{"txn_id":"HL-CLM-1095","assessment_id":"ra_9d6573a030154417","occurred_at":"2026-09-20T15:33:18+00:00","state":"NY","line_of_business":"health","stage":"claims","program_area":"Claims/Adjudication","ai_system":{"system_id":"claims-adjud","model_version":"5.1","vendor":"internal","vendor_name":null,"high_risk_class":"claims"},"inputs":{"feature_classes":["medical_records","claims_history"],"protected_factors_used":[],"ecdis_present":false,"consumer_report_used":false,"credit_used":false,"data_source_refs":[],"consumer_token":"tok_9c36462677"},"output":{"decision":"partial_pay","score":0.489,"reason_codes":[],"premium_delta_pct":null},"human_involvement":{"reviewed":false,"reviewer_role":"adjuster","overridden":false},"adverse_action":{"is_adverse":true,"notice_sent_at":null,"reasons_provided":true,"specific_reasons":false,"ecdis_disclosed":false,"appeal_channel":null},"carrier_note":null,"input":{"revision":1,"current_revision":1,"input_digest":"db48b9deed5405aae7ddf8427dc8cc3cd81c97b4a52f129eea06e9642740670a","digest_ok":true,"note":"input_digest is SHA-256 over the canonical JSON of the transaction revision assessed; it is inside the assessment the ledger hashes."},"assessment":{"disposition":"FLAG","coverage":{"status":"unsupported","state_rules_applied":0,"general_rules_applied":0,"advisory_rules_applied":1,"rules_considered":30,"rules_applied":["doctrine.unreviewed-adverse-high-risk"],"statement":"No black-letter rule in the pack covers a NY health claims transaction. Nothing binding was checked, so no disposition here says anything about compliance."},"evidence":{"status":"carrier_asserted","asserted":["ai_system.governance_attested","ai_system.model_doc_ref","ai_system.testing_report_ref"],"missing":[],"statement":"Supplied by the carrier and not verified by RegBench: ai_system.governance_attested, ai_system.model_doc_ref, ai_system.testing_report_ref."},"summary":"FLAG: 1 finding(s) under rules 2026.10+c4982313, corpus 2026-10-30-9c5dad5a. Routed to the carrier's compliance reviewer with cited findings. Coverage unsupported: No black-letter rule in the pack covers a NY health claims transaction. Nothing binding was checked, so no disposition here says anything about compliance.","narrative":"On 2026-09-20, claims-adjud v5.1 (an internally developed system) produced 'partial pay' in a NY health claims transaction. Inputs included medical records, claims history. No human reviewed the output before it took effect. The outcome was adverse to the consumer; no notice to the consumer is recorded. RegBench applied 1 rule(s) in force on 2026-09-20 and recorded 1 finding(s); the most serious is 'Adverse outcome from a high-risk AI system with no human review' (medium, L6).","findings":[{"rule_id":"doctrine.unreviewed-adverse-high-risk","layer":"L6","judgment_basis":"doctrine","advisory":true,"severity":"medium","title":"Adverse outcome from a high-risk AI system with no human review","required_action":"Route to the carrier's reviewer; record the review and any override on the transaction.","exhibits":["B","C"],"content_status":"verified","citations":[{"provision_id":"naic-ai-bulletin-s3-1-ais-program","label":"NAIC Model Bulletin on the Use of AI Systems by Insurers (adopted 4 Dec 2023), Section 3, 1.0 General Guidelines — the written AIS Program","source_url":"https://content.naic.org/sites/default/files/inline-files/2023-12-4%20Model%20Bulletin_Adopted_0.pdf","verified":true}]}],"point_in_time":{"as_of":"2026-09-20","basis":"transaction_date","rules_version":"2026.10+c4982313","corpus_snapshot":"2026-10-30-9c5dad5a","engine_version":"regbench-engine/0.5.0","model_version":"deterministic-1"},"evaluated_at":"2026-10-31T05:42:56.009148+00:00","fingerprint":"21ba960d3e066c3778002a8b"},"review":{"status":"resolved","outcome":"remediated","hours_to_resolve":16.5,"reviewer_role":"adjuster","resolved_at":"2026-09-21T08:06:55.859223+00:00"},"ledger":{"seq":6598,"hash":"79339c5e2c1824b8a9fbbb2c72a144f90d54ed882a86110419c8cef68d8efee2","prev_hash":"19a9054c8e8bbbe4c5a4910bb851ace4d30fed6cc9fdd4958aad145f4057f7b0","recorded_at":"2026-09-20T15:35:47+00:00"}}