The Reasoning Pipeline in Action

This illustrative workflow traces a complex trauma claim—a Heart Attack benefit— from policy wording through structured, expert-validated logic to a traceable recommendation and human review path.

Structured policy knowledge

Approved policy reasoning

Recommendation & escalation

Illustrative example only. Semantic Labs supports authorised human decision-making; it does not replace evidence verification, legal interpretation or delegated authority.

STAGE 01

Stage 1: Structured policy knowledge

In trauma insurance, a 'Heart Attack' is defined through policy-specific clinical conditions. We structure those conditions into a source-linked representation for expert review.

The structured representation makes each condition inspectable. Where wording, evidence or interpretation is incomplete or ambiguous, the issue is recorded and routed for expert review.

Source Policy Text

'Heart Attack' means an acute myocardial infarction evidenced by the elevation of cardiac troponin in combination with acute ischemic ECG changes.

Structured policy condition

Heart Attack

requires

Troponin Elevation

flowchart TD %% Node Definitions %% AND-group Causes (Light Green) E1(["Diagnostic Criterion Subject: the diagnosis of a heart attack Requirement: is present"]) E2(["Required Diagnostic Evidence Subject: cardiac biomarkers Requirement: Typical rise and/or fall of cardiac biomarkers with at least one value above the 99th percentile of the upper reference range"]) E6(["Evidence Insufficiency Subject: the above tests Requirement: are inconclusive"]) %% OR-group Causes (Mid Green) E3(["Alternative Clinical Indicator Subject: signs and symptoms of ischemia Requirement: consistent with a heart attack"]) E4(["Alternative Clinical Indicator Subject: pathological Q waves in the ECG Requirement: development of"]) E5(["Alternative Clinical Indicator Subject: imaging evidence Requirement: of new loss of viable myocardium or new regional wall motion abnormality"]) %% Logic Gates I0{"AND (Prec: False)"} I2{"OR (Prec: False)"} I4{"AND (Prec: False)"} %% Effects E0[("Review Requirement Subject: coverage assessment Requirement: requires authorised review")] E7[(" Required Next Action Subject: inconclusive tests Requirement: will consider other appropriate and medically recognised tests")] %% Layout and Relationships E1 --> I0 E2 --> I0 E3 --> I2 E4 --> I2 E5 --> I2 I0 --> I2 I2 ==> E0 I2 --> I4 I4 --> E6 E6 ==> E7 %% Styling style E0 fill:#43D585,stroke:#09110C,stroke-width:4px,color:#09110C style E7 fill:#43D585,stroke:#09110C,stroke-width:4px,color:#09110C style I0 fill:#F5F6F2,stroke:#1B2A22,stroke-width:2px,color:#09110C style I2 fill:#F5F6F2,stroke:#1B2A22,stroke-width:2px,color:#09110C style I4 fill:#F5F6F2,stroke:#1B2A22,stroke-width:2px,color:#09110C %% Cause Colors: Light for AND-group, Mid Green for OR-group style E1 fill:#EAF3EC,stroke:#1B2A22 style E2 fill:#EAF3EC,stroke:#1B2A22 style E6 fill:#EAF3EC,stroke:#1B2A22 style E3 fill:#B8D8B8,stroke:#43D585 style E4 fill:#B8D8B8,stroke:#43D585 style E5 fill:#B8D8B8,stroke:#43D585

STAGE 02

Stage 2: Approved policy reasoning

We do not just search for 'Heart Attack' in medical records. We apply approved, version-controlled policy conditions to structured available evidence.

Relevant policy conditions and definitions

Evidence mapped to each condition

Dependencies and approved logic gates

Ambiguity, missing-evidence and exception paths

If a required condition is not supported by available evidence—or the matter falls outside approved logic—the system identifies the gap and routes it for authorised review rather than silently resolving uncertainty.

STAGE 03

Stage 3: Traceable recommendation and escalation

The output is a source-linked reasoning record, showing applicable policy conditions, available evidence, missing information, the relevant policy version and the required human review path.

Policy A

Requires Troponin elevation

Requires ECG changes

Requires Hospital Admission

Policy B

Requires Troponin elevation

Requires ECG changes

No admission required

Policy comparison and change impact

The comparison highlights that Policy B does not include the hospital-admission condition present in Policy A. An authorised product, claims or broker specialist can review the operational and customer implications.

Recommendation: expert review

AUTHORISED HUMAN REVIEW REQUIRED

• Troponin: 0.85 ng/mL ( > 0.04)

• ECG: ST-segment elevation found

Make policy reasoning inspectable and governable.

Test whether human-verified policy logic can improve consistency, review effort and audit reconstruction—initially in shadow mode.

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