claims-triage

Claims Triage Skill

The first 24 hours of a claim set its cost and its customer experience. This skill runs a disciplined first-pass triage: does the policy respond, how big and how complicated is this, are there indicators that warrant investigation, what should we hold in reserve, and who should own it by when.

What This Skill Produces

• A coverage-trigger view against the actual policy wording (trigger, exclusions, conditions)
• A severity/complexity band with rationale
• A fraud-indicator screen — indicators only, never conclusions
• A first-pass reserve range (indemnity + expense), labelled as first-pass
• A routing recommendation (fast-track / adjuster / senior adjuster / SIU referral / coverage counsel) with SLA

Required Inputs

Ask for these if not provided; if working from a thin FNOL, proceed and label every inference [assumed — confirm]:

• Loss description — what happened, when, where, reported when
• Policy details — line of business, wording or key clauses, limits, deductible, period
• Claimed amount or damage description (even rough)
• Claimant/insured history if available (prior claims, tenure)

Triage Framework

1. Coverage trigger. Quote or paraphrase the operative insuring clause. State: trigger met / trigger uncertain / trigger likely not met — with the specific wording reason. Sweep exclusions and conditions precedent (notification timing, security warranties). If coverage is uncertain, flag a reservation-of-rights consideration and route to coverage counsel review — never let uncertainty default to "covered".

2. Severity/complexity banding:

| Band | Profile | Typical routing |

|---|---|---|

| 1 — Fast-track | Clear coverage, quantum near/below deductible-adjacent threshold, no injury, single party | Automated/desk settlement |

| 2 — Standard | Clear coverage, moderate quantum, routine investigation | Adjuster |

| 3 — Complex | Large loss, bodily injury, multiple parties, coverage questions, or business interruption | Senior adjuster, early expert instruction |

| 4 — Major/CAT | Catastrophe-linked, potential limit loss, litigation likely, reputational exposure | Major-loss team + counsel, executive notification |

Band on the worse of severity and complexity.

3. Fraud-indicator screen. Check common indicators: loss shortly after inception or cover increase, late reporting without explanation, documentation inconsistencies, over-documentation, prior similar claims, financial-distress signals, uncooperative or steering behaviour, loss narrative inconsistent with physical evidence. State only which indicators are present and absent. Two or more material indicators → recommend SIU referral in parallel with normal handling; the claim is still handled in good faith.

4. First-pass reserve. Give a range for ultimate incurred: indemnity + expense (adjusting, legal, experts), gross and net of deductible. State the basis (repair estimate, comparable claims, injury tariff) and label it first-pass, to be revised on investigation.

5. Routing + SLA. Name the route, the required first contact/action, and the SLA (e.g. fast-track: decision in 5 business days; Band 3: insured contacted within 24h, site inspection within 5 days).

Output Format

Claim triage: [claim ref / insured / loss date]

1. Loss summary — 2–3 sentences, facts only.

2. Coverage trigger — clause cited, trigger view, exclusions/conditions checked, open coverage questions.

3. Severity band — band + one-line rationale.

4. Indicator screen — table: indicator | present? | evidence. Then: SIU referral recommended yes/no.

5. First-pass reserve — range, basis, gross/net.

6. Routing & SLA — route, owner type, first actions with deadlines.

7. Information needed — the specific documents/statements to request next.

End every triage note with: "This is analytical support for triage, not a coverage determination. Coverage, reserving, and referral decisions follow your organisation's claims-handling policy and applicable regulation."

Quality Checks

• [ ] Coverage view cites specific wording, not just line of business
• [ ] Severity band has a stated rationale and used the worse of severity/complexity
• [ ] Fraud screen lists indicators present and checked-but-absent — no conclusion stated
• [ ] Reserve is a range with a stated basis, labelled first-pass, gross and net shown
• [ ] Routing includes an SLA and concrete first actions
• [ ] Assumptions from a thin FNOL are labelled [assumed — confirm]
• [ ] Regulatory support-not-determination line is included

Anti-Patterns

• [ ] Do not state a fraud conclusion — state indicators and route to SIU; the word is "indicator", never "fraudulent"
• [ ] Do not let a SIU referral pause good-faith handling of the claim
• [ ] Do not default an uncertain trigger to "covered" or "denied" — flag it for coverage review with the wording question stated
• [ ] Do not give a single-point reserve on day one — give a range with basis
• [ ] Do not invent policy terms — if the wording isn't provided, ask, or label the clause [to confirm against wording]