Insurance

Policy Eligibility Analyzer

Automated rule-based system that evaluates customer eligibility for insurance policies based on age, location, and specific risk factors.

This template can be edited in GoRules BRMS

Solution

This insurance eligibility system streamlines the underwriting process by automatically evaluating potential policyholders against key criteria. The system analyzes customer age to verify compliance with minimum and maximum age requirements, ensuring appropriate risk categorization. Location assessment filters applicants from high-risk geographic areas or regions outside service boundaries, maintaining portfolio balance across territories.

The risk assessment component evaluates both the quantity and nature of customer risk factors, considering them alongside health scores to determine overall insurability. When eligibility criteria are not met, the system provides specific denial reasons, enabling agents to clearly communicate decisions to applicants. This automated approach ensures consistent application of underwriting standards while accelerating the decision process for straightforward cases, allowing underwriters to focus on more complex applications.

How it works

The decision graph processes applications through multiple evaluation stages:

  1. Age Verification: Checks if the applicant falls within acceptable age ranges (18-75).
  2. Location Analysis: Evaluates the applicant's state/region against excluded high-risk areas and verifies the location is within supported territories.
  3. Risk Assessment: Evaluates the number of risk factors and their interaction with the applicant's health score.
  4. Eligibility Determination: Combines all evaluations to make a final decision, collecting specific reasons when applications are denied.

Each evaluation node operates independently but contributes to the final determination, with the system producing a clear approved/denied decision along with detailed reasoning.

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