{
  "schemaVersion": 1,
  "name": "Insurance claims (RJL demo)",
  "version": "1.0.0",
  "namespace": "https://rjlsol.com/ontology/demo/insurance-claims/",
  "namespaceNote": "Demonstration namespace for a synthetic scenario.",
  "goal": "Give an AI assistant and a claims workflow the approved meaning they need to prepare case context for an examiner.",
  "scope": "One synthetic disability claim under a group policy at a composite insurer. Synthetic data only.",
  "concepts": [
    {
      "id": "claim",
      "label": "Claim",
      "definition": "A request for benefits under a policy, filed for one loss and handled as one case in the claims system.",
      "aliases": [
        "case"
      ],
      "group": "Core",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "claimant",
      "label": "Claimant",
      "definition": "The person who filed the claim and whose loss it concerns. When a claims examiner says customer, they mean the claimant.",
      "aliases": [
        "customer (claims system)"
      ],
      "group": "Party role",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "policyholder",
      "label": "Policyholder",
      "definition": "The party that holds the policy. For a group policy this is the employer that bought the coverage, not the covered employee. In policy administration and the customer system, the customer is the policyholder.",
      "aliases": [
        "customer (policy administration)"
      ],
      "group": "Party role",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "insured",
      "label": "Insured",
      "definition": "A person whose life or health the policy covers. Under a group policy each covered employee is an insured.",
      "aliases": [
        "covered person"
      ],
      "group": "Party role",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "payee",
      "label": "Payee",
      "definition": "The party who receives a payment on a claim. Often the claimant, but recorded separately because it can differ.",
      "aliases": [],
      "group": "Party role",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "group-policy",
      "label": "Group policy",
      "definition": "A policy held by an employer that covers many employees. Claims filed by different employees share the policy but not the claimant.",
      "aliases": [],
      "group": "Core",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "policy-date",
      "label": "Policy date",
      "definition": "The effective date recorded for the policy in policy administration. In this scenario it selects the applicable procedure.",
      "aliases": [],
      "group": "Dates",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "notice-date",
      "label": "Notice date",
      "definition": "The date the insurer first received notice of the claim, recorded in the claims system.",
      "aliases": [
        "date of notice"
      ],
      "group": "Dates",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "applicable-procedure",
      "label": "Applicable procedure",
      "definition": "The claims-handling procedure version in force on the policy date. A newer approved version does not replace it for claims whose policy date falls earlier.",
      "aliases": [
        "current procedure"
      ],
      "group": "Rules",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "prior-claims",
      "label": "Prior claims",
      "definition": "Earlier claims filed by the same claimant. Claims filed by other employees under the same group policy are not the claimant's prior claims and must not be shown to the examiner for this case.",
      "aliases": [
        "claims history"
      ],
      "group": "Rules",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "open-claim-reserving",
      "label": "Open claim (reserving)",
      "definition": "A claim with an outstanding reserve greater than zero at the reporting date, including claims closed pending final payment and reopened claims.",
      "aliases": [
        "open claim"
      ],
      "group": "Metrics",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    },
    {
      "id": "open-claim-service",
      "label": "Open claim (service reporting)",
      "definition": "A claim whose status is Open or Reopened at the reporting date. Claims closed pending payment are excluded because the examiner's work is complete.",
      "aliases": [
        "open claim"
      ],
      "group": "Metrics",
      "status": "approved",
      "reviewer": "RJL Solutions demo (synthetic, not an authenticated approval)",
      "lifecycle": {
        "state": "active"
      },
      "sourceId": "rjl-book-ch12"
    }
  ],
  "relations": [
    {
      "from": "claim",
      "type": "filedBy",
      "to": "claimant",
      "status": "approved"
    },
    {
      "from": "claim",
      "type": "filedUnder",
      "to": "group-policy",
      "status": "approved"
    },
    {
      "from": "group-policy",
      "type": "heldBy",
      "to": "policyholder",
      "status": "approved"
    },
    {
      "from": "group-policy",
      "type": "covers",
      "to": "insured",
      "status": "approved"
    },
    {
      "from": "claim",
      "type": "paysTo",
      "to": "payee",
      "status": "approved"
    },
    {
      "from": "applicable-procedure",
      "type": "selectedBy",
      "to": "policy-date",
      "status": "approved"
    }
  ],
  "sources": [
    {
      "id": "rjl-book-ch12",
      "title": "The Day After the Demo, Chapter 12: Meaning before the query",
      "kind": "reference",
      "url": "https://rjlsol.com/book"
    }
  ],
  "draftsIncluded": false
}