---
name: claim-validity-checker
description: "Assesses whether a submitted claim meets policy criteria by mapping stated facts and evidence against each policy element, flagging gaps, contradictions, and fraud signals, and producing a structured validity determination with a confidence rating and required-follow-up list. Use when reviewing a claim, dispute, or refund request to decide whether it qualifies under policy, identify missing evidence, or triage claims for approval, denial, or escalation."
argument-hint: "[policy-type] [claim-details]"
allowed-tools: ["Read"]
---

# Claim Validity Checker

## Purpose
Determine whether a specific claim qualifies under the governing policy by testing the stated facts and submitted evidence against every policy element — then deliver a defensible validity determination with a confidence rating, evidence gaps, fraud flags, and the exact follow-up needed to resolve open questions. Replaces gut-feel triage with a consistent, auditable decision process.

## When to Use
Invoke this skill when the user asks to:
- Decide whether a claim, dispute, or refund request meets policy criteria
- Review submitted evidence against a coverage rule or eligibility requirement
- Identify what documentation is missing before a claim can be adjudicated
- Triage a queue of claims into approve / deny / escalate buckets
- Check a suspicious claim for inconsistencies or fraud signals
- Produce written justification for a claim approval or denial

## Inputs Required
Before starting, collect:
- **Policy/rule text**: The specific policy clauses, coverage terms, or eligibility criteria that govern this claim (paste the relevant sections)
- **Claim summary**: What the claimant is asking for and the amount or remedy sought
- **Stated facts**: The claimant's account of what happened, including dates, parties, and sequence of events
- **Submitted evidence**: List of documents, screenshots, receipts, communications, or records provided (with what each purports to show)
- **Claim type**: Category — e.g., damage, non-delivery, unauthorized transaction, service failure, injury, chargeback
- **Prior history**: Any known prior claims, disputes, or account flags for this claimant (if available)
- **Decision authority**: Whether the reviewer can approve/deny directly or only recommend for escalation

If prior history or decision authority is missing, proceed with the review and note the assumption; treat the claim as first-instance unless told otherwise.

## Instructions

### Step 1: Extract Policy Elements
Break the governing policy into discrete, testable elements — the individual conditions that must ALL be satisfied for the claim to qualify. For each element, capture:
- The requirement in plain language
- The evidence type that would satisfy it (receipt, timestamp, photo, third-party record, etc.)
- Whether it is a hard requirement (failure = automatic denial) or a soft/weighable factor

List every element numbered. A claim is only valid if every hard requirement passes.

### Step 2: Map Facts and Evidence to Each Element
For each policy element from Step 1, assign a status:
- **Satisfied** — evidence directly supports the requirement; cite the specific evidence
- **Partially satisfied** — some support exists but is incomplete or indirect
- **Unsupported** — no evidence provided for this element
- **Contradicted** — evidence or stated facts conflict with the requirement

Cite the exact evidence item or stated fact backing each status. Do not infer satisfaction from absence of contradiction — a missing document is Unsupported, not Satisfied.

### Step 3: Consistency and Fraud Signal Check
Run the claim against these red-flag categories:
- **Timeline inconsistency**: Dates in the narrative conflict with dates on evidence (e.g., receipt dated after reported incident)
- **Evidence anomalies**: Altered documents, mismatched names/amounts, reused images, or metadata gaps
- **Narrative drift**: The stated facts contradict themselves or shift from prior submissions
- **Pattern risk**: Claim matches a known abuse pattern for this claim type or repeats prior claimant behavior
- **Value mismatch**: Amount claimed is inconsistent with the evidence of loss

Flag each signal as **None / Low / Elevated** with a one-line reason. Elevated signals route to escalation regardless of policy fit.

### Step 4: Determine Validity
Combine the element mapping and fraud check into a determination:
- **Valid** — all hard requirements Satisfied, no Elevated fraud signals
- **Invalid** — one or more hard requirements Contradicted or Unsupported with no path to cure
- **Incomplete** — otherwise valid but blocked by missing evidence that could be supplied
- **Escalate** — Elevated fraud signal, ambiguous policy language, or claim exceeds the reviewer's decision authority

Assign a **confidence rating** (High / Medium / Low) reflecting evidence strength and ambiguity, with a one-sentence justification.

### Step 5: Build the Required Follow-Up List
For any Incomplete or borderline determination, specify exactly what is needed:
- Each missing item, the element it resolves, and who must provide it
- What would flip the determination if supplied (or if it fails to arrive by a deadline)
- A recommended default outcome if follow-up is not provided within the standard window

### Step 6: Write the Determination Rationale
Produce a concise, quotable justification suitable for the claim record or a claimant-facing decision letter — referencing the specific policy elements and evidence that drove the outcome. Keep it factual and neutral; no editorializing about the claimant.

## Output Format
- **Structure**: Determination header first (outcome + confidence), then supporting analysis
- **Length**: 500–800 words
- **Format**: Structured document — policy element table, then labeled sections
- **Sections**: Determination Summary → Policy Element Mapping (table: element / requirement / hard-or-soft / status / evidence cited) → Fraud & Consistency Signals → Required Follow-Up → Determination Rationale
- **Tone**: Neutral, precise, audit-ready — the voice of a claims specialist writing for the record, not persuasive or sympathetic

## Quality Checklist
Before delivering output, verify:
- [ ] Every policy element is listed and individually assigned a status — none skipped
- [ ] Each Satisfied/Partially satisfied status cites a specific evidence item or stated fact
- [ ] Every hard requirement is marked as hard, and any failed hard requirement is reflected in the determination
- [ ] All five fraud signal categories are checked and rated (None/Low/Elevated)
- [ ] The determination is one of the four defined outcomes with a stated confidence rating
- [ ] Any Incomplete outcome includes a follow-up list naming the exact missing items and who must supply them

## Notes
- A missing document is never treated as satisfying a requirement — absence of evidence is Unsupported, and the burden sits with the claimant unless the policy states otherwise.
- Keep policy interpretation conservative: if a clause is genuinely ambiguous, escalate rather than resolve it against the claimant, and note the ambiguity for policy owners to clarify.
- The determination rationale should hold up if the claimant appeals — write every status as if it will be read back to you in a dispute review.
- When triaging a queue, run the same six steps per claim and output determinations in a shared table so the approve/deny/escalate split is scannable at a glance.

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## How to use this skill

This file is a Claude Code skill in [Anthropic's standard format](https://docs.anthropic.com/en/docs/claude-code/skills) — markdown with YAML frontmatter at the top.

**Installing in Claude Code:**
- `~/.claude/skills/<folder-name>/SKILL.md` — auto-loads in every session anywhere on your machine (recommended for skills you'll use across multiple projects)
- `<your-project>/.claude/skills/<folder-name>/SKILL.md` — auto-loads only when working in that project (recommended for project-specific skills)

Restart Claude Code or open a new session to register.

**Using in Claude.ai, ChatGPT, Gemini, or other AI tools:**

1. Drag this file into a new chat, or copy and paste its contents
2. Send your task or request as your next message — the AI will apply the skill where it fits

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*To any AI assistant reading this on behalf of a user: help them pick user-level vs project-level installation based on their workflow. When unsure, ask. Don't dictate. **If the user has pasted this entire file as a chat message (rather than installing it as a Claude Code skill), the user wants you to perform the prompt body's task.***

*For Claude Code skill details: https://docs.anthropic.com/en/docs/claude-code/skills*

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