Medical Risk Assessment & Underwriting Decision Documentation
Structure Medical Underwriting Decisions with Risk Analysis & Compliance Docs
What You Can Do
Analyze applicant medical histories, financial profiles, and health metrics to produce structured underwriting recommendations. Claude generates clear risk assessments, identifies key medical findings, and recommends appropriate coverage levels with compliance-ready documentation. Each decision includes detailed rationale, red flags, and audit-trail support for your underwriting file.
Features
Parse and synthesize medical records, lab results, and health history into a clear clinical summary organized by system and severity
Classify applicants into risk tiers (Standard, Preferred, Rated, Decline) based on medical findings, age, occupation, and lifestyle factors
Suggest appropriate coverage amounts, riders, and exclusions tailored to the applicant's risk profile and medical conditions
Format decisions consistently with standardized sections: Summary, Key Medical Findings, Risk Assessment, Conditions/Exclusions, and Recommended Action
Generate audit-ready decision letters and underwriting memos with clear documentation of guidelines applied and exceptions justified
Automatically highlight high-risk factors, inconsistencies in medical history, and conditions requiring additional investigation or specialist review
Calculate and explain rating factors, surcharges, and premium adjustments based on identified risks and recommended coverage modifications
Create clear, plain-language explanations of underwriting decisions suitable for applicant communication and appeals documentation
Example Output
Example 1: Standard Risk Decision
Applicant Summary: 42-year-old male, non-smoker, $1M death benefit request
Key Medical Findings:
- Hypertension (controlled on lisinopril, BP 138/86)
- Mild hyperlipidemia (Total cholesterol 215, LDL 135)
- No prior cardiac events or family history of early MI
Risk Assessment: Standard Plus (Age/Health Rating +10%)
Recommended Decision: Approve $1M term life coverage with standard rates. Add 10% rate increase for hypertension management. Annual monitoring recommended.
Example 2: Rated Risk Decision with Conditions
Applicant Summary: 55-year-old female, smoker, $2M coverage requested
Key Medical Findings:
- Type 2 diabetes (A1C 7.2, on metformin)
- History of depression (treated, stable 3 years)
- Chronic bronchitis (3 exacerbations in past year)
Risk Assessment: Rated (Multiple Conditions) — 40% surcharge
Recommended Decision: Approve $1.5M with smoking rider (+25%). Require specialist clearance for pulmonary status. Annual health statement required. Coverage excludes respiratory-related claims first 2 years.
Example 3: Decline Decision
Applicant Summary: 38-year-old male, $5M coverage requested
Key Medical Findings:
- Recent diagnosis: Stage 3 kidney disease (eGFR 42)
- History: MI at age 35, now post-PCI with 2 stents
- Current labs: Troponin mildly elevated, BNP 180
Risk Assessment: Uninsurable — Decline
Recommended Decision: Decline at requested amount. Offer $250K simplified issue rider as alternative. Recommend reapplication after 3+ years of stability post-cardiac event.
What's Included
- Medical Data Intake Prompts: Structured prompts to guide you through applicant medical history, lab results, current medications, and family health background
- Risk Stratification Framework: Decision tree mapping medical conditions, age, lifestyle factors, and occupational hazards to standard underwriting risk categories
- Compliance-Ready Decision Templates: Pre-formatted sections for decision letters, underwriting memos, and appeal documentation that meet regulatory audit requirements
- Coverage Calculator: Guidance for calculating appropriate coverage limits, riders, exclusions, and premium adjustments based on risk profile
- Red Flag Checklist: Automated identification of high-risk conditions, inconsistent histories, and factors requiring specialist review or additional investigation
- Plain-Language Explainer Generator: Convert complex underwriting decisions into clear, applicant-friendly language suitable for decision notifications and appeals
Who It's For
- Underwriting Managers & Directors
- Medical Underwriters
- Risk Assessment Specialists
- Life Insurance Brokers & Agents
- Compliance & Audit Officers
Best For
- Individual life insurance underwriting decisions
- Group health benefit risk assessment
- Medical rating and coverage recommendations
- Underwriting appeals and exception documentation
- Compliance file preparation and audit trails
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