Claims and eligibility
Is this claim eligible? Decide it the same way, and explain it.
An eligibility rules engine checks every claim, application or request against the same criteria, then approves it, rejects it or routes it to the right person. You can explain every outcome, step by step.
Incoming request
evaluatingIs warranty claim WC-3318 covered?
- Look up the warranty period for the product group in the Warranty terms lookup table: pumps are covered for 24 months
- If the product is in the Excluded items list, reject the claim
- If the claim is within the warranty period and under £1,000, approve it
- If the claim is £1,000 or more, route it to the claims supervisor
Answer, with the reason
Approved. The pump is 14 months into a 24-month warranty, it is not an excluded item, and £850 is under the £1,000 threshold. The customer gets a clear yes, and the trace records exactly why.
Sound familiar?
Claims that depend on who opens them
The rules exist. They are just applied a little differently every time.
"It depends who you get"
Two identical claims get different outcomes because two different handlers read the terms differently. Customers notice, and they talk.
"Why was mine rejected?"
A claimant wants a reason. The handler can see the outcome but not the logic, so the reply is vague and the complaint escalates.
"The terms changed in April"
New eligibility terms apply to policies from April, old terms to the rest. Handlers keep both in their heads and sometimes pick the wrong one.
The quiet cost
What inconsistent eligibility costs
- Claims are paid that should not be, and valid ones are turned down.
- Complaints grow when claimants cannot get a clear reason.
- Simple claims wait in the same queue as the complex ones.
- Changing the terms means retraining everyone and hoping it sticks.
Before and after
From handler judgement to rules you can stand behind
Today
- Outcomes vary depending on who handles the claim
- Reasons for a rejection are vague or missing
- Every claim waits in one queue for a person
- Old and new terms applied from memory
With Condexa
- Every claim checked against the same eligibility rules
- A step-by-step trace behind every outcome
- Straightforward claims decided at once; complex ones routed
- Versioned rules, so the right terms apply to the right claim
How you get there
How eligibility becomes clear and consistent
- 1
The terms, turned into checks
Write down each eligibility condition: dates, cover periods, excluded items and value thresholds. Reference data sits in lookup tables and lists the claims team owns.
- 2
Outcomes you have already checked
Run past claims through the rules and compare the results with the decisions your handlers made. Where they differ, the trace shows which condition caused it.
- 3
Every claim routed on arrival
Your claims system or portal calls the decision as each claim comes in. Clear cases are settled, the rest reach the right handler with the reason already attached.
A worked example
Example: a warranty claim on an industrial pump
A customer submits warranty claim WC-3318 for a pump bought 14 months ago. The repair estimate is £850.
The rules, in plain English
- R1Look up the warranty period for the product group in the Warranty terms lookup table: pumps are covered for 24 months
- R2If the product is in the Excluded items list, reject the claim
- R3If the claim is within the warranty period and under £1,000, approve it
- R4If the claim is £1,000 or more, route it to the claims supervisor
Condexa answers
Approved. The pump is 14 months into a 24-month warranty, it is not an excluded item, and £850 is under the £1,000 threshold. The customer gets a clear yes, and the trace records exactly why.
FAQ
Questions people ask
What is an eligibility rules engine?
An eligibility rules engine checks a claim, application or request against a set of written criteria and returns whether it qualifies. It applies the same rules every time and can explain which condition led to the result.
How do claims eligibility rules work?
Claims eligibility rules compare the facts of a claim, such as dates, amounts and what is being claimed for, with the terms that apply. The outcome is usually approve, reject or refer to a person. Automating them means straightforward claims are settled quickly and consistently.
Can eligibility rules change without affecting older claims?
Yes. Condexa keeps versions of each decision, and every run records the version that produced it. You can also build the start date of the terms into the rules, so older claims are judged on the terms that applied to them.
How do we explain an eligibility decision to a customer?
Open the run for that claim and read the trace. It shows each condition that was checked, the values used and the one that decided the outcome, so you can give a specific reason rather than a general one.
What kinds of claims can Condexa handle?
Any claim or eligibility check that follows clear rules, such as warranty claims, returns, rebates, expense claims or benefit eligibility. You write the rules for your own terms, and your systems call them for an answer.
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