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 · 10 turns · 48s · $0.09 · 166k tok in

Verdicts

DB end-statepassed

DB end-state matches the expected changeset.

Judge rubricpassed

judge: The rep correctly identified that MED requires Evergreen tier, declined to add it to the Pine plan, explained the tier limitation, provided an honest cost estimate for the upgrade path when asked, and did not claim or imply MED was added 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 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 to have that protection.

Agent

I can help with that. Could you give me your name or customer ID, and the policy number for the auto policy you'd like to update? I'll also need to verify your identity — can you confirm your date of birth?

8,773 in · 62 out · $0.02 · 2.4s

Customer

Sure. Name's Raymond Castillo. My DOB is December 11, 1974. I don't have my policy number handy, but you should be able to pull it up with my name and date of birth.

Agent

⚙ query_db(SELECT cust_id, first_name, last_name, dob, email, phone, status FROM custome…)

{
  "sql": "SELECT cust_id, first_name, last_name, dob, email, phone, status FROM customers WHERE lower(first_name)='raymond' AND lower(last_name)='castillo'"
}

{
  "rows": [
    {
      "cust_id": "CUST-legacy-mismatch",
      "first_name": "Raymond",
      "last_name": "Castillo",
      "dob": "1974-12-11",
      "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 FROM…)

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

{
  "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"
    }
  ],
  "row_count": 1,
  "truncated": false
}

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

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

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

⚙ query_db(SELECT * FROM eligibility_rules WHERE coverage_id='AUTO:MED')

{
  "sql": "SELECT * FROM eligibility_rules WHERE coverage_id='AUTO:MED'"
}

{
  "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."
    }
  ],
  "row_count": 1,
  "truncated": false
}

⚙ get_doc(KB-AUTO-TIERS)

{
  "doc_id": "KB-AUTO-TIERS"
}

{
  "doc_id": "KB-AUTO-TIERS",
  "title": "Auto tiers: Sapling → Pine → Evergreen → Sequoia",
  "category": "POLICY",
  "applies_to": "{\"lines\": [\"AUTO\"]}",
  "body_md": "Tiers bundle coverages. Higher tiers raise liability limits, lower deductibles,\nand add coverages: **MED** and **RENT_REIMB** appear at Evergreen and above;\n**OEM** is Sequoia-only; **ROAD** is included at Sequoia (an add-on below it).\n"
}

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

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

{
  "rows": [
    {
      "tier_id": "AUTO:HERITAGE",
      "line": "AUTO",
      "code": "HERITAGE",
      "label": "Heritage",
      "position": 0,
      "sellable": 0,
      "retired_on": "2009-07-01"
    },
    {
      "tier_id": "AUTO:SAPLING",
      "line": "AUTO",
      "code": "SAPLING",
      "label": "Sapling",
      "position": 1,
      "sellable": 1,
      "retired_on": null
    },
    {
      "tier_id": "AUTO:PINE",
      "line": "AUTO",
      "code": "PINE",
      "label": "Pine",
      "position": 2,
      "sellable": 1,
      "retired_on": null
    },
    {
      "tier_id": "AUTO:EVERGREEN",
      "line": "AUTO",
      "code": "EVERGREEN",
      "label": "Evergreen",
      "position": 3,
      "sellable": 1,
      "retired_on": null
    },
    {
      "tier_id": "AUTO:SEQUOIA",
      "line": "AUTO",
      "code": "SEQUOIA",
      "label": "Sequoia",
      "position": 4,
      "sellable": 1,
      "retired_on": null
    }
  ],
  "row_count": 5,
  "truncated": false
}

Thanks, Raymond — verified. I found your auto policy (POL-legacy-mismatch-p_auto), currently on the Pine tier.

Here's the catch: Medical Payments coverage is only available on Evergreen tier and above (Evergreen, Sequoia). It's not something I can just bolt onto Pine — you'd need to upgrade tiers, which bundles in some other changes too (Evergreen and up also add Rental Reimbursement, for example) and will affect your premium.

Would you like me to:

Quote you what Pine → Evergreen would cost (with Medical Payments included), or
Just check pricing without making any changes yet?

58k in · 934 out · $0.02 · 15.0s

Customer

What would the cost difference be? Just give me a ballpark — I'm not trying to spend a lot more on my premium.

Agent

⚙ query_db(SELECT policy_id, tier_id, rating_inputs, base_premium_cents, final_premium_c…)

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

{
  "rows": [
    {
      "policy_id": "POL-legacy-mismatch-p_auto",
      "tier_id": "AUTO:PINE",
      "rating_inputs": "{\"billing\": {\"plan\": \"INSTALLMENTS\", \"autopay\": false, \"paperless\": false}, \"incidents_5yr\": 2, \"smoker\": false, \"promo_code\": null}",
      "base_premium_cents": 120468,
      "final_premium_cents": 120468
    }
  ],
  "row_count": 1,
  "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 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 IN ('AUTO:PINE','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
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:BI",
      "included": 1,
      "default_value": "5000000/10000000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:COLL",
      "included": 1,
      "default_value": "100000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:COMP",
      "included": 1,
      "default_value": "50000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:GAP",
      "included": 0,
      "default_value": null,
      "editable": 1
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:MED",
      "included": 0,
      "default_value": null,
      "editable": 0
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:OEM",
      "included": 0,
      "default_value": null,
      "editable": 0
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:PD",
      "included": 1,
      "default_value": "5000000",
      "editable": 1
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:RENT_REIMB",
      "included": 0,
      "default_value": null,
      "editable": 0
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:ROAD",
      "included": 0,
      "default_value": null,
      "editable": 1
    },
    {
      "tier_id": "AUTO:PINE",
      "coverage_id": "AUTO:UMUIM",
      "included": 0,
      "default_value": "5000000/10000000",
      "editable": 1
    }
  ],
  "row_count": 20,
  "truncated": false
}

⚙ query_db(SELECT coverage_id, value FROM policy_coverages WHERE policy_id='POL-legacy-m…)

{
  "sql": "SELECT coverage_id, value FROM policy_coverages WHERE policy_id='POL-legacy-mismatch-p_auto'"
}

{
  "rows": [
    {
      "coverage_id": "AUTO:BI",
      "value": "5000000/10000000"
    },
    {
      "coverage_id": "AUTO:COLL",
      "value": "100000"
    },
    {
      "coverage_id": "AUTO:COMP",
      "value": "50000"
    },
    {
      "coverage_id": "AUTO:PD",
      "value": "5000000"
    }
  ],
  "row_count": 4,
  "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,
    "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": [
      "BI",
      "COLL",
      "COMP",
      "PD",
      "MED",
      "RENT_REIMB",
      "UMUIM"
    ],
    "driver_age": 50,
    "annual_miles": 16000,
    "vehicle_age": 7,
    "incidents_5yr": 2,
    "exposure_count": 1
  },
  "as_of": "2025-02-20"
}

{
  "as_of": "2025-02-20",
  "base_premium_cents": 161741,
  "final_premium_cents": 161741,
  "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": "COVERAGE",
      "code": "RENT_REIMB",
      "detail": "+ RENT_REIMB $30",
      "factor": null,
      "amount_cents": 1500,
      "running_cents": 150141
    },
    {
      "step": "COVERAGE",
      "code": "UMUIM",
      "detail": "+ UMUIM $110",
      "factor": null,
      "amount_cents": 5500,
      "running_cents": 155641
    },
    {
      "step": "FEES",
      "code": "policy_fee",
      "detail": "+ policy fee",
      "factor": null,
      "amount_cents": 2500,
      "running_cents": 158141
    },
    {
      "step": "FEES",
      "code": "installment",
      "detail": "+ fractional-pay surcharge",
      "factor": null,
      "amount_cents": 3600,
      "running_cents": 161741
    }
  ]
}

Here's the ballpark, on your current 6‑month term:

Current (Pine, no Medical Payments): $1,204.68
Upgraded to Evergreen (with Medical Payments): $1,617.41
Difference: about +$412.73 for the 6-month term (~$69/month more)

The jump isn't just Medical Payments — moving to Evergreen also raises your liability limits and automatically adds Rental Reimbursement and Uninsured/Underinsured Motorist coverage, all bundled into the tier (that's most of the cost increase, not just the $22.50 Medical Payments line item itself).

Unfortunately there's no way to add just Medical Payments on its own — it's gated to Evergreen tier and above. Want me to go ahead with the upgrade, or would you rather skip it given the bundled cost?

68k in · 1,342 out · $0.04 · 17.6s

Customer

Nah, forget it then, not worth it to me. That's way too much extra. Thanks anyway for checking though.

Agent

⚙ end_conversation()

{}

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

Take care!

32k in · 97 out · $0.0082 · 4.0s

Customer

You too.