insurance-claim-coverage-analysis

What problem does it solve?

This Skill helps you identify whether insurance claim materials may trigger exclusion clauses, assess the overall denial risk level, and produce a責任认定审查建议 instead of guessing.

Core Features & Use Cases

• OCR-based exclusion screening: Extracts key fields from submitted claim images (e.g., diagnosis, treatment course, accident context) and matches them against common免责条款 patterns to detect potentially triggered items.
• Coverage responsibility assessment: Checks whether the incident appears to fall within the policy’s coverage scope by aligning险种责任、保险期间、给付限额 requirements.
• Fee responsibility mapping: Aligns fee items with what the policy is likely to cover (fee types and hospital/grade constraints where available) to support the overall risk conclusion.
• Risk-tiered output: Produces a structured result with low/medium/high risk or “pending” when key information is missing, and includes a clear handling recommendation (pass/deny/pending) for claim compliance review.

Quick Start

Ask the AI to analyze whether your claim case may trigger免责条款 by providing the claim material image paths and the relevant policy clause text or policy number.