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.

Passedcustomer: Dana Whitfield · 7 turns · 17s · $0.0092 · 44k tok in

Verdicts

DB end-statepassed

DB end-state matches the expected changeset.

Judge rubricpassed

judge: The rep clearly stated hospital indemnity is not available in Washington, declined to sell it, explained the state restriction, and never claimed to have enrolled or set up the plan.

Conversation

Agent

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

Customer

Hi! Thanks for picking up. I'm interested in getting a hospital indemnity plan — you know, one that pays me a daily cash benefit if I end up in the hospital. Can you help me with that?

Agent

⚙ 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 WHERE label LIKE '%hospital%' OR line LIKE '%HOSP%' OR label LIKE '%indemnity%'"
}

{
  "rows": [],
  "row_count": 0,
  "truncated": false
}

⚙ 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 ORDER BY line"
}

{
  "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": "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."
    },
    {
      "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": "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": "HOME",
      "label": "Homeowners",
      "category": "P&C",
      "parent_line": null,
      "requires_suitability": 0,
      "requires_underlying": null,
      "notes": "Dwelling, structure, contents, liability (HO-3 style)."
    },
    {
      "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": "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": "PET",
      "label": "Pet",
      "category": "P&C",
      "parent_line": null,
      "requires_suitability": 0,
      "requires_underlying": null,
      "notes": "Accident & illness; fun, low-stakes line."
    },
    {
      "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": "RV",
      "label": "Recreational Vehicle",
      "category": "P&C",
      "parent_line": "AUTO",
      "requires_suitability": 0,
      "requires_underlying": null,
      "notes": "Motorhome / travel-trailer; adds vacation-liability."
    },
    {
      "line": "TRVL",
      "label": "Travel",
      "category": "TRAVEL",
      "parent_line": null,
      "requires_suitability": 0,
      "requires_underlying": null,
      "notes": "Per-trip and annual multi-trip."
    },
    {
      "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."
    }
  ],
  "row_count": 14,
  "truncated": false
}

⚙ search_kb(HLTH hospital indemnity underwriting suitability disclosures daily cash benef…)

{
  "query": "HLTH hospital indemnity underwriting suitability disclosures daily cash benefit",
  "limit": 5
}

{
  "results": [
    {
      "doc_id": "KB-DISC-WHOLE-LIFE",
      "title": "Whole life disclosures: surrender, cash value, not an investment",
      "category": "COMPLIANCE",
      "applies_to": "{\"lines\": [\"LIFE_W\"]}",
      "snippet": "Before binding whole life, disclose and record: (1) **surrender charges** apply for\nthe first several policy years and reduce early cash value; (2) cash value accrues\nslowly and may be borrowed against, reducing the death benefit; (3) whole…"
    },
    {
      "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…"
    },
    {
      "doc_id": "KB-HERITAGE",
      "title": "Heritage tier (retired 2009) — do not drop without disclosure",
      "category": "UNDERWRITING",
      "applies_to": "{\"lines\": [\"AUTO\"]}",
      "snippet": "Heritage was retired on 2009-07-01 and cannot be sold or re-bound. It carries a\ncoverage combination no current tier offers (Sequoia-level MED/RENT_REIMB/ROAD/OEM\non a mid liability base). A customer who drops Heritage **loses that combinat…"
    }
  ]
}

Yes — PEICO does offer a Supplemental Health line that includes hospital indemnity benefits.

A couple important notes:

It’s not major medical; it’s supplemental coverage that pays a cash benefit, not your hospital bill directly.
Before we can bind any Supplemental Health policy, PEICO requires a suitability record.
Also, in Washington, hospital indemnity is not available.

If you’d like, I can help with next steps:

check whether you’re eligible in your state, and
gather the suitability information needed to quote/bind it.

22k in · 259 out · $0.0050 · 5.7s

Customer

Oh, I see. So hospital indemnity isn't available in Washington? That's disappointing. Do you have any other supplemental options that might work for me instead — like something that would still help cover costs if something unexpected happens?

Agent

⚙ search_kb(Supplemental health lines accident critical illness hospital indemnity not ma…)

{
  "query": "Supplemental health lines accident critical illness hospital indemnity not major-medical pre-existing limits state availability Washington",
  "limit": 10
}

{
  "results": [
    {
      "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-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-NE-MIN-LIMITS",
      "title": "NY/NJ minimum auto liability limits",
      "category": "COMPLIANCE",
      "applies_to": "{\"lines\": [\"AUTO\"], \"states\": [\"NY\", \"NJ\"]}",
      "snippet": "New York and New Jersey mandate minimum BI/PD limits above the Sapling tier's\nlimits, so **Sapling auto is not sellable** in those states — quote Pine or higher.\n"
    },
    {
      "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-CLAIMS-STATUS",
      "title": "Claim status: FNOL → OPEN → CLOSED, and who may move it",
      "category": "POLICY",
      "applies_to": "{\"lines\": \"ALL\"}",
      "snippet": "**FNOL** = loss reported, not yet accepted for handling. **OPEN** = accepted\nand with an adjuster (the adjuster sets the reserve). **CLOSED** = resolved.\nA service rep may promote FNOL → OPEN once the loss details are confirmed\nwith the cus…"
    },
    {
      "doc_id": "KB-LOYALTY-AUTHORITY",
      "title": "PineRewards points: what a service rep may post",
      "category": "POLICY",
      "applies_to": "{\"lines\": \"ALL\"}",
      "snippet": "Tiers (Seedling → Sprout → Timber → OldGrowth) are assigned annually from\ntenure and lifetime earning, **not** the current point balance. Points earned\n2019 or later expire **24 months** after the earn date; older entries were\nwritten witho…"
    },
    {
      "doc_id": "KB-DISC-WHOLE-LIFE",
      "title": "Whole life disclosures: surrender, cash value, not an investment",
      "category": "COMPLIANCE",
      "applies_to": "{\"lines\": [\"LIFE_W\"]}",
      "snippet": "Before binding whole life, disclose and record: (1) **surrender charges** apply for\nthe first several policy years and reduce early cash value; (2) cash value accrues\nslowly and may be borrowed against, reducing the death benefit; (3) whole…"
    },
    {
      "doc_id": "KB-HERITAGE",
      "title": "Heritage tier (retired 2009) — do not drop without disclosure",
      "category": "UNDERWRITING",
      "applies_to": "{\"lines\": [\"AUTO\"]}",
      "snippet": "Heritage was retired on 2009-07-01 and cannot be sold or re-bound. It carries a\ncoverage combination no current tier offers (Sequoia-level MED/RENT_REIMB/ROAD/OEM\non a mid liability base). A customer who drops Heritage **loses that combinat…"
    },
    {
      "doc_id": "KB-UMBR-UNDERLYING",
      "title": "Umbrella requires an underlying policy",
      "category": "UNDERWRITING",
      "applies_to": "{\"lines\": [\"UMBR\"]}",
      "snippet": "A Personal Umbrella cannot be bound unless the household has an in-force underlying\n**AUTO or HOME** policy meeting minimum liability limits. Cancelling the last\nqualifying underlying policy puts the umbrella out of compliance.\n"
    }
  ]
}

Yes — in Washington, PEICO’s hospital indemnity benefit specifically isn’t available, but the broader Supplemental Health line does include other options that may still help with unexpected costs, such as:

Accident coverage — cash benefits for covered injuries from accidents
Critical illness coverage — cash benefits for specified serious illnesses

A few important points:

These are still supplemental policies, not major medical.
They can help with out-of-pocket costs, but they don’t replace regular health insurance.
Because this is a Health line, PEICO requires a suitability record before binding.

If you want, I can walk you through which supplemental option fits your situation best, and then we can see whether it’s eligible in your state.

14k in · 207 out · $0.0032 · 3.0s

Customer

I appreciate you explaining those options. Honestly, I was really looking for the hospital indemnity specifically — that daily cash benefit while hospitalized was what appealed to me. Since that's not available in Washington, I think I'm going to pass for now and look around at other carriers to see if they offer it in my state. Thanks for checking though, and for walking me through what PEICO does have available.

Agent

Absolutely — that makes sense. I’m sorry we couldn’t offer the specific hospital indemnity benefit in Washington.

If you decide to revisit supplemental coverage later, or have questions about any PEICO policy, we’ll be here to help.

Thanks for contacting PEICO, and best of luck with your search.

8,015 in · 64 out · $0.0010 · 1.2s