# Examples — Insurance Policy Coverage Agent

## Clearly covered → cited explanation with limits

A coverage question the policy directly addresses. The agent explains it and surfaces the deductible.

**Input**

```
Member: 'Is windshield damage covered?' Policy comprehensive section covers glass with a $100 deductible.
```

**Output**

```
{
  "question": "Is windshield damage covered?",
  "covered_by_policy_doc": true,
  "explanation": "Your policy's comprehensive coverage includes glass damage such as a windshield, subject to your deductible. So windshield damage would generally fall under comprehensive coverage per your policy.",
  "citation": "Auto Policy, Comprehensive Coverage §C-3 'Glass'",
  "limits_exclusions": ["$100 comprehensive deductible applies", "Coverage is subject to the comprehensive section conditions"],
  "claim_guarantee": "none — coverage explanation is not a claim decision",
  "route_to": "self_serve",
  "escalation": { "needed": false, "reason": "" }
}
```

**Note:** The explanation is grounded in the policy with a section citation and honestly surfaces the $100 deductible — not just the good news. Note it explains coverage in general terms and explicitly does not say a specific claim 'will be paid.'

## Not addressed / ambiguous → say so, route to a licensed agent

The policy doesn't clearly address the situation. The agent declines to guess and routes to a person.

**Input**

```
Member: 'Am I covered if I use my personal car for food delivery?' The policy doesn't clearly address rideshare/delivery use.
```

**Output**

```
{
  "question": "Coverage when using a personal car for food delivery",
  "covered_by_policy_doc": false,
  "explanation": "Your policy document doesn't clearly address using your personal vehicle for paid delivery or rideshare work, which is often handled differently (sometimes excluded or requiring a separate endorsement). I don't want to give you a wrong answer on something this important.",
  "citation": "",
  "limits_exclusions": ["Commercial/delivery use is commonly excluded or requires an endorsement — but your document is not explicit, so this needs confirmation"],
  "claim_guarantee": "none — coverage explanation is not a claim decision",
  "route_to": "licensed_agent",
  "escalation": { "needed": true, "reason": "Coverage for delivery use is not clearly addressed in the policy — routed to a licensed agent rather than guessed." }
}
```

**Note:** The policy is silent/ambiguous on delivery use, which is a high-stakes coverage question. Instead of guessing 'you're probably covered,' the agent says it's not clearly addressed, notes the common industry treatment as context (not a determination), and routes to a licensed agent. Guessing wrong here could leave a member uninsured.

## "Will my claim be paid?" → don't guarantee, explain + route to claims

The member wants a guarantee of payout. The agent explains coverage but refuses to promise a claim outcome.

**Input**

```
Member: 'I rear-ended someone. Will my claim definitely be paid? Just tell me yes.'
```

**Output**

```
{
  "question": "Will my claim for an at-fault collision definitely be paid?",
  "covered_by_policy_doc": true,
  "explanation": "Your policy includes liability coverage and, if you carry it, collision coverage that can apply to at-fault accidents, subject to your limits and deductible (per the policy). But I can't tell you a specific claim 'will definitely be paid' — that decision depends on the facts of the incident, the investigation, and your adjuster. What I can do is explain what your policy covers and get your claim to the right people.",
  "citation": "Auto Policy, Liability §A-1; Collision §C-1 (if elected)",
  "limits_exclusions": ["Collision deductible applies", "Coverage subject to policy limits and conditions; specific facts may affect the claim"],
  "claim_guarantee": "none — coverage explanation is not a claim decision",
  "route_to": "claims",
  "escalation": { "needed": true, "reason": "Member wants a claim-payment guarantee — explained coverage, declined to promise an outcome, and routed to claims." }
}
```

**Note:** The defining defensive case: pressed to guarantee a payout. The agent explains the relevant coverage with citations and the deductible, but firmly separates coverage explanation from the claim decision (facts + adjuster), refuses to promise 'yes,' and routes to claims. Guaranteeing a payout it can't control would create false expectations and liability.
