Policy language on the chart
Stage IIB triggers the standard cancer benefit; Stage IV triggers the metastatic rider; first-heart-attack language excludes prior MI; carcinoma in situ pays at a quarter, not in full. Owl reads the pathology, the imaging and the policy, then maps the diagnosis to every benefit and rider that fires.
Pathology confirms invasive ductal carcinoma. Stage IIB. Policy §3.1 fires at any invasive malignancy excluding skin (basal/squamous).
Rider §3.2.b requires Stage IV or distant metastases. PET 2025-08-14 negative for distant disease. Lymph node N1 = regional, not distant.
Diagnosis is invasive, not in situ. CIS pays at 25% under §3.1.c, superseded by full §3.1 trigger.
Separate rider attached to the policy. Inpatient stay 2025-08-22 → 08-25 confirms 3-day eligible admission. Pays independently of CI benefit.
1 of 4
CI benefits triggered by this dx
$0
Metastatic rider ruled out by PET
12 mo
Pre-existing window checked vs. EHR
The diagnosis is the easy part. The policy says fourteen things have to be checked.
One claim: invasive ductal carcinoma, five riders, four checks per rider.
Anonymized composite. Claimant L.D., 47, Stage IIB invasive ductal carcinoma diagnosed 2025-07-22. Policy effective 2024-08-01. CI claim filed 2025-08-04.
External data only. None of this lives in your CMS. Owl gathered it from public records, professional networks, registries and the open web, then resolved it to this claimant.
External EHR pull (state HIE / Datavant) shows symptom documentation 38 days pre-effective-date, within the 12-month PEC lookback. Symptom: breast pain, evaluated 2024-06-22; no diagnosis at that visit, evaluation closed without follow-up.
External claim networks return no prior critical-illness claim with any other carrier for this claimant. Auto-clear on this dimension.
Corporate registry and tax public records show no material change in employment, business ownership, or income that would affect group-CI eligibility in the coverage period.
Standard cancer benefit only. Pathology confirms invasive ductal carcinoma, Stage IIB. The metastatic rider (§3.2.b) requires Stage IV or distant metastases. The PET scan dated 2025-08-14 is negative for distant disease. Lymph node involvement is regional (N1), which qualifies as Stage IIB but not metastatic. Standard benefit pays at 100% face under §3.1; metastatic rider does not fire.
Possibly. External EHR shows a 2024-06-22 visit (pre-effective-date) for breast pain, with no diagnosis at that visit and no follow-up. Under PEC §4.2, the question is whether the symptom was “manifest” before effective date. Recommend medical review: if breast pain is determined retrospectively to have been a manifestation of the eventual carcinoma, PEC applies and benefit is denied; if not, full benefit pays. We have flagged the visit and have the cited record.
What the world says about your Critical Illness claimants, none of which lives in your CMS.
Internal claim data is half the picture: it tells you what the claimant told you. OwlSignal continuously gathers external data (public records, professional and corporate registries, court dockets, social and open web) and matches it back to the claimant. These are the families that move the needle on Critical Illness.
The PEC window is the most consequential CI question. We pull external EHR (Datavant, state HIE), Rx history (Surescripts) and provider records, across the entire lookback, not just the records in your file.
Whether the claimant has a prior CI claim with another carrier, answered before adjudication, not after a regulatory complaint.
For employer-group CI, eligibility hinges on employment status at effective and at diagnosis. Sourced from corporate registries, state UI, and public payroll mentions, not from the certificate.
Address changes, marital changes, employer changes, dependent changes: anything that touches CI eligibility, riders or beneficiary structure.
Court dockets and adverse media, primarily relevant when application misrepresentation is in question on a contestable file.
Numbers from L&H carriers running Owl on Critical Illness in production.
Built for the regulatory shape of Critical Illness.
Lives where your Critical Illness files live.
Claim systems
FINEOS, Guidewire, DCS, in-house
Document intake
Box, OnBase, Documentum, ImageRight
EHR / records
Epic, Cerner, MRO, Verisma, Ciox/Datavant
Pharmacy
Surescripts, ScriptCheck, MIB Rx
Policy admin
Vitech, LifePRO, OIPA, in-house
Identity & SSO
Okta, Azure AD, PingFederate, SAML
Bring us your most-disputed CI rider. We’ll show you the trigger analysis on real files.
Two-week pilot. Your records, your tenant, your policy forms. We measure trigger accuracy, PEC defensibility, and cycle time against your own ground truth.