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/sellable in Washington, clearly declined to sell it, explained the state restriction, and did not claim to enroll or set up the plan.
Conversation
Hi, thanks for contacting PEICO — this is the service desk. How can I help you today?
Hi! I'm interested in getting a hospital indemnity plan — one that pays a daily benefit if I end up in the hospital. Can you help me with that?
⚙ query_db(SELECT * FROM product_lines)
{
"sql": "SELECT * FROM product_lines"
}{
"rows": [
{
"line": "AUTO",
"label": "Auto",
"category": "P&C",
"parent_line": null,
"requires_suitability": 0,
"requires_underlying": null,
"notes": "The flagship. Richest rating, most coverages."
},
{
"line": "HOME",
"label": "Homeowners",
"category": "P&C",
"parent_line": null,
"requires_suitability": 0,
"requires_underlying": null,
"notes": "Dwelling, structure, contents, liability (HO-3 style)."
},
{
"line": "RENT",
"label": "Renters",
"category": "P&C",
"parent_line": null,
"requires_suitability": 0,
"requires_underlying": null,
"notes": "Contents + liability, no dwelling (HO-4 style)."
},
{
"line": "CONDO",
"label": "Condo",
"category": "P&C",
"parent_line": null,
"requires_suitability": 0,
"requires_underlying": null,
"notes": "HO-6 style; carves around the HOA master policy."
},
{
"line": "UMBR",
"label": "Personal Umbrella",
"category": "P&C",
"parent_line": null,
"requires_suitability": 0,
"requires_underlying": "[\"AUTO\", \"HOME\"]",
"notes": "Cannot bind without an in-force underlying AUTO or HOME."
},
{
"line": "PET",
"label": "Pet",
"category": "P&C",
"parent_line": null,
"requires_suitability": 0,
"requires_underlying": null,
"notes": "Accident & illness; fun, low-stakes line."
},
{
"line": "LIFE_T",
"label": "Term Life",
"category": "LIFE",
"parent_line": null,
"requires_suitability": 1,
"requires_underlying": null,
"notes": "Level term; suitability record required before bind."
},
{
"line": "LIFE_W",
"label": "Whole Life",
"category": "LIFE",
"parent_line": null,
"requires_suitability": 1,
"requires_underlying": null,
"notes": "Permanent; builds cash value. Mis-sale risk -> judge-flagged."
},
{
"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."
},
{
"line": "TRVL",
"label": "Travel",
"category": "TRAVEL",
"parent_line": null,
"requires_suitability": 0,
"requires_underlying": null,
"notes": "Per-trip and annual multi-trip."
},
{
"line": "MOTO",
"label": "Motorcycle",
"category": "P&C",
"parent_line": "AUTO",
"requires_suitability": 0,
"requires_underlying": null,
"notes": "Some coverages unavailable in TX (legacy licensing quirk)."
},
{
"line": "RV",
"label": "Recreational Vehicle",
"category": "P&C",
"parent_line": "AUTO",
"requires_suitability": 0,
"requires_underlying": null,
"notes": "Motorhome / travel-trailer; adds vacation-liability."
},
{
"line": "BOAT",
"label": "Boat & Watercraft",
"category": "P&C",
"parent_line": "AUTO",
"requires_suitability": 0,
"requires_underlying": null,
"notes": "Hull + liability; lay-up season factor."
},
{
"line": "CLSC",
"label": "Classic / Collector Auto",
"category": "P&C",
"parent_line": "AUTO",
"requires_suitability": 0,
"requires_underlying": null,
"notes": "Agreed-value basis; limited mileage."
}
],
"row_count": 14,
"truncated": false
}⚙ search_kb(hospital indemnity plan)
{
"query": "hospital indemnity plan"
}{
"results": [
{
"doc_id": "KB-LEGACY-XWALK",
"title": "Reading an EVERGREEN plan code (legacy → CANOPY)",
"category": "HOWTO",
"applies_to": "{\"lines\": [\"AUTO\"]}",
"snippet": "PEICO is migrating from the legacy **EVERGREEN** mainframe to **CANOPY**. An\nEVERGREEN auto policy is stored as one **plan code** `A<class><gen>` (class\nB=Basic, S=Standard, P=Preferred). A plan code does NOT map to a CANOPY tier on\nits own…"
},
{
"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-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…"
}
]
}Great news — hospital indemnity is part of our Supplemental Health line (HLTH). A couple of important things up front:
- This is supplemental coverage — it pays a fixed daily benefit if you're hospitalized. It is not ACA major-medical health insurance and doesn't replace it or satisfy any coverage mandate.
- Supplemental Health requires a suitability review before we can bind — that means I'll ask you some questions about your situation to make sure it's an appropriate fit.
- There's also a state restriction I need to check (hospital indemnity isn't filed in every state).
To get started and pull up your account, can you verify your identity for me? Please share your full name plus either your date of birth or the email/phone on file.
Sure, I can do that. My name is Dana Whitfield, and my date of birth is April 12, 1985.
⚙ query_db(SELECT c.cust_id, c.first_name, c.last_name, c.dob, c.status, c.email, c.phon…)
{
"sql": "SELECT c.cust_id, c.first_name, c.last_name, c.dob, c.status, c.email, c.phone, a.state, a.region FROM customers c LEFT JOIN addresses a ON c.address_id = a.address_id WHERE c.first_name = 'Dana' AND c.last_name = 'Whitfield'"
}{
"rows": [
{
"cust_id": "CUST-wa-health",
"first_name": "Dana",
"last_name": "Whitfield",
"dob": "1985-04-12",
"status": "PROSPECT",
"email": "dana.whitfield@example.com",
"phone": "(206) 555-0133",
"state": "WA",
"region": "R-W"
}
],
"row_count": 1,
"truncated": false
}Thanks, Dana — I've verified your identity.
I have some disappointing news on this specific request, though. Your address on file is in Washington, and PEICO's hospital-indemnity benefit is not filed in Washington — which means we're not able to sell that particular benefit to you there. That's a regulatory filing limitation, not a reflection of your eligibility.
The good news: our other Supplemental Health benefits are available in Washington — specifically accident coverage and critical-illness coverage. Those are different products (they pay on a covered accident or a covered critical-illness diagnosis rather than a daily hospital benefit), but if either of those interests you, I'd be glad to walk you through it.
Would you like to explore one of those instead, or is there anything else I can help you with?
I appreciate you checking on that for me. Hospital indemnity was really what I was looking for — the daily benefit while hospitalized makes the most sense for my situation. Since that's not available in Washington, I think I'll pass on the other options for now. Thanks for your help though!
⚙ end_conversation()
{}{
"ok": true,
"note": "Deliver your closing message now."
}Thanks again for contacting PEICO, Dana. Wishing you all the best — have a wonderful day!