Insurance · Deterministic · Governed · Auditable

Every Claims Decision Should Be Defensible. Right Now, Are They?

Underwriting varies by reviewer, not by guidelines. Claims adjudication is slow and opaque. Regulatory compliance is manual. Insurance policies compile into the same governed decision packages used across the platform — deterministic, traceable, and governed. AI assists at build time; runtime decisions are reproducible.

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Zero AI at runtime. Deterministic. Auditable. Traceable.

The problem in insurance

Underwriting is inconsistent

Different underwriters interpret the same guidelines differently. Risk assessment varies by reviewer, not by policy. Underwriting rules should be deterministic and auditable — not dependent on who reviews the application.

Claims adjudication is slow and opaque

Manual claims review creates backlogs. When claims are denied, policyholders can’t understand why. Every denial should carry traceable reason codes and source citations.

Regulatory compliance is manual

State-specific regulations and rate filings are enforced through tribal knowledge, not through versioned, auditable systems. Rule changes should be governed, not implicit.

How Sertainly Helps

Automated Underwriting Triage

Underwriting guidelines compiled into deterministic decision packages. Applications evaluated against referral thresholds, exclusion criteria, and risk-tier rules.

  • Risk scoring with referral thresholds (e.g. auto-decline above combined ratio)
  • Exclusion and endorsement checks against policy terms
  • Structured evidence requests for missing medical or financial disclosures
  • Manual review triggers with traceable escalation reason codes

Claims Adjudication

Claims rules compiled into governed decision packages. Every adjudication carries reason codes, source citations, and a signed trace for disputes.

  • Policy status and lapse validation before adjudication
  • Deductible, sublimit, and aggregate limit checks
  • Denial reason codes traceable to specific policy clauses
  • Trace-backed evidence package for appeals and regulatory review

Rate and Eligibility Rules

Rate tables, product eligibility, and rider rules versioned and executed deterministically across all channels and jurisdictions.

  • State-specific rate table versioning and filing compliance
  • Product and rider eligibility determination by applicant profile
  • Multi-state regulatory rule enforcement with audit trail
  • Version-pinned rate logic with signed builds and provenance

Claims adjudication: auto-repair claim

A claim is submitted for evaluation. Sertainly checks policy status, coverage terms, and evidence requirements, returning a deterministic decision with full trace.

evaluate_case input

{
  "version": 2,
  "case": {
    "claim": {
      "type": "COLLISION",
      "amount": 4200,
      "deductible": 500
    },
    "policy_holder": {
      "coverage_type": "COMPREHENSIVE",
      "policy_status": "ACTIVE"
    },
    "evidence": [
      "POLICE_REPORT",
      "REPAIR_ESTIMATE"
    ]
  }
}

evaluate_case output

{
  "status": "ok",
  "outputs": {
    "tags": ["COMPLIANT"],
    "reason_codes": [
      "COVERAGE_ACTIVE",
      "COLLISION_COVERED",
      "EVIDENCE_COMPLETE"
    ],
    "facts": {
      "approved_amount": 3700
    }
  },
  "trace_id": "tr_cl_9d2e…"
}

Related use cases

The decision problems this industry runs on.

Claims Adjudication →Eligibility →

Sertainly doesn't replace your core systems — it supplies the governed, traceable decision packages your claims, eligibility, and policy systems call.

Ready to get started?

Sertainly Enterprise includes dedicated runtime, governance workflows, signed builds, VPC deployment, and full audit controls.

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Ready to make every claims decision defensible?

Compile policy into governed decision packages. Execute deterministically with full trace, provenance, and audit controls. Same decision layer across every use case.

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