{"txn_id":"HL-CLM-1114","assessment_id":"ra_cd94cf14ddef4330","occurred_at":"2026-08-07T13:04:52+00:00","state":"TX","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_ebbd5841a5"},"output":{"decision":"deny","score":0.895,"reason_codes":["E-114"],"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,"assessment":{"disposition":"FLAG","summary":"FLAG: 3 finding(s) under rules 2026.10+dbe5ddf6, corpus 2026-10-30-5f07c521. Routed to the carrier's compliance reviewer with cited findings.","narrative":"On 2026-08-07, claims-adjud v5.1 (an internally developed system) produced 'deny' in a TX 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 7 rule(s) in force on 2026-08-07 and recorded 3 finding(s); the most serious is 'Algorithmic denial, reduction or fraud hold with no human review' (critical, L2).","findings":[{"rule_id":"tx.542.algorithmic-denial-without-human-review","layer":"L2","judgment_basis":"black_letter","advisory":false,"severity":"critical","title":"Algorithmic denial, reduction or fraud hold with no human review","required_action":"Route to an adjuster for review before the outcome is communicated; record the reviewer and outcome.","exhibits":["C"],"citations":[{"provision_id":"tx-ins-542-003","label":"Tex. Ins. Code § 542.003 — unfair claim settlement practices prohibited","source_url":"https://statutes.capitol.texas.gov/?tab=1&code=IN&chapter=IN.542","verified":true},{"provision_id":"tx-ins-542-055","label":"Tex. Ins. Code § 542.055 — receipt of notice of claim (15-day acknowledgement)","source_url":"https://statutes.capitol.texas.gov/?tab=1&code=IN&chapter=IN.542","verified":true}]},{"rule_id":"tx.tdi.consequential-decision-without-human-review","layer":"L4","judgment_basis":"guidance","advisory":false,"severity":"high","title":"Consequential AI-supported decision taken without a person reviewing and agreeing","required_action":"Route to the responsible reviewer before the outcome takes effect; record the reviewer on the transaction.","exhibits":["B","C"],"citations":[{"provision_id":"tx-tdi-b-0003-26-human-review","label":"TDI Commissioner's Bulletin B-0003-26 (12 June 2026), Use of Artificial Intelligence — human review of consequential decisions","source_url":"https://www.tdi.texas.gov/bulletins/2026/b-0003-26.html","verified":true},{"provision_id":"tx-tdi-b-0003-26-governance","label":"TDI Commissioner's Bulletin B-0003-26 (12 June 2026) — governance, procedures on request, and monitoring","source_url":"https://www.tdi.texas.gov/bulletins/2026/b-0003-26.html","verified":true}]},{"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"],"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":"2026-08-07","rules_version":"2026.10+dbe5ddf6","corpus_snapshot":"2026-10-30-5f07c521","engine_version":"regbench-engine/0.4.0","model_version":"deterministic-1"},"evaluated_at":"2026-10-30T11:23:25.334947+00:00","fingerprint":"6d8bddf7580ec21f38182ef8"},"review":{"status":"resolved","outcome":"remediated","hours_to_resolve":17.5,"reviewer_role":"adjuster","resolved_at":"2026-08-08T06:40:20.211821+00:00"},"ledger":{"seq":1114,"hash":"f9352938026dfab207500fa42edaf23d9d9355c68add2e05b02da9284a6d40a0","prev_hash":"3e6cb388c593085388b186770970ac388af571c5e2c8f484ae9a85e551955648","recorded_at":"2026-08-07T13:08:50+00:00"}}