Insurance Claims — Implementation Guide
Audience: Insurers, reinsurers, brokers, TPAs, implementation teams. Vertical: Insurance — motor, home, liability, catastrophe claims. Status: Configuration-only design; seeded Kenya insurance packs (motor, medical, home); no bespoke tables. Substrate: Reuses Jijibora community sourcing scenario, building reflex, and Kenya claim routing seed.
1. Claim Types — Insurance
| Claim Type | CNS URI | Bound To | Typical Evidence Required |
|---|
| Motor Claim | cns://claim/type/insurance/motor_claim | resource:vehicle | Loss notice, adjuster report, garage estimate, police report, photos |
| Home Claim | cns://claim/type/insurance/home_claim | resource:property | Loss notice, adjuster report, repair estimates, photos, authority report |
| Liability Claim | cns://claim/type/insurance/liability_claim | truth_node:person | Incident report, witness statements, legal evidence, adjuster report |
| Catastrophe Claim | cns://claim/type/insurance/catastrophe_claim | resource:policy | Loss notice, reinsurer notice, catastrophe modeling, mass adjuster deployment |
2. Provider Panel — Insurance
Insurance claims use a provider panel with four roles (broker, adjuster, garage, reinsurer). Panel membership composes canonical organisation, capability, and attestation records.
| Role | Capabilities Required | Attestation | Lease TTL | Claim Types |
|---|
| Broker | recognised_intake, distribution, policy_placement | Yes | 1 hour | All (first notice of loss) |
| Adjuster | adjustment, loss_assessment, claims_review | Yes | 1 hour | Motor, home, liability |
| Garage | motor_body_repair, glass_repair, paint_work | Yes | 1 hour | Motor |
| Reinsurer | reinsurance, evidence_review, catastrophe_screening | Yes | 8 hours | Motor, home, liability, catastrophe |
All roles require: approved affiliation + active status + attestation. Fail-closed: missing values refuse with a service error.
3. Guard Policies — Insurance
3.1 Separation of Duties
| Claim Type | Creator May Approve? | Barred Pairs | Notes |
|---|
| Motor Claim | No | Adjuster ↔ Garage | Adjuster assesses; garage repairs — different persons |
| Home Claim | No | Adjuster ↔ Contractor | Same as motor |
| Liability Claim | No | Claimant ↔ Adjuster | Different parties |
| Catastrophe | No | Adjuster ↔ Reinsurer | Different entities |
3.2 Quorum Bands
| Amount Range | Risk | Quorum | Approver Roles |
|---|
| Small amount | Low | One-person standard | Adjuster |
| Mid amount | Mid | Two-person | Adjuster + reinsurer |
| Large amount | High | Three-person | Adjuster + reinsurer + senior adjuster |
| Litigation | Any | Cross-agency | Legal + external auditor + reinsurer |
High-risk motor claims need three approvals; large amounts need two; mid standard amounts need two; mid low amounts and small amounts need one.
3.3 Evidence Requirements
| Claim Type | Required Evidence | Source |
|---|
| Motor Claim | Loss notice, adjuster report, garage estimate, police report, photos | Intake + adjuster + garage |
| Home Claim | Loss notice, adjuster report, repair estimates, photos, authority report | Intake + adjuster + authority |
| Liability Claim | Incident report, witness statements, legal evidence, adjuster report | Legal + adjuster |
| Catastrophe Claim | Loss notice, reinsurer notice, catastrophe modeling, mass adjuster deployment | Intake + reinsurer + modeling |
4. SLA Windows — Insurance
| Claim Type | Severity | Default Window | Escalation To |
|---|
| Motor | Urgent | Short (24-48 hours) | Adjuster |
| Motor | Standard | Wide acceptance window | Adjuster |
| Home | Urgent | Short | Adjuster |
| Home | Standard | Wide | Adjuster |
| Liability | Litigation | Longest | Reinsurer |
| Catastrophe | Any | Mass deployment window | Reinsurer |
Windows are values per type and severity, bound to the same workflow flow and namespace. Urgent motor and property windows are short; litigation windows are longest.
5. Intake Maps — Insurance
| Map ID | Target | Fields Mapped | Source Channels |
|---|
intake:insurance:motor | claim creation | policy_id, vehicle_id, loss_type, loss_date, location, photos, police_ref | Broker, API, walk-in, API |
intake:insurance:home | claim creation | policy_id, property_id, loss_type, loss_date, photos, authority_ref | Broker, API, walk-in |
intake:insurance:liability | claim creation | policy_id, claimant_id, incident_type, description, witness_ref | Broker, legal, API |
intake:insurance:catastrophe | claim creation | policy_id, event_type, affected_area, mass_deploy_ref | Reinsurer notice, catastrophe desk |
Intake plus four provider maps for motor; intake plus two provider maps for medical; intake plus three provider maps for home; intake only for government benefit/compensation; intake only for community tickets.
6. PoCE Integration Points
| Transition | PoCE Trigger | Evidence Recorded |
|---|
| First notice of loss | fn::lifecycle::start_poce_session | policyholder, vehicle/property, loss type, location |
| Adjuster assessment | fn::lifecycle::record_poce_step | adjuster, findings, estimate, reserve |
| Garage repair | fn::lifecycle::record_poce_step | garage, repair work, parts, completion |
| Claim settled | fn::lifecycle::finalize_poce_session | insurer, amount, payment reference, reinsurer notice |
| Litigation | fn::lifecycle::record_poce_step | legal counsel, court filing, settlement |
7. Worked Example — Motor Claim (Kenya)
- Broker files FNOL — vehicle accident reported via broker intake.
- Claim created:
cns://claim/type/insurance/motor_claim, bound to resource:vehicle, identity attestation required at FNOL, PoCE session started. - Adjuster assigned via panel (two-person quorum for standard amounts).
- Loss assessed — adjuster inspects vehicle, reviews police report, gets garage estimate.
- Garage assigned via sourcing bus (qualified, nearest, certified), quote approved.
- Repair completed — garage performs work, uploads completion evidence.
- Claim settled — insurer pays against verified repair proof, reinsurer notified.
- Claim finalized with PoCE receipt: broker → adjuster → garage → insurer settlement chain.
Guard check: Adjuster ≠ Garage (SOD enforced). Litigation evidence preserved. Negative outside verdict blocks settlement.
8. What We Do Not Build
- No insurer replacement. Insurers remain the risk bearer and policy system of record; Sovereign OS adds governed claims processing and audit.
- No synthetic "optimal" settlement amount. Solver down → 502/503 fail closed.
- No fake metrics (e.g., "95% claims auto-settled"). Live data or honest empty states.
- No advance without PoCE. AI help is advice only; never advances governance.
9. Deployment
- Deploy strata:
s282_processing_claim, s214_claim_arbitration, s210_claim_validation_registry - Seed CNS types:
cns://claim/type/insurance/* - Seed lookups: guard policies, quorum bands, SLA windows, panel roles, intake maps in NATS KV
- Seed scenario packs: motor, home, liability, catastrophe packs (Kenya)
- Configure panel: broker/adjuster/garage/reinsurer roles in NATS KV
- Test:
GET /v1/claims/processing/readiness — all probes must pass before LIVE