Assessing a newly notified claim
Provides an indicative coverage assessment grounded in the applicable policy wording, schedule and endorsements. Identifies relevant cover, limits and excess alongside the clauses supporting the assessment.
— Risk & Compliance
Claims Coverage Triage Engine
Reads a submitted claim against the policy wording that governs it and returns a coverage assessment showing whether it appears covered, potentially excluded or in need of specialist review, mapped clause by clause and never issued without a handler's sign-off.
- Risk & Compliance
- Traceable reasoning
- Runs anywhere
1–2 hours → ~5 minutes
For one document, brief or record at a time
No coding required
- Input
- Claimant details, policy number and insurance product
- Output
- Coverage Assessment Report requiring handler sign-off
- Runs in
- Skillsize · ChatGPT · Claude · Copilot
- Export
- SKILL.md · MCP
- Time saved
- ~1–2 hours per run
— USE CASES
What people use Claims Coverage Triage Engine for
Clarifying exclusions and evidence gaps
Examines relevant exclusions and conditions against the reported loss. Makes the key uncertainty and evidence still required explicit, supporting a defensible handling decision.
Identifying mandatory specialist referrals
Flags claims outside the policy period, beyond handler authority or showing potential fraud or large-loss indicators as requiring specialist review. Gives the handler a recommended route with the supporting policy evidence.
Supporting consistent handler judgement
Uses claims-handling guidance and comparable past triage decisions to support consistent assessments. Keeps policy citations, uncertainties and the indicative outcome visible for handler sign-off.
What it works from
- Claimant details, policy number and insurance product
- Loss date, description, reported cause and amount claimed
- Supporting claim evidence
- Applicable policy wording, schedule and endorsements versions relevant to the loss date
What you get back
- Coverage Assessment Report requiring handler sign-off
- Indicative outcome of apparent cover, potential exclusion or specialist review
- Relevant cover, policy limits and excess
- Possible exclusions and applicable conditions assessments grounded in the claim facts
Why this is expensive by hand
Early coverage decisions depend on precise policy wording, incomplete evidence and clear limits on handler authority. In practice it shows up as assessing a newly notified claim: provides an indicative coverage assessment grounded in the applicable policy wording, schedule and endorsements. Identifies relevant cover, limits and excess alongside the clauses supporting the assessment. It is the kind of work that decides whether a recommendation survives scrutiny — and the kind that quietly eats 1–2 hours of senior time whenever it comes round.
How this Skill produces it
As a Skill, the work is already sequenced. You bring the evidence, and the run produces coverage Assessment Report requiring handler sign-off plus indicative outcome of apparent cover, potential exclusion or specialist review. What sits between input and output is the codified method: thresholds, sequencing and the points where a human confirms a call — all of it visible and editable in the Skill. The practical effect: 1–2 hours of manual work becomes a ~5 minutes run, held to an identical standard on the tenth engagement as on the first.
Who it's for
- Internal audit and risk functions
- Compliance and controls teams
- Second-line functions reporting to committees
- Risk consultants running assessments
Run it in Skillsize — or export it anywhere
Claims Coverage Triage Engine exports as a structured SKILL.md file and is MCP-ready, so the same method runs in ChatGPT, Claude, Copilot or your own AI products. Adapt it to your methodology, and the intelligence stays yours — not locked to one vendor.
ChatGPTClaudeCopilotAI Products (MCP)
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