitted, owns, stewards, validates, contests or may access source, actor, assertion, method, confidence, conflict, event time and knowledge time, under what authority and purpose? relationship
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify source, actor, assertion, method, confidence, conflict, event time and knowledge time? constraint

Purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention

Records purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention? privacy
Who asserted, submitted, owns, stewards, validates, contests or may access purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention, under what authority and purpose? state
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention? process

Master systems, projections and mapping loss

Groups governed assertions about master systems, projections and mapping loss for an insurance claim.

Master record, authoritative identifier, digest, revision and synchronization state

Records master record, authoritative identifier, digest, revision and synchronization state as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish master record, authoritative identifier, digest, revision and synchronization state? quality
Who asserted, submitted, owns, stewards, validates, contests or may access master record, authoritative identifier, digest, revision and synchronization state, under what authority and purpose? lifecycle
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify master record, authoritative identifier, digest, revision and synchronization state? event

FHIR, ACORD, API, document, code-list, policy projection, version and semantic loss

Records fhir, acord, api, document, code-list, policy projection, version and semantic loss as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.

Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish fhir, acord, api, document, code-list, policy projection, version and semantic loss? interoperability
Who asserted, submitted, owns, stewards, validates, contests or may access fhir, acord, api, document, code-list, policy projection, version and semantic loss, under what authority and purpose? temporal
Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify fhir, acord, api, document, code-list, policy projection, version and semantic loss? measurement

Classifiers Filled

Family: World Models
Category: Society, people and institutions
Entry kind: aggregate
Navigation path: NAV.SOC.ECO.INS
Domain: SOC.ECO.INS
Industry: Cross-industry
Tags: insuranceclaimsoc.eco.ins

What it is Filled

Owns claim and version identity; claim use, class, insurance line, jurisdiction, priority and claim-owned lifecycle; policy, scheme, coverage and benefit bindings; claimant, insured, policyholder, beneficiary, injured party, provider, insurer, representative and authority roles; occurrence, peril, cause, causal-nexus, catastrophe, insured-interest, asset, person, service, damage, injury, illness, expense, loss-of-use and requested-benefit assertions; claim lines, groups, details, codes, quantities, units, service dates, billable periods, places, providers and recipients; claimed amounts, currency, prices, factors, tax, totals, deductibles, copayments, coinsurance, limits, excess, other coverage and allocation; notification, presentation, submitter, channel, receipt, language, accessibility, completeness, admissibility, validation errors and corrections; supporting-information and evidence references; related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior-claim links; separately sourced claimant, insurer, expert and authority positions; reserve, decision, offer, settlement, award, payment, recovery, subrogation, salvage, complaint, dispute, fraud, appeal and regulator references; amendment, withdrawal, closure, reopening, correction, split, merge and supersession lineage; provenance, event and knowledge clocks, quality, privacy, access, retention, audit and loss-aware projections. Policy, occurrence, party, subject, evidence, handling, assessment, decision, reserve, settlement, payment, complaint, dispute, fraud, recovery, regulator, audit and records masters remain authoritative.

In scope

Claim identity, version, class, insurance basis, participant roles, occurrence and insured-subject references
Source-qualified substantive assertions, claim lines, quantities, claimed values, evidence bindings and related-claim lineage
External position and outcome bindings, claim-owned lifecycle, provenance, privacy, retention and interoperability

Out of scope

Owning Insurance Policy, Coverage, Loss Event, Person, Organization, Role, Asset, Injury, Evidence, Handling Case, Assessment, Decision, Reserve, Settlement, Payment, Complaint, Dispute, Fraud Case, Recovery, Regulator, Audit or Record masters
Treating notice as claim validity, policy existence as coverage, allegation as fact, claimed amount as assessed or allowed, reserve as liability, settlement as payment, closure as extinguished rights or fraud indicator as fraud
Autonomous coverage, liability, valuation, settlement, payment, fraud, dispute, disclosure or disposition decisions

Why it exists Filled

Distinguishing features Filled

Holds the claimant's request and assertions, not the policy, the loss event or the insurer's decision.
Notification of a claim does not establish validity, coverage or liability.
Claimed, assessed, reserved, settled and paid amounts are separately typed.
Handling workflow belongs to the claim handling model; this record is the claim itself.

What robots and AI may and may not do Filled

Must not

Accept or deny coverage.
Determine liability or fraud.
Agree a settlement or release a payment.
Disclose medical or injury information beyond the stated purpose.
Close a claim to meet a deadline without a decision.

Only with a human decision

Coverage and liability decisions.
Settlement offers and payments above delegated limits.
Fraud referral.

May

Register a claim notification with its source and policy reference.
Collect and index supporting evidence.
Detect likely duplicates for human confirmation.
Inform the claimant of missing information and deadlines.

Moral aspects Filled

Claimants are often in distress after a loss; delays and opaque denials cause harm.
Health and injury data in claims is sensitive.
Automated fraud scoring can unfairly target groups and needs human review.

Who is affected

Claimants and insured persons
Injured third parties
Insurers
Providers and repairers

Owners Filled

Steward

Dimension owner, namespace authority and delegated claim, insurance, legal, privacy, security and records authorities

Roles

Claimant, insured, beneficiary or injured party: Present and correct source-qualified claim assertions and receive accessible status and outcome information under applicable rights.
Policyholder, representative or provider: Submit authorized information and preserve the exact represented party, mandate and source.
Insurer, scheme or compensation body: Master the claim identifier or recognize an external claim and bind authoritative policy, coverage, handling and outcome records.
Claim handler, adjuster, expert and reviewer: Work through external handling and evidence models without overwriting claimant assertions or external masters.
Privacy, security and records steward: Enforce purpose, minimum access, privilege, legal hold, retention, audit and safe projection.
Regulator, ombudsman, tribunal or court: Issue separately mastered oversight, redress or legal outcomes without becoming the claim owner.

Links to other meta-models Filled

references

WM-ECO-003 Insurance - Reference the candidate policy-context parent without treating it as approved containment or cascading policy authority.
Policy, Coverage, Party, Loss, Subject, Evidence, Decision, Settlement, Payment, Complaint, Dispute, Fraud, Recovery, Regulator, Audit and Records models - Resolve external masters without duplicating their lifecycles or authority.

composes

WM-ACT-045 Insurance Claim Handling - Candidate claim-to-handling-case composition preserving distinct identities and potentially multiple handling cases per claim.

aligned

FHIR R5 Claim, ClaimResponse, ExplanationOfBenefit, Coverage and CoverageEligibility profiles - Project health-insurance request, adjudication, patient and coverage views with Trial Use and semantic-loss declarations.
ACORD P&C, ISO 4217, ISO 3166, RFC 3339, PROV-O, DQV and ODRL - Project insurance exchange, code, temporal, provenance, quality and policy views with version, access and loss controls.

neighbor

WM-ECO-003 Insurance - The policy or insurance context owns the insurance promise and coverage terms. The claim owns the request and claim assertions invoking that basis. The candidate CONTAINS edge grants no cascade authority.
WM-ACT-045 Insurance Claim Handling - The claim owns identity, request, claim lines and substantive assertions. The handling case owns assignments, investigation work, assessments, decisions, communications and handoffs. Their candidate COMPOSE edge remains unapproved.
Loss, evidence and party masters - A claim references occurrence, subject, party, document and evidence identities and records what each source asserts without absorbing or promoting them to truth.
Coverage, assessment, reserve, decision, settlement and payment - Claimed, assessed, allowed, offered, reserved, settled and paid positions remain distinct, source-qualified and externally mastered.
Complaint, dispute, fraud, recovery and regulator case - These may originate from or affect a claim but retain separate identity, authority, procedure and outcome lineage.
FHIR and ACORD profiles - FHIR Claim is a Trial Use health request-side profile and ACORD is a licensed insurance exchange family; projections do not define the universal semantic identity of a claim.

parent

WM-ECO-003

What else AI and robots need to interact with it Filled

Sources Filled

Insurance Core Principles and Common Framework for the Supervision of Internationally Active Insurance Groups - International Association of Insurance Supervisors
Unfair Claims Settlement Practices Act - National Association of Insurance Commissioners
Unfair Property/Casualty Claims Settlement Practices Model Regulation - National Association of Insurance Commissioners
Market Conduct Record Retention and Production Model Regulation - National Association of Insurance Commissioners
ICOBS 8 Claims handling - Financial Conduct Authority
Guidelines on Complaints-Handling by Insurance Undertakings - European Insurance and Occupational Pensions Authority
Directive 2009/103/EC on motor vehicle liability insurance - European Union
Directive (EU) 2016/97 on insurance distribution - European Union
Enterprise Act 2016, Part 5: Late Payment of Insurance Claims - United Kingdom Legislation
FHIR R5 Claim - Health Level Seven International
FHIR R5 Claim detailed descriptions - Health Level Seven International
FHIR R5 ClaimResponse - Health Level Seven International
FHIR R5 ExplanationOfBenefit - Health Level Seven International
FHIR R5 Coverage - Health Level Seven International
FHIR R5 CoverageEligibilityRequest - Health Level Seven International
FHIR R5 CoverageEligibilityResponse - Health Level Seven International
ACORD Property and Casualty Data Standards - Association for Cooperative Operations Research and Development
Regulation (EU) 2016/679 General Data Protection Regulation - European Union
ISO 4217 Currency Codes - International Organization for Standardization
Date and Time on the Internet: Timestamps - Internet Engineering Task Force
PROV-O: The PROV Ontology - World Wide Web Consortium
Data on the Web Best Practices: Data Quality Vocabulary - World Wide Web Consortium
ODRL Information Model 2.2 - World Wide Web Consortium
ISO 3166 Country Codes - International Organization for Standardization

Open questions

Approve or reject the WM-ECO-003 and WM-ACT-045 candidate relations and define claim-to-policy, claim-to-handling-case, multi-insurer, reopening, split and merge cardinality.
Create independently validated life, health, disability, workers compensation, property, motor, liability, travel, cyber, marine, reinsurance, catastrophe and public-scheme profiles.
Benchmark claim identity matching, claim-line codes, evidence requirements, amount classes, coordination of benefits, duplicate detection, privacy, retention and cross-border handling.
Validate jurisdiction, policy class, claimant standing, limitation, coverage, liability, settlement, payment, appeal, complaint, fraud and regulator rules.
Pin exact external releases and licensing conditions and obtain independent insurance, claims, legal, privacy, security and records review before promotion beyond reviewable-draft assurance.
Claude and Grok each timed out on one bounded attempt; no independent external result was admitted.
WM-ECO-003 CONTAINS WM-ECO-036 and WM-ECO-036 COMPOSE WM-ACT-045 are candidate relations, not approved edges.
Life, health, disability, workers compensation, property, motor, liability, travel, cyber, marine, reinsurance, catastrophe and public-scheme claims require separate profiles.
ACORD evidence is limited to a public overview and FHIR R5 financial resources are Trial Use; no full ACORD or universal FHIR conformance is claimed.
Coverage, liability, valuation, reserves, settlement, payment, fraud and legal outcomes remain external authority planes.

Machine files

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

Provenance

world-models research · reviewable-draft

Built from: models/wm-eco-036-insurance-claim/spec.yaml, ver-cy/world-models/card-supplements/wm-eco-036-insurance-claim.json