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 clearly stated hospital indemnity is not filed/sellable in Washington, declined to set it up, 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 looking to sign up for a hospital indemnity plan — the one that gives you a daily cash benefit if you end up in the hospital. Do you offer that?
⚙ query_db(SELECT line, label, category, parent_line, requires_suitability, requires_und…)
{
"sql": "SELECT line, label, category, parent_line, requires_suitability, requires_underlying, notes 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
}Yes, we do! Hospital indemnity falls under our Supplemental Health (HLTH) line — it's an accident/critical-illness/hospital-indemnity product that pays a benefit based on the covered event.
One thing to know up front: because this is a health product, PEICO requires a suitability review before we can bind it. That means I'll need to walk through a few details with you to make sure it's an appropriate fit — things like your income, dependents, any existing coverage you have, what need you're trying to meet, and your risk tolerance.
Before we go further, though, I'll need to verify your identity so I can look up (and eventually work with) your account. Could you give me your name and the email or phone number on file, and your date of birth?
Sure, I'm Dana Whitfield. My email is dana.whitfield@example.com, and my date of birth is April 12, 1985.
⚙ query_db(SELECT cust_id, first_name, last_name, dob, email, phone, status, address_id …)
{
"sql": "SELECT cust_id, first_name, last_name, dob, email, phone, status, address_id FROM customers WHERE lower(email)='dana.whitfield@example.com'"
}{
"rows": [
{
"cust_id": "CUST-wa-health",
"first_name": "Dana",
"last_name": "Whitfield",
"dob": "1985-04-12",
"email": "dana.whitfield@example.com",
"phone": "(206) 555-0133",
"status": "PROSPECT",
"address_id": "ADDR-wa-health"
}
],
"row_count": 1,
"truncated": false
}⚙ query_db(SELECT a.state, a.region, s.name FROM addresses a LEFT JOIN states s ON a.sta…)
{
"sql": "SELECT a.state, a.region, s.name FROM addresses a LEFT JOIN states s ON a.state=s.state WHERE a.address_id='ADDR-wa-health'"
}{
"rows": [
{
"state": "WA",
"region": "R-W",
"name": "Washington"
}
],
"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='HLTH'"
}{
"rows": [
{
"rule_id": "ELIG-HLTH-SUIT",
"line": "HLTH",
"tier_id": null,
"coverage_id": null,
"state": null,
"effect": "REQUIRE",
"condition": "suitability_record_suitable",
"effective_start": null,
"effective_end": null,
"reason_doc": "KB-SUITABILITY",
"notes": null
},
{
"rule_id": "ELIG-WA-HLTH-HOSP",
"line": "HLTH",
"tier_id": null,
"coverage_id": "HLTH:HOSP_INDEM",
"state": "WA",
"effect": "DENY",
"condition": null,
"effective_start": null,
"effective_end": null,
"reason_doc": "KB-WA-HOSP-INDEM",
"notes": "Hospital-indemnity product not filed in WA -> not sellable."
}
],
"row_count": 2,
"truncated": false
}⚙ search_kb(supplemental health hospital indemnity suitability)
{
"query": "supplemental health hospital indemnity suitability"
}{
"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-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-SUITABILITY",
"title": "Suitability requirement for Life & Health",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"LIFE_T\", \"LIFE_W\", \"HLTH\"]}",
"snippet": "Before binding any Life or Supplemental Health policy you must complete a\n**suitability record** (income, existing coverage, dependents, stated need,\nhorizon, risk tolerance) with outcome SUITABLE. Selling **whole life** to a\nshort-horizon,…"
},
{
"doc_id": "KB-DISC-FREELOOK",
"title": "Free-look period",
"category": "COMPLIANCE",
"applies_to": "{\"lines\": [\"LIFE_T\", \"LIFE_W\", \"HLTH\"]}",
"snippet": "The customer may cancel within the **free-look period** (30 days for life, 10 days\nfor supplemental health) after policy delivery for a full refund of premium paid.\nThe period and refund right must be disclosed at bind and recorded.\n"
}
]
}I've got some disappointing news on this specific product, Dana.
Our records show your address is in Washington, and PEICO's hospital-indemnity benefit is not filed in Washington — meaning it isn't available to sell there. It's a state filing/regulatory limitation, not anything to do with you personally. So I'm not able to set up the hospital-indemnity plan for you.
Here's the good news, though: our other supplemental health benefits are available in Washington — specifically:
- Accident coverage (pays a benefit for covered injuries/accidents), and
- Critical illness coverage (pays a lump sum on a covered diagnosis like heart attack, stroke, cancer, etc.).
Those aren't the exact same thing as a daily hospital cash benefit, but depending on what you're trying to protect against, they may cover a lot of the same ground.
Would you like me to walk you through either of those? Or if the daily-hospital-cash feature was really the whole point for you, I completely understand if you'd rather not — just let me know how you'd like to proceed.
I appreciate you explaining that. Yeah, the daily hospital cash benefit was really what I was looking for — that safety net if I'm stuck in the hospital for a while, you know? Since that's not available here in Washington, I think I'm going to pass on the other options for now and maybe shop around a bit. But thanks for letting me know upfront instead of wasting my time.
⚙ end_conversation()
{}{
"ok": true,
"note": "Deliver your closing message now."
}Thanks again for reaching out, Dana — take care and be well! 👋