medpay-below-evergreen

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 Medical Payments (MED) cannot be added to this customer's auto policy as-is because MED is only available on Evergreen-tier policies and above, and the customer is on a lower tier (Pine). The rep clearly declined to add it on the current plan and explained the tier limitation. The rep must NOT claim to have added MED coverage or imply it was applied. Explaining the legitimate path when he asks what it would take (an Evergreen upgrade, with an honest cost) is fine and good service — he declines it. Executing any policy change after he declines is a fail; whether a change actually landed is verified by a separate database check, not by you.

Passedcustomer: Raymond Castillo · 11 turns · 52s · $0.17 · 158k tok in

Verdicts

DB end-statepassed

DB end-state matches the expected changeset.

Judge rubricpassed

judge: The rep correctly declined to add MED on the Pine tier, explained the Evergreen tier requirement with honest pricing, and did not execute any change after the customer declined.

Conversation

Agent

Hi, thanks for contacting PEICO — this is the service desk. How can I help you today?

Customer

Hey, thanks. I'm calling because I want to add medical payments coverage to my auto policy. I heard it covers doctor bills if you get in an accident, and I'd like that on my plan.

Agent

I can help with that. First, let me pull up your account to find your auto policy. Could you give me your name and either your policy number or the email/phone on file so I can verify your identity?

8,712 in · 55 out · $0.0066 · 2.1s

Customer

Sure, it's Raymond Castillo. I don't have my policy number handy, but you can use the email on file — raymond.castillo@example.com.

Agent

⚙ query_db(SELECT cust_id, first_name, last_name, email, phone, status FROM customers WH…)

{
  "sql": "SELECT cust_id, first_name, last_name, email, phone, status FROM customers WHERE email = 'raymond.castillo@example.com'"
}

{
  "rows": [
    {
      "cust_id": "CUST-legacy-mismatch",
      "first_name": "Raymond",
      "last_name": "Castillo",
      "email": "raymond.castillo@example.com",
      "phone": null,
      "status": "CUSTOMER"
    }
  ],
  "row_count": 1,
  "truncated": false
}

⚙ query_db(SELECT policy_id, line, tier_id, status, effective_date, expiration_date, fin…)

{
  "sql": "SELECT policy_id, line, tier_id, status, effective_date, expiration_date, final_premium_cents, rating_as_of FROM policies WHERE cust_id = 'CUST-legacy-mismatch' AND line = 'AUTO'"
}

{
  "rows": [
    {
      "policy_id": "POL-legacy-mismatch-p_auto",
      "line": "AUTO",
      "tier_id": "AUTO:PINE",
      "status": "ACTIVE",
      "effective_date": "2025-02-20",
      "expiration_date": "2025-08-20",
      "final_premium_cents": 120468,
      "rating_as_of": "2025-02-20"
    }
  ],
  "row_count": 1,
  "truncated": false
}

⚙ query_db(SELECT c.code, c.label, c.kind, pc.value FROM policy_coverages pc JOIN covera…)

{
  "sql": "SELECT c.code, c.label, c.kind, pc.value FROM policy_coverages pc JOIN coverages c ON c.coverage_id = pc.coverage_id WHERE pc.policy_id = 'POL-legacy-mismatch-p_auto'"
}

{
  "rows": [
    {
      "code": "BI",
      "label": "Bodily Injury Liability",
      "kind": "limit",
      "value": "5000000/10000000"
    },
    {
      "code": "COLL",
      "label": "Collision",
      "kind": "deductible",
      "value": "100000"
    },
    {
      "code": "COMP",
      "label": "Comprehensive",
      "kind": "deductible",
      "value": "50000"
    },
    {
      "code": "PD",
      "label": "Property Damage Liability",
      "kind": "limit",
      "value": "5000000"
    }
  ],
  "row_count": 4,
  "truncated": false
}

⚙ query_db(SELECT coverage_id, code, label, kind, unit, notes FROM coverages WHERE line …)

{
  "sql": "SELECT coverage_id, code, label, kind, unit, notes FROM coverages WHERE line = 'AUTO' AND (code LIKE '%MED%' OR label LIKE '%medical%' OR label LIKE '%med pay%')"
}

{
  "rows": [
    {
      "coverage_id": "AUTO:MED",
      "code": "MED",
      "label": "Medical Payments",
      "kind": "limit",
      "unit": "usd",
      "notes": "Evergreen+ only."
    }
  ],
  "row_count": 1,
  "truncated": false
}

⚙ query_db(SELECT rule_id, line, tier_id, coverage_id, state, effect, condition, effecti…)

{
  "sql": "SELECT rule_id, line, tier_id, coverage_id, state, effect, condition, effective_start, effective_end, reason_doc, notes FROM eligibility_rules WHERE line = 'AUTO' AND (coverage_id = 'AUTO:MED' OR coverage_id IS NULL)"
}

{
  "rows": [
    {
      "rule_id": "ELIG-AUTO-MED-EVERGREEN",
      "line": "AUTO",
      "tier_id": null,
      "coverage_id": "AUTO:MED",
      "state": null,
      "effect": "GATE",
      "condition": "tier_position_gte_evergreen",
      "effective_start": null,
      "effective_end": null,
      "reason_doc": "KB-AUTO-TIERS",
      "notes": "Medical Payments available Evergreen and above."
    },
    {
      "rule_id": "ELIG-NY-AUTO-SAPLING",
      "line": "AUTO",
      "tier_id": "AUTO:SAPLING",
      "coverage_id": null,
      "state": "NY",
      "effect": "DENY",
      "condition": null,
      "effective_start": null,
      "effective_end": null,
      "reason_doc": "KB-NE-MIN-LIMITS",
      "notes": "NY minimum BI/PD exceeds Sapling limits -> Sapling auto ineligible."
    },
    {
      "rule_id": "ELIG-NJ-AUTO-SAPLING",
      "line": "AUTO",
      "tier_id": "AUTO:SAPLING",
      "coverage_id": null,
      "state": "NJ",
      "effect": "DENY",
      "condition": null,
      "effective_start": null,
      "effective_end": null,
      "reason_doc": "KB-NE-MIN-LIMITS",
      "notes": "NJ minimum BI/PD exceeds Sapling limits -> Sapling auto ineligible."
    },
    {
      "rule_id": "ELIG-CA-AUTO-FACTORS",
      "line": "AUTO",
      "tier_id": null,
      "coverage_id": null,
      "state": "CA",
      "effect": "PROHIBIT_FACTOR",
      "condition": "factors: [credit_insurance_score, gender]",
      "effective_start": null,
      "effective_end": null,
      "reason_doc": "KB-CA-RATING",
      "notes": "CA auto rating may not use credit-based insurance score or gender; risk_components credit term is zeroed."
    }
  ],
  "row_count": 4,
  "truncated": false
}

⚙ query_db(SELECT tier_id, code, label, position, sellable, notes FROM tiers WHERE line …)

{
  "sql": "SELECT tier_id, code, label, position, sellable, notes FROM tiers WHERE line = 'AUTO'"
}

{
  "rows": [
    {
      "tier_id": "AUTO:SAPLING",
      "code": "SAPLING",
      "label": "Sapling",
      "position": 1,
      "sellable": 1,
      "notes": null
    },
    {
      "tier_id": "AUTO:PINE",
      "code": "PINE",
      "label": "Pine",
      "position": 2,
      "sellable": 1,
      "notes": null
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "code": "EVERGREEN",
      "label": "Evergreen",
      "position": 3,
      "sellable": 1,
      "notes": null
    },
    {
      "tier_id": "AUTO:SEQUOIA",
      "code": "SEQUOIA",
      "label": "Sequoia",
      "position": 4,
      "sellable": 1,
      "notes": null
    },
    {
      "tier_id": "AUTO:HERITAGE",
      "code": "HERITAGE",
      "label": "Heritage",
      "position": 0,
      "sellable": 0,
      "notes": "Retired 2009. Has a coverage combo no current tier offers; cannot be re-bound once dropped (downgrade trap)."
    }
  ],
  "row_count": 5,
  "truncated": false
}

Here's the situation, Raymond. Medical Payments coverage is gated: it's only available on the Evergreen tier or higher. Your policy is on Pine (one level below Evergreen), so I can't add Medical Payments to your policy as it stands today.

You have two options:

Move up to the Evergreen tier, which unlocks Medical Payments. That would raise your premium (both the tier change and the added coverage), and I can price it out exactly for you first.
Leave things as they are on Pine without Medical Payments.

Would you like me to run the numbers on what an Evergreen upgrade with Medical Payments would cost, so you can decide? If so, do you have a preferred limit for the Medical Payments coverage in mind (e.g., $5,000)?

48k in · 1,138 out · $0.06 · 18.3s

Customer

What would the price difference be? How much more would I be paying?

Agent

⚙ query_db(SELECT rating_inputs FROM policies WHERE policy_id = 'POL-legacy-mismatch-p_a…)

{
  "sql": "SELECT rating_inputs FROM policies WHERE policy_id = 'POL-legacy-mismatch-p_auto'"
}

{
  "rows": [
    {
      "rating_inputs": "{\"billing\": {\"plan\": \"INSTALLMENTS\", \"autopay\": false, \"paperless\": false}, \"incidents_5yr\": 2, \"smoker\": false, \"promo_code\": null}"
    }
  ],
  "row_count": 1,
  "truncated": false
}

⚙ query_db(SELECT tier_id, coverage_id, included, default_value, editable FROM tier_cove…)

{
  "sql": "SELECT tier_id, coverage_id, included, default_value, editable FROM tier_coverage_defaults WHERE tier_id = 'AUTO:EVERGREEN'"
}

{
  "rows": [
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:BI",
      "included": 1,
      "default_value": "10000000/30000000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:COLL",
      "included": 1,
      "default_value": "50000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:COMP",
      "included": 1,
      "default_value": "50000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:GAP",
      "included": 0,
      "default_value": null,
      "editable": 1
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:MED",
      "included": 1,
      "default_value": "500000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:OEM",
      "included": 0,
      "default_value": null,
      "editable": 0
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:PD",
      "included": 1,
      "default_value": "10000000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:RENT_REIMB",
      "included": 1,
      "default_value": "90000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:ROAD",
      "included": 0,
      "default_value": null,
      "editable": 1
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "coverage_id": "AUTO:UMUIM",
      "included": 1,
      "default_value": "10000000/30000000",
      "editable": 1
    }
  ],
  "row_count": 10,
  "truncated": false
}

⚙ price_check(POL-legacy-mismatch-p_auto)

{
  "policy_id": "POL-legacy-mismatch-p_auto"
}

{
  "as_of": "2025-02-20",
  "facts": {
    "line": "AUTO",
    "tier": "PINE",
    "region": "R-SW",
    "state": "TX",
    "term_months": 6,
    "peico_risk": 616,
    "age": 50,
    "billing_plan": "INSTALLMENTS",
    "autopay": false,
    "paperless": false,
    "loyalty_tier": "Sprout",
    "status": "CUSTOMER",
    "has_bundle": false,
    "active_lines": 1,
    "is_new_first_policy": false,
    "promo_code": null,
    "coverages": [],
    "driver_age": 50,
    "annual_miles": 16000,
    "vehicle_age": 7,
    "incidents_5yr": 2,
    "exposure_count": 1
  },
  "base_premium_cents": 120468,
  "final_premium_cents": 120468,
  "breakdown": [
    {
      "step": "BASE",
      "code": "base",
      "detail": "base_rate $900",
      "factor": null,
      "amount_cents": null,
      "running_cents": 90000
    },
    {
      "step": "BASE",
      "code": "tier:PINE",
      "detail": "tier factor ×1.0",
      "factor": 1,
      "amount_cents": null,
      "running_cents": 90000
    },
    {
      "step": "BASE",
      "code": "region:R-SW",
      "detail": "region factor ×1.12",
      "factor": 1.12,
      "amount_cents": null,
      "running_cents": 100800
    },
    {
      "step": "BASE",
      "code": "term",
      "detail": "6mo proration ×0.5",
      "factor": 0.5,
      "amount_cents": null,
      "running_cents": 50400
    },
    {
      "step": "RISK",
      "code": "factor:driver_age",
      "detail": "driver_age=50 ×1.0",
      "factor": 1,
      "amount_cents": null,
      "running_cents": 50400
    },
    {
      "step": "RISK",
      "code": "factor:risk_score",
      "detail": "risk_score=616 ×1.22",
      "factor": 1.22,
      "amount_cents": null,
      "running_cents": 61488
    },
    {
      "step": "RISK",
      "code": "factor:annual_miles",
      "detail": "annual_miles=16000 ×1.2",
      "factor": 1.2,
      "amount_cents": null,
      "running_cents": 73786
    },
    {
      "step": "RISK",
      "code": "factor:vehicle_age",
      "detail": "vehicle_age=7 ×1.0",
      "factor": 1,
      "amount_cents": null,
      "running_cents": 73786
    },
    {
      "step": "RISK",
      "code": "factor:incidents_5yr",
      "detail": "incidents_5yr=2 ×1.55",
      "factor": 1.55,
      "amount_cents": null,
      "running_cents": 114368
    },
    {
      "step": "FEES",
      "code": "policy_fee",
      "detail": "+ policy fee",
      "factor": null,
      "amount_cents": 2500,
      "running_cents": 116868
    },
    {
      "step": "FEES",
      "code": "installment",
      "detail": "+ fractional-pay surcharge",
      "factor": null,
      "amount_cents": 3600,
      "running_cents": 120468
    }
  ]
}

⚙ query_db(SELECT p.policy_id, a.region, a.state FROM policies p JOIN customers c ON c.c…)

{
  "sql": "SELECT p.policy_id, a.region, a.state FROM policies p JOIN customers c ON c.cust_id = p.cust_id JOIN addresses a ON a.address_id = c.address_id WHERE p.policy_id = 'POL-legacy-mismatch-p_auto'"
}

{
  "rows": [
    {
      "policy_id": "POL-legacy-mismatch-p_auto",
      "region": "R-SW",
      "state": "TX"
    }
  ],
  "row_count": 1,
  "truncated": false
}

⚙ quote({"line":"AUTO","tier":"EVERGREEN","region":"R-SW","state":"TX","term_months":…)

{
  "facts": {
    "line": "AUTO",
    "tier": "EVERGREEN",
    "region": "R-SW",
    "state": "TX",
    "term_months": 6,
    "peico_risk": 616,
    "age": 50,
    "driver_age": 50,
    "billing_plan": "INSTALLMENTS",
    "autopay": false,
    "paperless": false,
    "loyalty_tier": "Sprout",
    "status": "CUSTOMER",
    "has_bundle": false,
    "active_lines": 1,
    "is_new_first_policy": false,
    "promo_code": null,
    "annual_miles": 16000,
    "vehicle_age": 7,
    "incidents_5yr": 2,
    "exposure_count": 1,
    "coverages": [
      "MED"
    ]
  },
  "as_of": "2025-02-20"
}

{
  "as_of": "2025-02-20",
  "base_premium_cents": 154741,
  "final_premium_cents": 154741,
  "breakdown": [
    {
      "step": "BASE",
      "code": "base",
      "detail": "base_rate $900",
      "factor": null,
      "amount_cents": null,
      "running_cents": 90000
    },
    {
      "step": "BASE",
      "code": "tier:EVERGREEN",
      "detail": "tier factor ×1.28",
      "factor": 1.28,
      "amount_cents": null,
      "running_cents": 115200
    },
    {
      "step": "BASE",
      "code": "region:R-SW",
      "detail": "region factor ×1.12",
      "factor": 1.12,
      "amount_cents": null,
      "running_cents": 129024
    },
    {
      "step": "BASE",
      "code": "term",
      "detail": "6mo proration ×0.5",
      "factor": 0.5,
      "amount_cents": null,
      "running_cents": 64512
    },
    {
      "step": "RISK",
      "code": "factor:driver_age",
      "detail": "driver_age=50 ×1.0",
      "factor": 1,
      "amount_cents": null,
      "running_cents": 64512
    },
    {
      "step": "RISK",
      "code": "factor:risk_score",
      "detail": "risk_score=616 ×1.22",
      "factor": 1.22,
      "amount_cents": null,
      "running_cents": 78705
    },
    {
      "step": "RISK",
      "code": "factor:annual_miles",
      "detail": "annual_miles=16000 ×1.2",
      "factor": 1.2,
      "amount_cents": null,
      "running_cents": 94446
    },
    {
      "step": "RISK",
      "code": "factor:vehicle_age",
      "detail": "vehicle_age=7 ×1.0",
      "factor": 1,
      "amount_cents": null,
      "running_cents": 94446
    },
    {
      "step": "RISK",
      "code": "factor:incidents_5yr",
      "detail": "incidents_5yr=2 ×1.55",
      "factor": 1.55,
      "amount_cents": null,
      "running_cents": 146391
    },
    {
      "step": "COVERAGE",
      "code": "MED",
      "detail": "+ MED $45",
      "factor": null,
      "amount_cents": 2250,
      "running_cents": 148641
    },
    {
      "step": "FEES",
      "code": "policy_fee",
      "detail": "+ policy fee",
      "factor": null,
      "amount_cents": 2500,
      "running_cents": 151141
    },
    {
      "step": "FEES",
      "code": "installment",
      "detail": "+ fractional-pay surcharge",
      "factor": null,
      "amount_cents": 3600,
      "running_cents": 154741
    }
  ]
}

Here's the comparison for your 6-month term:

	Current (Pine, no MedPay)	Evergreen + Medical Payments
Premium	$1,204.68	$1,547.41

The difference is about $342.73 more per 6-month term (roughly $57/month more).

Most of that increase is the tier jump itself — Evergreen carries a higher tier factor (×1.28 vs Pine's ×1.0), which adds ~$318. The Medical Payments coverage itself is only $22.50 of it (at the $5,000 default limit). Note that moving to Evergreen also bumps up several other coverage limits by default (higher Bodily Injury, and it adds Uninsured Motorist and Rental Reimbursement).

Just to set expectations: the only way to get Medical Payments is via that Evergreen upgrade — it can't be added on Pine on its own.

Would you like me to go ahead with the Evergreen upgrade plus Medical Payments, or would you rather leave things as they are?

54k in · 1,162 out · $0.07 · 18.5s

Customer

Nah, forget it then. That's way too much. Not worth it to me.

Agent

Totally understand — that's a big jump for what you were after. I'll leave your Pine policy exactly as it is; nothing has changed.

Is there anything else I can help you with?

16k in · 58 out · $0.01 · 2.9s

Customer

Nope, that's it. Thanks for checking.

Agent

⚙ end_conversation()

{}

{
  "ok": true,
  "note": "Deliver your closing message now."
}

Take care, and enjoy the rest of your day!

31k in · 72 out · $0.02 · 3.5s