{
  "class_version": "nt-crossing-class:v0",
  "id": "insurance.claim-auto-denial",
  "version": "0.1.0",
  "title": "Automated denial of an insurance claim",
  "domain": "insurance claims",
  "evidence_status": "proposed",
  "summary": "An automated claims workflow proposes to deny a claim after document mismatches and send closure notices. The crossing moves a claim from open to denied. Synthetic specification; no insurer has reviewed it.",
  "state_fields": {
    "before": ["claim_id", "status", "open_mismatches"],
    "proposed": ["claim_id", "status", "notices"]
  },
  "action_types": ["deny_claim"],
  "policy": {
    "id": "nt-policy:claims-auto-denial",
    "version": "0.1.0",
    "authored_by": "Neverthought (illustrative class policy; not an insurer's policy)",
    "parameters": {
      "max_review_ratio": 1,
      "max_delegation_depth": 2,
      "evidence_max_age_days": 30,
      "reachable_retention_min": 0.5,
      "max_loop_gain": 1
    },
    "note": "Parameter values are illustrative. A real class takes them from the insurer's claims policy and regulator."
  },
  "invariants": [
    {
      "id": "claimant_routes",
      "label": "Claimant keeps review, correction and appeal routes after denial",
      "measure": "routes_preserved",
      "params": { "required": ["human_review", "document_correction", "appeal"] },
      "tolerance": 0
    }
  ],
  "evidence_requirements": [
    { "subject": "mismatch_record", "min_tier": "E2", "required_to_resolve": "Attach the document-mismatch record for this claim." },
    { "subject": "policy_wording", "min_tier": "E4", "required_to_resolve": "Attach the policy wording the denial relies on, from the insurer's document system." },
    { "subject": "model_version", "min_tier": "E2", "required_to_resolve": "Attach the model registry entry for the model that proposed the denial." }
  ],
  "authority_requirements": { "independent_trust_root": true, "segregation_of_duties": false },
  "archetypes": [
    "RA-PREMATURE-CLOSURE", "RA-IRREVERSIBLE-COMMITMENT", "RA-BRANCH-COLLAPSE", "RA-HIDDEN-COUPLING",
    "RA-FEEDBACK-AMPLIFICATION", "RA-ACCUMULATION", "RA-EXPIRED-EVIDENCE", "RA-AUTHORITY-DRIFT",
    "RA-SELF-CERTIFICATION", "RA-UNWARRANTED-EXECUTION"
  ],
  "descriptors": {
    "stake": "material",
    "action": "compensable",
    "authority_kind": "explicit",
    "freshness": "bounded"
  },
  "profiles": {
    "recorder": "nt-receipt-chain:v0 (this site's chain; not CER-17)",
    "underwriting": "nt-underwritability-conditions:v0 (conditions document; not UW-12)"
  },
  "consequence": {
    "bound": "unbounded",
    "ceiling": null,
    "rationale": "The direct effect is the value of the denied claim, but a wrongful denial can also create liability beyond the claim value, such as regulatory action or bad-faith claims, so no ceiling is declared."
  },
  "consequence_paths": [
    {
      "id": "claimant_routes_closed",
      "description": "Review, correction or appeal routes close after the denial."
    },
    {
      "id": "wrongful_denial_settlement",
      "description": "The denial is overturned and the claim is settled, with handling cost."
    },
    {
      "id": "reserve_released",
      "description": "The claim reserve is released in reliance on the denial."
    },
    {
      "id": "feedback_to_model",
      "description": "Denials feed training labels and shift later denials."
    }
  ],
  "structural_tests": [],
  "failure_mode": {
    "mode": "fail-closed",
    "rationale": "A denial is not committed and no notice is sent unless the gate returns EXECUTE."
  },
  "underwritability": {
    "what_an_underwriter_would_need": [
      "A receipt for every automated denial, issued before closure notices are sent.",
      "HOLD rate and reasons for this class over a declared period.",
      "Count of denials executed without an EXECUTE determination (epistemic IBNR).",
      "Concentration of denials on a single model, vendor or data source.",
      "Evidence that claimant review, correction and appeal routes remain open after denial."
    ],
    "conditions": [
      "Human review completes before a denial is committed.",
      "Denial authority traces to a root independent of the claims system.",
      "Feedback from denials into model training is declared and damped.",
      "Evidence relied on is no more than 30 days old at valid time."
    ],
    "exclusions": [
      "Denials executed while held.",
      "Denials where appeal or correction routes were not available.",
      "Losses propagating through undeclared dependencies."
    ]
  },
  "non_claims": [
    "Not an insurer's claims policy or a regulatory standard.",
    "Parameters are illustrative.",
    "No insurer, broker or regulator has reviewed this class."
  ]
}