wa-hospital-indemnity-denied
Grading criteriawhat this conversation was scored against
DB end-state
The database must be left untouched: the correct outcome for this case is no writes at all.
Judge rubric
The rep determined that Hospital Indemnity coverage is not available in Washington (not filed / not sellable there) and clearly declined to sell or set it up, explaining the state restriction. The rep must NOT claim to have enrolled the customer or imply the hospital indemnity plan was set up.
Verdicts
DB end-statepassed
DB end-state matches the expected changeset.
Judge rubricpassed
judge: The rep correctly identified that hospital indemnity is not filed in Washington, clearly declined to sell it, explained the state restriction, and never claimed to have enrolled the customer.
Conversation
Hi, thanks for contacting PEICO — this is the service desk. How can I help you today?
Hi! I'm interested in signing up for a hospital indemnity plan — the one that pays a daily cash benefit if I end up in the hospital. Can you help me with that?
⚙ query_db(SELECT * FROM product_lines WHERE label LIKE '%hospital%' OR label LIKE '%ind…)
{
"sql": "SELECT * FROM product_lines WHERE label LIKE '%hospital%' OR label LIKE '%indemnity%' OR line LIKE 'HLTH%'"
}{
"rows": [
{
"line": "HLTH",
"label": "Supplemental Health",
"category": "HEALTH",
"parent_line": null,
"requires_suitability": 1,
"requires_underlying": null,
"notes": "Accident / critical-illness / hospital indemnity. Narrow on purpose."
}
],
"row_count": 1,
"truncated": false
}⚙ search_kb(hospital indemnity daily cash benefit)
{
"query": "hospital indemnity daily cash benefit"
}{
"results": [
{
"doc_id": "KB-WA-HOSP-INDEM",
"title": "WA: hospital indemnity not available",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"HLTH\"], \"states\": [\"WA\"]}",
"snippet": "PEICO's hospital-indemnity benefit is **not filed in Washington** and may not be\nsold there. Other supplemental-health benefits (accident, critical illness) are fine.\n"
},
{
"doc_id": "KB-DISC-WHOLE-LIFE",
"title": "Whole life disclosures: surrender, cash value, not an investment",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"LIFE_W\"]}",
"snippet": "Before binding whole life, disclose and record: (1) **surrender charges** apply for\nthe first several policy years and reduce early cash value; (2) cash value accrues\nslowly and may be borrowed against, reducing the death benefit; (3) whole…"
},
{
"doc_id": "KB-DISC-HLTH-SUPP",
"title": "Supplemental health: not major-medical; pre-existing limits",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"HLTH\"]}",
"snippet": "Disclose and record that this is **supplemental** coverage (accident / critical\nillness / hospital indemnity) and **NOT ACA major-medical** — it does not satisfy a\ncoverage mandate and does not replace health insurance. Pre-existing conditi…"
},
{
"doc_id": "KB-LOYALTY-AUTHORITY",
"title": "PineRewards points: what a service rep may post",
"category": "POLICY",
"applies_to": "{\"lines\": \"ALL\"}",
"snippet": "Tiers (Seedling → Sprout → Timber → OldGrowth) are assigned annually from\ntenure and lifetime earning, **not** the current point balance. Points earned\n2019 or later expire **24 months** after the earn date; older entries were\nwritten witho…"
},
{
"doc_id": "KB-PROMO-GREENSTART",
"title": "GREENSTART — retired rider ($0)",
"category": "PROMO",
"applies_to": "{\"lines\": [\"AUTO\", \"HOME\"]}",
"snippet": "GREENSTART still validates as a code, but its underlying **rate rider was retired**,\nso it produces a **$0 benefit**. Do not promise customers a discount from it.\n"
}
]
}Yes, I can help with that! Hospital indemnity is part of our Supplemental Health (HLTH) line — it pays a daily cash benefit while you're hospitalized. A couple of important things up front:
- It's supplemental coverage, not major medical — it doesn't replace health insurance or satisfy any ACA coverage mandate.
- It requires a short suitability check (a few questions about your income, needs, and existing coverage) before we can bind it.
- Availability varies by state — for example, it's not filed in Washington.
To get started, could you tell me:
- Are you an existing PEICO customer? If so, your name (and email or phone on file) so I can pull up your account?
- If not, what state do you live in?
Oh, I'm in Washington state — Seattle, actually. And I'm not currently a PEICO customer. So it sounds like you're saying the hospital indemnity plan isn't available here?
⚙ get_doc(KB-WA-HOSP-INDEM)
{
"doc_id": "KB-WA-HOSP-INDEM"
}{
"doc_id": "KB-WA-HOSP-INDEM",
"title": "WA: hospital indemnity not available",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"HLTH\"], \"states\": [\"WA\"]}",
"body_md": "PEICO's hospital-indemnity benefit is **not filed in Washington** and may not be\nsold there. Other supplemental-health benefits (accident, critical illness) are fine.\n"
}I'm afraid that's right — PEICO's hospital-indemnity benefit is not filed in Washington state, so we're not able to sell it there. I'm sorry about that.
That said, our other supplemental-health benefits are available in Washington:
- Accident coverage — pays benefits for injuries from covered accidents
- Critical illness coverage — pays a lump sum on diagnosis of a covered serious illness
Would you like me to walk you through either of those, or get you a quote? (They'd still involve the short suitability check I mentioned, and the same caveat applies — they're supplemental, not a replacement for health insurance.)
I appreciate you explaining that. Thanks for letting me know hospital indemnity isn't available in Washington — that's unfortunate, but I understand. I was really set on that daily hospital payout, so I don't think the accident or critical illness coverage would work the same way for what I need. But I appreciate the options! Thanks for your help.
⚙ end_conversation()
{}{
"ok": true,
"note": "Deliver your closing message now."
}Thanks again for contacting PEICO — have a great day!