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Fictional product rules and scenario catalog
Status: accepted. The owner accepted this rule set with "Yes, proceed" after reviewing the proposed product outcomes, payment applicability, and deferrals. The authoritative resolution is in Define fictional product rules and exception scenarios for selected journeys. This catalog defines synthetic demo behavior, not real insurance terms, medical judgments, or legal eligibility rules. It preserves the accepted journey scope, role matrix, and record ownership.
Common review behavior
Use human review for the selected decisions. An assigned reviewer can approve, request additional information, or decline with a customer-facing reason. A manager makes employer leave/RTW decisions within their existing role boundary. Required-field, date, ownership, and amount checks remain deterministic backend validation. CMS conditions and browser validation provide interaction guidance, not authority to approve a submission.
Applications and claims can be saved as drafts. Required information is checked on submission and again by the owning business service before a decision. A request for information returns the case to the customer for a correction or document; it does not silently create a second case. Exact task/state contracts belong to the workflow decision.
No automated medical underwriting, actuarial pricing, clinical judgment, statutory leave eligibility engine, tax calculation, or penalty calculation is included. Use illustrative seeded amounts and coverage data, clearly identified as synthetic, wherever an amount is needed.
Product scenarios
| Product | Minimum synthetic inputs | Successful outcome | Required exception |
|---|
| Life insurance | Customer reference, requested coverage, beneficiary details where supplied, declarations, and an EOI document when requested. | Assigned review accepts the complete application and creates coverage in the simulated system of record. | Reviewer requests missing EOI; customer supplies it and resumes the same application. |
| Medicare supplement | Customer reference, synthetic existing-coverage reference, requested effective date, and application declarations. | Complete application receives a simulated enrollment decision and resulting coverage record. | Reviewer requests missing application information; enrollment does not complete until it is supplied and accepted. No live Medicare verification occurs. |
| Disability income | Seeded coverage reference, claimed absence period, supporting evidence, and a payout-account reference. | Assigned reviewer approves a seeded benefit amount; a separate simulated payment outcome is recorded. A related leave case has its own manager decision. | Missing evidence pauses the claim; leave approval alone cannot release the insurance payout. |
| Dental | Seeded policy, synthetic service date/type, claimed amount, and claim evidence. | Reviewer approves a seeded allowed amount and the coverage owner updates benefit use once. The allowed amount must not exceed the claimed amount or available seeded benefit. | Invalid/excess requested benefit use cannot complete as an approved benefit update; the reviewer requests correction or declines with a reason. No separate dental payout journey is added. |
| Long-term care | Seeded coverage, requested benefit period, supporting evidence, and payout-account reference. | Complete evidence is accepted by the assigned reviewer, and a seeded benefit amount proceeds to simulated payout. | Missing required evidence produces a request for information; no benefit payment is released while review is incomplete. |
| Annuities | Seeded contract, a withdrawal amount, and a payout-account reference. | Choose withdrawal as the first annuity request variant. A positive amount within the available seeded balance can be reviewed and disbursed; successful completion reduces the balance once. | A request above the available balance is rejected. A failed disbursement must not be displayed as a completed withdrawal. Payout-schedule changes, taxes, and penalties are deferred. |
The seeded values supply repeatable data, not a new pricing engine. Exact fixture amounts, field schemas, and customer-facing copy belong to the specs after these rules are accepted. No product gains extra journeys by reusing a form or workflow.
Leave and return to work
Use a fictional employer policy with a continuous date range for each leave request. Demonstrate both isolated employers and the employee's reporting-manager relationship. Reject invalid date ranges; the manager can approve, request information, or decline with a reason. Intermittent-leave scheduling and jurisdiction-specific entitlement calculations are deferred.
For return to work, the employee supplies a proposed return date and requested supporting evidence. An assigned insurer reviewer reviews that evidence where required; the manager sees the resulting review status and relevant return information and can approve the return. Medical evidence remains hidden from the manager. Leave approval, evidence-review outcome, return-to-work approval, and disability-benefit decision remain separate records/steps.
Demonstrate a pending-evidence return request that cannot be treated as fully approved until the required review is completed. The exact manager-visible RTW fields and whether restrictions need structured fields remain security/workflow details. No clinical clearance claim is inferred from a synthetic review outcome.
Premium collection and disbursement applicability
- Demonstrate the shared ACH premium-collection flow against seeded individual life, Medicare supplement, dental, and long-term-care premium obligations. Disability is employer-funded in the initial fixtures; annuity funding/premium collection is not part of the selected annuity journey.
- Use direct-deposit account setup and simulated disbursement for approved disability and long-term-care benefits. The annuity withdrawal uses the disbursement capability with a contract-withdrawal purpose rather than an insurance-benefit claim.
- Dental demonstrates claim status and benefit use, without a separate disbursement flow. Employer leave approval never itself triggers an insurance payout.
- Use synthetic account data. A successful collection settles the corresponding obligation once; a failed collection leaves it unpaid. A failed payout remains visibly unsuccessful/pending recovery and must not appear settled. Retries must not duplicate collection, benefit use, or disbursement.
- Include one repeatable simulated payment failure/recovery scenario across the shared payment capability. Exact retry, reservation, reversal, and reconciliation mechanics belong to the API/workflow decisions.
Decision boundary
This decision fixes these fictional outcomes, evidence gates, product/payment applicability, the initial annuity withdrawal variant, and the stated deferrals. It does not settle BPMN diagrams, task assignment/reassignment mechanics, field-level authorization, payment reservation strategy, interface schemas, or runtime choices. Those remain in existing tickets.