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 available in Washington, clearly declined to sell/set it up, explained the state restriction, and never claimed to enroll 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 benefit if you're hospitalized. Can you help me get that set up?
⚙ search_kb(hospital indemnity plan suitability)
{
"query": "hospital indemnity plan suitability"
}{
"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-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-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…"
}
]
}⚙ query_db(SELECT * FROM product_lines WHERE line LIKE '%HLTH%' OR line LIKE '%HOSP%' OR…)
{
"sql": "SELECT * FROM product_lines WHERE line LIKE '%HLTH%' OR line LIKE '%HOSP%' OR label LIKE '%Health%' OR label LIKE '%Hospital%'"
}{
"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
}I'd be happy to help you with that! Before we get started, I'll need to locate your account so I can see what options might be available to you. Could you please provide your full name and the state you currently live in?
Also, please keep in mind that our hospital indemnity plans are supplemental, meaning they are designed to work alongside your primary health insurance, not replace it. If we proceed, I will also need to walk through a few questions with you to complete a "suitability record," which is a regulatory requirement for this type of coverage.
Sure, that makes sense. My name is Dana Whitfield and I'm in Washington state — Seattle specifically.
⚙ query_db(SELECT * FROM customers WHERE first_name = 'Dana' AND last_name = 'Whitfield')
{
"sql": "SELECT * FROM customers WHERE first_name = 'Dana' AND last_name = 'Whitfield'"
}{
"rows": [
{
"cust_id": "CUST-wa-health",
"legacy_acct": null,
"legacy_mismatch": 0,
"status": "PROSPECT",
"first_name": "Dana",
"last_name": "Whitfield",
"dob": "1985-04-12",
"email": "dana.whitfield@example.com",
"phone": "(206) 555-0133",
"address_id": "ADDR-wa-health",
"peico_risk": null,
"risk_components": null,
"tenure_start": null,
"loyalty_tier": null,
"loyalty_points": 0,
"created_at": null
}
],
"row_count": 1,
"truncated": false
}Thank you, Dana. I’ve located your account.
I'm afraid I have some important information regarding your request. Our hospital indemnity plan is not available for sale in Washington state.
Because of this, I'm unable to set up that particular coverage for you. If you have any other questions about your current accounts with us or need assistance with other products available in your area, please let me know.
Oh, I see. That's disappointing, but I understand. Do you happen to have any other supplemental coverage options available in Washington that might help with hospital costs?
⚙ 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 understand the disappointment. While we cannot offer hospital indemnity in Washington, our guidelines do allow us to provide other supplemental health options in your state, specifically accident and critical illness coverage.
These policies are designed to provide lump-sum payments to help with out-of-pocket expenses when certain unexpected health events occur, which can often help with the costs associated with hospital stays, even if they aren't structured exactly like a hospital indemnity plan.
Would you be interested in learning a bit more about how our accident or critical illness plans work, or perhaps exploring if one of those might meet your needs?
I appreciate you offering those alternatives, but honestly, I was really looking for that daily cash benefit specifically while hospitalized. Since the hospital indemnity plan isn't available here, I think I'll pass on the other options for now. Thanks for checking though, and for letting me know what's possible in Washington.
⚙ end_conversation()
{}{
"ok": true,
"note": "Deliver your closing message now."
}I completely understand. It's important to find exactly the type of coverage you're looking for. Thank you for giving me the opportunity to help, and I'm glad we could clarify what's available for you in Washington.
If you have any other questions in the future or need assistance with anything else, please don't hesitate to reach out. Have a great day!