MARKET: Insurance — Claims Processing & Fraud Detection

examples/45-market-insurance.halo policies |* parallel |! people

Automate the claims lifecycle — from initial filing through fraud scoring, adjuster review, payout calc, and disbursement. Replaces BPM tools (Camunda, Pega) that cost $500K+/year to license and maintain.

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// ============================================================
// MARKET: Insurance — Claims Processing & Fraud Detection
// PURPOSE: Automate the claims lifecycle — from initial filing
//          through fraud scoring, adjuster review, payout calc,
//          and disbursement. Replaces BPM tools (Camunda, Pega)
//          that cost $500K+/year to license and maintain.
// ============================================================

// --- Policies ---
policy ClaimsPrivacy   : Redact(SSN) & Redact(CreditCard) & Redact(HealthData)
policy FraudPolicy     : Block(DestructiveOps)
policy PayoutLimit     : Validate("amount", "<=", "context.data.verify_coverage.max_payout")
policy CostGuard       : MaxSpend(1.50)

// --- Tools ---
tool PolicyAPI     : REST("api.guidewire.com/v1/policies", apiKey: Env.GUIDEWIRE_KEY)
tool ClaimsDB      : REST("api.guidewire.com/v1/claims", apiKey: Env.GUIDEWIRE_KEY)
tool PaymentGW     : POST("api.stripe.com/v1/payouts", apiKey: Env.STRIPE_KEY)
tool AdjusterSlack : POST("hooks.slack.com/services/claims-team")

// --- Store ---
tool FraudPatterns : VectorStore(Env.PINECONE_KEY, namespace: "fraud-indicators")
tool ClaimHistory  : VectorStore(Env.PINECONE_KEY, namespace: "historical-claims")

// --- Struct ---
schema ClaimDecision {
  claim_id        : String
  fraud_score     : Number
  coverage_valid  : Boolean
  payout_amount   : Number
  decision        : String
  adjuster_notes  : String
}

// --- Agents ---
agent ClaimsBot [openai/gpt-4o-mini, temp: 0.0]
  equips PolicyAPI, PaymentGW
  requires ClaimsPrivacy, CostGuard

agent FraudAnalyst [anthropic/claude-sonnet-4, temp: 0.0]
  equips FraudPatterns, ClaimHistory
  requires ClaimsPrivacy, FraudPolicy, CostGuard

@correct(3)
agent AdjusterAssistant [openai/gpt-4o, temp: 0.2]
  equips ClaimHistory
  requires ClaimsPrivacy, CostGuard, PayoutLimit

// --- The Pipeline ---
@timeout(5m)
@retry(2, 10s)
pipeline ProcessClaim(claim: ClaimFiling) -> ClaimDecision:
  claim
    // Step 1: Parallel verification — policy lookup + fraud scoring
    |* {
         ClaimsBot.verify_coverage(
           tool: PolicyAPI,
           policy_number: context.data.claim.policy_number,
           incident_date: context.data.claim.incident_date,
           claim_type: context.data.claim.type
         ),
         FraudAnalyst.score_fraud(
           claimant: context.data.claim.claimant_name,
           amount_requested: context.data.claim.amount,
           incident_description: context.data.claim.description,
           submission_metadata: context.data.claim.metadata
         )
       }

    // Step 2: Gate — immediate flag if fraud score is high
    |? (context.data.score_fraud.fraud_score > 80)
    |> AdjusterSlack.post(
         message: "🚨 HIGH FRAUD RISK — manual review required immediately",
         claim_id: context.data.claim.claim_id,
         fraud_score: context.data.score_fraud.fraud_score,
         channel: "fraud-investigations"
       )
    |! yield(AdjusterSlack, context.data.score_fraud, [context.data.verify_coverage], 4h)
    ~> listen(AdjusterSlack.Reaction)

    // Step 3: Gate — reject if policy doesn't cover this claim type
    |? (context.data.verify_coverage.covered == false)

    // Step 4: Calculate payout based on coverage limits + damage assessment
    |> AdjusterAssistant.calculate_payout(
         coverage: context.data.verify_coverage,
         claim: context.data.claim,
         fraud_assessment: context.data.score_fraud,
         comparable_claims: ClaimHistory
       )

    // Step 5: Gate — auto-approve small, low-risk claims
    |? (context.data.calculate_payout.amount > 5000)
    |! yield(
         AdjusterSlack,
         context.data.calculate_payout,
         [context.data.verify_coverage, context.data.score_fraud],
         24h
       )
    ~> listen(AdjusterSlack.Reaction)

    // Step 6: Disburse payment
    |> ClaimsBot.disburse(
         tool: PaymentGW,
         claim_id: context.data.claim.claim_id,
         amount: context.data.calculate_payout.amount,
         method: context.data.claim.payment_method
       )

    // Step 7: Log to claims system
    |> ClaimsDB.post(
         event: "CLAIM_RESOLVED",
         claim_id: context.data.claim.claim_id,
         payout: context.data.calculate_payout.amount,
         fraud_score: context.data.score_fraud.fraud_score,
         decision: "approved"
       )