HL-CLM-1011 HOLD
On 2026-09-08, claims-adjud v5.1 (an internally developed system) produced 'partial pay' in a TX health claims transaction. Inputs included medical records, claims history. A human reviewed the output by a adjuster. The outcome was adverse to the consumer; no notice to the consumer is recorded. RegBench applied 7 rule(s) in force on 2026-09-08 and recorded 1 finding(s); the most serious is 'Claim rejected or reduced without stated reasons' (high, L2).
HOLD: 1 finding(s) under rules 2026.10+c4982313, corpus 2026-10-30-9c5dad5a. Recommended hold for the carrier's compliance review before the outcome is communicated; the carrier decides.
Evidence (carrier asserted). Supplied by the carrier and not verified by RegBench: ai_system.governance_attested, ai_system.model_doc_ref, ai_system.testing_report_ref.
Findings (1)
Claim rejected or reduced without stated reasons
Finding. The claim decision rejects or reduces payment, and the transaction records no reasons given to the claimant.
Basis. § 542.056(a) requires written notice of acceptance or rejection within 15 business days of receiving the items required to secure final proof of loss, and § 542.056(c) provides that "if the insurer rejects the claim, the notice ... must state the reasons for the rejection"; § 542.003(b)(3)–(4) prohibits unfair claim settlement practices.
Required action. Hold the rejection until the reasons are stated in the claimant notice and recorded; confirm the 15-business-day clock. 15 days
Excerpt: tx-ins-542-056 · state statute (government edict) · in force from 2005-04-01
"(a) Except as provided by Subsection (b) or (d), an insurer shall notify a claimant in writing of the acceptance or rejection of a claim not later than the 15th business day after the date the insurer receives all items, statements, and forms required by the insurer to secure final proof of loss. ... (c) If the insurer rejects the claim, the notice required by Subsection (a) or (b) must state the reasons for the rejection."
Excerpt: tx-ins-542-003 · state statute (government edict) · in force from 2005-04-01
"(a) An insurer engaging in business in this state may not engage in an unfair claim settlement practice. (b) Any of the following acts by an insurer constitutes unfair claim settlement practices: ... (3) failing to adopt and implement reasonable standards for the prompt investigation of claims arising under the insurer's policies; (4) not attempting in good faith to effect a prompt, fair, and equitable settlement of a claim submitted in which liability has become reasonably clear ..."
Point in time
- Law as of
- 2026-09-08
- Rules version
- 2026.10+c4982313
- Corpus snapshot
- 2026-10-30-9c5dad5a
- Engine
- regbench-engine/0.5.0 · deterministic-1
- Fingerprint
- bf6f8acff048caacb18ea7bc (pattern grouping, not an integrity check)
- Input digest
- 4785dd310f60c636944377f4d8dc6ab9b73a58cca7b3343919be9f0b566d68a8
- Evaluated
- 2026-10-31 05:42:55 UTC
- Exhibit C case file
- yes
Ledger
- Entry
- #6514 · assessment · recorded 2026-09-08T20:51:39+00:00
- Hash
- 73e320027ad0563a3d2ae3b9e0786a1b4fa2e3e1b0c980930104810a692c3885
- Previous
- c5865577267920b26d65947fba77dd0235cbe020fb4635ae678a0e24295ab900
- Stored copy intact
- yes, hashes match
- Assessed input intact
- yes, revision 1 matches the input digest
Carrier review
Resolved by adjuster · outcome overridden · 5.8 hours after it opened · Resolved in the carrier's review queue (synthetic).
Recorded facts revision 1
As asserted by the carrier. References are recorded, not verified: RegBench holds no copy of the documents they name.
- AI system
- claims-adjud v5.1 · internal · high-risk class: claims
- Governance attested
- True
- Testing report
- test://harborline/claims-adjud/2026Q1
- Model documentation
- doc://harborline/claims-adjud/5.1
- Feature classes
- medical_records, claims_history
- Protected factors used
- none
- External data (ECDIS)
- False
- Consumer report / credit
- False / False
- Data sources
- none recorded
- Decision
- partial pay · score 0.552
- Human review
- yes (adjuster)
- Adverse to consumer
- True
- Notice
- not recorded · reasons: False · specific: False · external data disclosed: False
- Appeal channel
- –
- Consumer token
- tok_fc1e962a0f