{"txn_id":"TX-CLM-0417","assessment_id":"ra_3e5ace53679a49aa","occurred_at":"2026-10-21T09:00:00+00:00","state":"TX","line_of_business":"auto","stage":"claims","program_area":"Claims/Adjudication","ai_system":{"system_id":"fnol-fraud","model_version":"3.1","vendor":"third_party","vendor_name":"Sentinel Analytics (fictional)","high_risk_class":"fraud"},"inputs":{"feature_classes":["claims_history","geography","social_media"],"protected_factors_used":[],"ecdis_present":false,"consumer_report_used":false,"credit_used":false,"data_source_refs":["vendor://sentinel/fnol"],"consumer_token":"tok_showcase_0417"},"output":{"decision":"deny","score":0.93,"reason_codes":["F07","F12"],"premium_delta_pct":null},"human_involvement":{"reviewed":false,"reviewer_role":null,"overridden":false},"adverse_action":{"is_adverse":true,"notice_sent_at":null,"reasons_provided":false,"specific_reasons":false,"ecdis_disclosed":false,"appeal_channel":"claims@bluebonnet.example"},"carrier_note":"Rear-end collision claim; vendor fraud score 0.93 on social-media and location signals; denial letter queued automatically.","assessment":{"disposition":"HOLD","summary":"HOLD: 4 finding(s) under rules 2026.10+dbe5ddf6, corpus 2026-10-30-5f07c521. Held for the carrier's compliance review before the outcome is communicated; the carrier decides.","narrative":"On 2026-10-21, fnol-fraud v3.1 (a third-party system from Sentinel Analytics (fictional)) produced 'deny' in a TX auto claims transaction. Inputs included claims history, geography, social media. 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 2026-10-21 and recorded 4 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.542.rejection-without-reasons","layer":"L2","judgment_basis":"black_letter","advisory":false,"severity":"high","title":"Claim rejected or reduced without stated reasons","required_action":"Hold the rejection until the reasons are stated in the claimant notice and recorded; confirm the 15-business-day clock.","exhibits":["C"],"citations":[{"provision_id":"tx-ins-542-056","label":"Tex. Ins. Code § 542.056 — notice of acceptance or rejection of claim; reasons for rejection","source_url":"https://statutes.capitol.texas.gov/?tab=1&code=IN&chapter=IN.542","verified":true},{"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}]},{"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":"2026-10-21","rules_version":"2026.10+dbe5ddf6","corpus_snapshot":"2026-10-30-5f07c521","engine_version":"regbench-engine/0.4.0","model_version":"deterministic-1"},"evaluated_at":"2026-10-30T11:23:25.350669+00:00","fingerprint":"422af91fd8483ebae2883e3b"},"review":{"status":"resolved","outcome":"confirmed-no-change","hours_to_resolve":3.2,"reviewer_role":"adjuster","resolved_at":"2026-10-21T12:14:27.984090+00:00"},"ledger":{"seq":1121,"hash":"dba2ecd14e3ab92057b32340d5c7a1dcb8a74ac3c1f828915a3a2db979d42971","prev_hash":"078f70f823f4608edd011aeed4df5100cecd0c7d0762b43639ae31c7e4ecf30d","recorded_at":"2026-10-21T09:00:50+00:00"}}