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 · 9 turns · 30s · $0.10 · 53k tok in

Verdicts

DB end-statepassed

DB end-state matches the expected changeset.

Judge rubricpassed

judge: The rep correctly identified that Hospital Indemnity is not filed/available in Washington, clearly declined to sell it, explained the state restriction, and never claimed or implied enrollment/setup of the plan.

Conversation

Agent

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

Customer

Hi! Thanks for having me. I'm looking to sign up for a hospital indemnity plan — something that would give me a daily cash benefit if I end up in the hospital. Do you offer 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 line LIKE '%HLTH%' OR label LIKE '%hospital%' OR label LIKE '%health%' OR notes 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
}

⚙ search_kb(hospital indemnity daily cash benefit health product availability suitability, 5)

{
  "query": "hospital indemnity daily cash benefit health product availability suitability",
  "limit": 5
}

{
  "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-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-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-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…"
    }
  ]
}

⚙ get_doc(KB-SUITABILITY)

{
  "doc_id": "KB-SUITABILITY"
}

{
  "doc_id": "KB-SUITABILITY",
  "title": "Suitability requirement for Life & Health",
  "category": "COMPLIANCE",
  "applies_to": "{\"lines\": [\"LIFE_T\", \"LIFE_W\", \"HLTH\"]}",
  "body_md": "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, tight-budget customer is a mis-sale. Required disclosures: free-look\nperiod, surrender charges, and that whole life is **not an investment account**.\n"
}

⚙ get_doc(KB-DISC-HLTH-SUPP)

{
  "doc_id": "KB-DISC-HLTH-SUPP"
}

{
  "doc_id": "KB-DISC-HLTH-SUPP",
  "title": "Supplemental health: not major-medical; pre-existing limits",
  "category": "COMPLIANCE",
  "applies_to": "{\"lines\": [\"HLTH\"]}",
  "body_md": "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 condition\nlimitations apply for a defined look-back period.\n"
}

⚙ query_db(SELECT c.coverage_id, c.code, c.label, c.kind, c.unit, c.notes FROM coverages…)

{
  "sql": "SELECT c.coverage_id, c.code, c.label, c.kind, c.unit, c.notes FROM coverages c WHERE c.line='HLTH' ORDER BY c.coverage_id"
}

{
  "rows": [
    {
      "coverage_id": "HLTH:ACCIDENT",
      "code": "ACCIDENT",
      "label": "Accident Benefit",
      "kind": "limit",
      "unit": "usd",
      "notes": "Lump sum per covered accident."
    },
    {
      "coverage_id": "HLTH:CRIT_ILL",
      "code": "CRIT_ILL",
      "label": "Critical Illness Lump Sum",
      "kind": "limit",
      "unit": "usd",
      "notes": null
    },
    {
      "coverage_id": "HLTH:ER_BENEFIT",
      "code": "ER_BENEFIT",
      "label": "Emergency Room Benefit",
      "kind": "limit",
      "unit": "usd",
      "notes": null
    },
    {
      "coverage_id": "HLTH:HOSP_INDEM",
      "code": "HOSP_INDEM",
      "label": "Hospital Indemnity",
      "kind": "limit",
      "unit": "usd_daily",
      "notes": "Per-day benefit. NOT sellable in WA (not filed)."
    },
    {
      "coverage_id": "HLTH:WELLNESS",
      "code": "WELLNESS",
      "label": "Wellness Benefit",
      "kind": "flag",
      "unit": "bool",
      "notes": null
    }
  ],
  "row_count": 5,
  "truncated": false
}

⚙ query_db(SELECT tier_id, code, label, sellable, retired_on, notes FROM tiers WHERE lin…)

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

{
  "rows": [
    {
      "tier_id": "HLTH:SAPLING",
      "code": "SAPLING",
      "label": "Sapling",
      "sellable": 1,
      "retired_on": null,
      "notes": null
    },
    {
      "tier_id": "HLTH:PINE",
      "code": "PINE",
      "label": "Pine",
      "sellable": 1,
      "retired_on": null,
      "notes": null
    },
    {
      "tier_id": "HLTH:EVERGREEN",
      "code": "EVERGREEN",
      "label": "Evergreen",
      "sellable": 1,
      "retired_on": null,
      "notes": null
    }
  ],
  "row_count": 3,
  "truncated": false
}

Yes — PEICO offers a Supplemental Health line that includes a Hospital Indemnity benefit, which is a per-day cash benefit for covered hospital stays.

A couple important notes up front:

It’s supplemental coverage, not major medical health insurance, and it doesn’t replace ACA/regular health insurance.
Pre-existing condition limitations may apply.
Before we can bind any supplemental health policy, PEICO requires a suitability review.
Hospital indemnity is not available in Washington, because it isn’t filed there.

If you’d like, I can help check availability and options. What state do you live in?

17k in · 470 out · $0.04 · 9.6s

Customer

Oh, I'm in Washington state — Seattle specifically. So you're saying the hospital indemnity isn't available here?

Agent

That’s correct — PEICO’s Hospital Indemnity benefit is not available for sale in Washington, including Seattle. It hasn’t been filed for Washington, so I can’t quote or bind that specific daily hospital cash benefit there.

PEICO may still offer other Supplemental Health benefits in Washington, such as accident or critical illness coverage, but those would also require a suitability review before purchase.

6,502 in · 80 out · $0.0067 · 2.2s

Customer

Got it, thanks for letting me know. That's disappointing, but I understand. Do you happen to know if any of those other options — like the accident or critical illness coverage — would give me something similar to what I was looking for?

Agent

⚙ query_db(SELECT er.rule_id, er.line, er.tier_id, er.coverage_id, er.state, er.effect, …)

{
  "sql": "SELECT er.rule_id, er.line, er.tier_id, er.coverage_id, er.state, er.effect, er.condition, er.effective_start, er.effective_end, er.reason_doc, er.notes FROM eligibility_rules er WHERE er.line='HLTH' AND (er.state='WA' OR er.state IS NULL) ORDER BY er.coverage_id, er.rule_id"
}

{
  "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
}

⚙ 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='HLTH' ORDER BY code"
}

{
  "rows": [
    {
      "coverage_id": "HLTH:ACCIDENT",
      "code": "ACCIDENT",
      "label": "Accident Benefit",
      "kind": "limit",
      "unit": "usd",
      "notes": "Lump sum per covered accident."
    },
    {
      "coverage_id": "HLTH:CRIT_ILL",
      "code": "CRIT_ILL",
      "label": "Critical Illness Lump Sum",
      "kind": "limit",
      "unit": "usd",
      "notes": null
    },
    {
      "coverage_id": "HLTH:ER_BENEFIT",
      "code": "ER_BENEFIT",
      "label": "Emergency Room Benefit",
      "kind": "limit",
      "unit": "usd",
      "notes": null
    },
    {
      "coverage_id": "HLTH:HOSP_INDEM",
      "code": "HOSP_INDEM",
      "label": "Hospital Indemnity",
      "kind": "limit",
      "unit": "usd_daily",
      "notes": "Per-day benefit. NOT sellable in WA (not filed)."
    },
    {
      "coverage_id": "HLTH:WELLNESS",
      "code": "WELLNESS",
      "label": "Wellness Benefit",
      "kind": "flag",
      "unit": "bool",
      "notes": null
    }
  ],
  "row_count": 5,
  "truncated": false
}

⚙ query_db(SELECT disclosure_id, code, title, when_required, free_look_days, mandatory, …)

{
  "sql": "SELECT disclosure_id, code, title, when_required, free_look_days, mandatory, state, condition, doc_id FROM required_disclosures WHERE line='HLTH' AND (state='WA' OR state IS NULL) ORDER BY mandatory DESC, code"
}

{
  "rows": [
    {
      "disclosure_id": "DISC-HLTH-FREELOOK",
      "code": "FREE_LOOK",
      "title": "Free-look period",
      "when_required": "AT_BIND",
      "free_look_days": 10,
      "mandatory": 1,
      "state": null,
      "condition": null,
      "doc_id": "KB-DISC-FREELOOK"
    },
    {
      "disclosure_id": "DISC-HLTH-NOTMAJOR",
      "code": "NOT_MAJOR_MEDICAL",
      "title": "This is supplemental",
      "when_required": "AT_QUOTE",
      "free_look_days": null,
      "mandatory": 1,
      "state": null,
      "condition": null,
      "doc_id": "KB-DISC-HLTH-SUPP"
    },
    {
      "disclosure_id": "DISC-HLTH-PREEX",
      "code": "PRE_EXISTING",
      "title": "Pre-existing condition limitations",
      "when_required": "AT_BIND",
      "free_look_days": null,
      "mandatory": 1,
      "state": null,
      "condition": null,
      "doc_id": "KB-DISC-HLTH-SUPP"
    }
  ],
  "row_count": 3,
  "truncated": false
}

They can provide some cash benefits, but they are not quite the same as hospital indemnity.

Here’s the plain-English difference:

Hospital Indemnity — the one you originally asked about — is typically a per-day hospital benefit. PEICO can’t sell this in Washington.
Accident Benefit — pays a lump sum per covered accident. It may help if a hospitalization is caused by a covered accident, but it is not a daily hospital-stay benefit.
Critical Illness — pays a lump sum for a covered serious illness. It may help with costs after a covered diagnosis, but again it is not tied to “number of days in the hospital.”
Emergency Room Benefit — may provide a set benefit for covered ER treatment, but it’s not a daily inpatient hospital benefit.

So if your main goal is specifically “cash per day while hospitalized,” PEICO’s Washington-approved alternatives would only be partial substitutes, not a direct match.

If you’re interested in accident or critical illness coverage, I can walk you through options, but we’d need to complete PEICO’s suitability review before any purchase.

14k in · 505 out · $0.03 · 8.3s

Customer

I appreciate you breaking that down. Since none of those are really what I'm looking for — I specifically wanted that daily hospital benefit — I think I'll have to pass for now. Thanks for checking though, and for explaining why it's not available here.

Agent

⚙ end_conversation()

{}

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

You’re very welcome — I’m sorry we couldn’t offer the exact daily hospital benefit in Washington, but I’m glad I could clarify it for you. Thanks for contacting PEICO, and have a good day.

16k in · 60 out · $0.03 · 3.3s