Ontology · insurance

auto-claims @2

Motor vehicle claims: policy, coverage, claim, incident, handling, money in and out.

17 classes, 27 relations, 1 rules, 0 actions, extends oto-core. oto registry add https://github.com/Cynergis/oto-registry, oto ontology add auto-claims, then oto init --ontology auto-claims.

Classes

Class	What it is	The question it answers	Why it exists
Document	A source document in the corpus: a policy wording, a bulletin, a procedure, a transcript.	Where is this written down?	Every fact needs a source that can be checked, and the source is a file with its own date.
Action	Something that can be done about an entity, described the way an MCP server describes a tool and bound to the graph. Oto lists it; the caller invokes it; the recorded run is evidence.	What can be done about this, and how?	The binding between an entity, the tool that acts on it, its inputs, its credentials by name and its preconditions is otherwise tribal knowledge in an agent's prompt; as a fact it is versioned, reviewed and shared. Oto never invokes it.
Policy	A contract of insurance, identified by a policy number and effective period.	Which policy was in force when this loss happened?	Cover is decided against a policy at a moment in time, so the policy must be a thing with a period, not a field on a claim.
Coverage	One protection within a policy, with its own limit and deductible.	Which coverage is this claim being paid under, and what limit applies?	Limits, deductibles and exclusions attach to a coverage rather than a policy, and payments are charged against one.
Endorsement	A change to a policy: an addition, removal or amendment of terms.	What changed on this policy, and from when?	A mid-term change alters cover for part of the period only, so it needs its own dates and its own source.
Claim	A request for payment made under a policy after an incident.	What is being asked for, under which policy, and what state is it in?	The claim is the unit of work and the unit of reporting, and it exists from first notice until closure.
Incident	The loss event itself: what happened, when and where. Distinct from the Claim reporting it.	What actually happened, and how many claims came out of it?	One event can produce several claims, and it happens before any of them is reported, so it needs its own date.
Vehicle	A motor vehicle, identified by its vehicle identification number.	Which vehicle was involved, and what has been claimed on it before?	A vehicle outlives any single policy or claim, so history attaches to it rather than to either.
Party	A person or organization involved: policyholder, claimant, third party, witness, repairer, medical provider.	Who is involved, and in what capacity?	Policyholder, claimant, third party, witness, repairer and provider all need to be referenced, and the same person can be more than one.
Role	A defined function in claims handling, such as adjuster, appraiser or examiner. A role is filled by a party.	Who is accountable for handling this, without naming a person?	Handling authority and workload attach to a function, and the person filling it changes while the history must stay correct.
Task	A unit of handling work on a claim, with an owner and a state.	What still has to happen on this claim, and who owns it?	Handling is a sequence of committed pieces of work with owners and states, which an attribute cannot carry.
Assessment	A damage appraisal, estimate or expert opinion supporting a decision.	What evidence supports the decision on quantum or damage?	An estimate or expert opinion has its own author and date, and a decision must be able to cite it.
Decision	A determination on a claim: coverage, liability, quantum, or a denial, with the reason recorded.	What was determined, when, and on what basis?	A determination has a date, a reason, evidence it relied on, and it can be superseded by a later one.
Payment	Money paid out, whether indemnity to a claimant or expense to a vendor.	What has been paid out, to whom, and against which coverage?	Each payment is charged to a coverage and made to a party, and the total is a question about many of them.
Recovery	Money recovered, whether by subrogation from a responsible party or by salvage disposal.	What came back in, and from whom?	Net cost is a question about money in and money out, and a model with only payments cannot answer it.
Procedure	A documented internal way of handling something: a guideline, a checklist, a service standard.	How are we supposed to handle this?	The documented way of working is what handling is measured against, and it changes over time.
Regulation	An external rule that constrains handling: a statute, a regulator's guidance, an industry standard.	What external rule constrains how we handle this?	An external rule has a source outside the organization and cannot be changed by it, which makes it a different kind of thing from a procedure.

Relations

Relation	From	To	Meaning
`cites`	Document	Document	This document refers to that one, so a fact traced to it can be traced one step further.
`acts_on`	Action		The entity a recorded run of this action read or changed.
`executed_by`	Action		Who is accountable for invoking this action: a team, never a person.
`covers`	Policy	Coverage	A policy provides this coverage.
`amended_by`	Policy	Endorsement	An endorsement changes this policy.
`insures`	Policy	Vehicle\|Party	A policy insures this vehicle or party.
`held_by`	Policy	Party	The party that holds the policy.
`claims_under`	Claim	Policy	The policy a claim is made under.
`arises_from`	Claim	Incident	The incident a claim arises from.
`filed_by`	Claim	Party	The party who made the claim.
`claims_against`	Claim	Coverage	The coverage a claim is made against.
`involves`	Incident	Vehicle\|Party	A vehicle or party involved in the incident.
`part_of_claim`	Task\|Assessment\|Decision\|Payment\|Recovery	Claim	This item belongs to that claim.
`assigned_to`	Task	Role	The role responsible for a task.
`filled_by`	Role	Party	The party performing a role.
`follows`	Task	Procedure	The procedure a task follows.
`assesses`	Assessment	Vehicle	The vehicle an assessment examines.
`supports`	Assessment\|Document	Decision	Evidence relied on for a decision.
`decides`	Decision	Claim	The claim a decision is about.
`authorizes`	Decision	Payment	A decision that authorizes a payment.
`paid_to`	Payment	Party	Who a payment was made to.
`charged_to`	Payment	Coverage	The coverage a payment is charged against.
`recovered_from`	Recovery	Party	The party a recovery came from.
`governs`	Regulation	Procedure	A rule that constrains a procedure.
`documented_in`	Procedure\|Regulation\|Policy	Document	Where this is written down.
`supersedes`	Procedure\|Regulation\|Policy\|Coverage	Procedure\|Regulation\|Policy\|Coverage	This replaced that. Use with the temporal fields, never by overwriting.
`performs`	Role	Procedure	The role that carries out this procedure.