{
  "test_cases": [
    {
      "case_id": "TC001",
      "case_name": "Simple Consultation - Approved",
      "description": "Regular doctor consultation for fever, all documents valid",
      "input_data": {
        "member_id": "EMP001",
        "member_name": "Rajesh Kumar",
        "treatment_date": "2024-11-01",
        "claim_amount": 1500,
        "documents": {
          "prescription": {
            "doctor_name": "Dr. Sharma",
            "doctor_reg": "KA/45678/2015",
            "diagnosis": "Viral fever",
            "medicines_prescribed": ["Paracetamol 650mg", "Vitamin C"]
          },
          "bill": {
            "consultation_fee": 1000,
            "diagnostic_tests": 500,
            "test_names": ["CBC", "Dengue test"]
          }
        }
      },
      "expected_output": {
        "decision": "APPROVED",
        "approved_amount": 1350,
        "deductions": {
          "copay": 150
        },
        "confidence_score": 0.95
      }
    },
    {
      "case_id": "TC002",
      "case_name": "Dental Treatment - Partial Approval",
      "description": "Root canal treatment with cosmetic whitening",
      "input_data": {
        "member_id": "EMP002",
        "member_name": "Priya Singh",
        "treatment_date": "2024-10-15",
        "claim_amount": 12000,
        "documents": {
          "prescription": {
            "doctor_name": "Dr. Patel",
            "doctor_reg": "MH/23456/2018",
            "diagnosis": "Tooth decay requiring root canal",
            "procedures": ["Root canal treatment", "Teeth whitening"]
          },
          "bill": {
            "root_canal": 8000,
            "teeth_whitening": 4000
          }
        }
      },
      "expected_output": {
        "decision": "PARTIAL",
        "approved_amount": 8000,
        "rejected_items": ["Teeth whitening - cosmetic procedure"],
        "confidence_score": 0.92
      }
    },
    {
      "case_id": "TC003",
      "case_name": "Limit Exceeded - Rejected",
      "description": "Claim exceeds per-claim limit",
      "input_data": {
        "member_id": "EMP003",
        "member_name": "Amit Verma",
        "treatment_date": "2024-10-20",
        "claim_amount": 7500,
        "documents": {
          "prescription": {
            "doctor_name": "Dr. Gupta",
            "doctor_reg": "DL/34567/2016",
            "diagnosis": "Gastroenteritis",
            "medicines_prescribed": ["Antibiotics", "Probiotics"]
          },
          "bill": {
            "consultation_fee": 2000,
            "medicines": 5500
          }
        }
      },
      "expected_output": {
        "decision": "REJECTED",
        "rejection_reasons": ["PER_CLAIM_EXCEEDED"],
        "notes": "Claim amount exceeds per-claim limit of ₹5000",
        "confidence_score": 0.98
      }
    },
    {
      "case_id": "TC004",
      "case_name": "Missing Documents - Rejected",
      "description": "Prescription missing from claim submission",
      "input_data": {
        "member_id": "EMP004",
        "member_name": "Sneha Reddy",
        "treatment_date": "2024-10-25",
        "claim_amount": 2000,
        "documents": {
          "bill": {
            "consultation_fee": 1500,
            "medicines": 500
          }
        }
      },
      "expected_output": {
        "decision": "REJECTED",
        "rejection_reasons": ["MISSING_DOCUMENTS"],
        "notes": "Prescription from registered doctor is required",
        "confidence_score": 1.0
      }
    },
    {
      "case_id": "TC005",
      "case_name": "Pre-existing Condition - Waiting Period",
      "description": "Diabetes treatment within waiting period",
      "input_data": {
        "member_id": "EMP005",
        "member_name": "Vikram Joshi",
        "member_join_date": "2024-09-01",
        "treatment_date": "2024-10-15",
        "claim_amount": 3000,
        "documents": {
          "prescription": {
            "doctor_name": "Dr. Mehta",
            "doctor_reg": "GJ/56789/2014",
            "diagnosis": "Type 2 Diabetes",
            "medicines_prescribed": ["Metformin", "Glimepiride"]
          },
          "bill": {
            "consultation_fee": 1000,
            "medicines": 2000
          }
        }
      },
      "expected_output": {
        "decision": "REJECTED",
        "rejection_reasons": ["WAITING_PERIOD"],
        "notes": "Diabetes has 90-day waiting period. Eligible from 2024-11-30",
        "confidence_score": 0.96
      }
    },
    {
      "case_id": "TC006",
      "case_name": "Alternative Medicine - Approved",
      "description": "Ayurvedic treatment within limits",
      "input_data": {
        "member_id": "EMP006",
        "member_name": "Kavita Nair",
        "treatment_date": "2024-10-28",
        "claim_amount": 4000,
        "documents": {
          "prescription": {
            "doctor_name": "Vaidya Krishnan",
            "doctor_reg": "AYUR/KL/2345/2019",
            "diagnosis": "Chronic joint pain",
            "treatment": "Panchakarma therapy"
          },
          "bill": {
            "consultation_fee": 1000,
            "therapy_charges": 3000
          }
        }
      },
      "expected_output": {
        "decision": "APPROVED",
        "approved_amount": 4000,
        "notes": "Alternative medicine covered under policy",
        "confidence_score": 0.89
      }
    },
    {
      "case_id": "TC007",
      "case_name": "Diagnostic Tests - Pre-auth Required",
      "description": "MRI scan without pre-authorization",
      "input_data": {
        "member_id": "EMP007",
        "member_name": "Suresh Patil",
        "treatment_date": "2024-11-02",
        "claim_amount": 15000,
        "documents": {
          "prescription": {
            "doctor_name": "Dr. Rao",
            "doctor_reg": "AP/67890/2017",
            "diagnosis": "Suspected lumbar disc herniation",
            "tests_prescribed": ["MRI Lumbar Spine"]
          },
          "bill": {
            "mri_scan": 15000
          }
        }
      },
      "expected_output": {
        "decision": "REJECTED",
        "rejection_reasons": ["PRE_AUTH_MISSING"],
        "notes": "MRI requires pre-authorization for claims above ₹10000",
        "confidence_score": 0.94
      }
    },
    {
      "case_id": "TC008",
      "case_name": "Fraud Detection - Manual Review",
      "description": "Multiple high-value claims same day",
      "input_data": {
        "member_id": "EMP008",
        "member_name": "Ravi Menon",
        "treatment_date": "2024-10-30",
        "claim_amount": 4800,
        "previous_claims_same_day": 3,
        "documents": {
          "prescription": {
            "doctor_name": "Dr. Khan",
            "doctor_reg": "UP/45678/2016",
            "diagnosis": "Migraine",
            "medicines_prescribed": ["Sumatriptan", "Propranolol"]
          },
          "bill": {
            "consultation_fee": 2000,
            "medicines": 2800
          }
        }
      },
      "expected_output": {
        "decision": "MANUAL_REVIEW",
        "flags": ["Multiple claims same day", "Unusual pattern detected"],
        "confidence_score": 0.65
      }
    },
    {
      "case_id": "TC009",
      "case_name": "Excluded Treatment - Rejected",
      "description": "Weight loss treatment not covered",
      "input_data": {
        "member_id": "EMP009",
        "member_name": "Anita Desai",
        "treatment_date": "2024-10-18",
        "claim_amount": 8000,
        "documents": {
          "prescription": {
            "doctor_name": "Dr. Banerjee",
            "doctor_reg": "WB/34567/2015",
            "diagnosis": "Obesity - BMI 35",
            "treatment": "Bariatric consultation and diet plan"
          },
          "bill": {
            "consultation_fee": 3000,
            "diet_plan": 5000
          }
        }
      },
      "expected_output": {
        "decision": "REJECTED",
        "rejection_reasons": ["SERVICE_NOT_COVERED"],
        "notes": "Weight loss treatments are excluded from coverage",
        "confidence_score": 0.97
      }
    },
    {
      "case_id": "TC010",
      "case_name": "Network Hospital - Cashless Approved",
      "description": "Treatment at network hospital with instant approval",
      "input_data": {
        "member_id": "EMP010",
        "member_name": "Deepak Shah",
        "treatment_date": "2024-11-03",
        "claim_amount": 4500,
        "hospital": "Apollo Hospitals",
        "cashless_request": true,
        "documents": {
          "prescription": {
            "doctor_name": "Dr. Iyer",
            "doctor_reg": "TN/56789/2013",
            "diagnosis": "Acute bronchitis",
            "medicines_prescribed": ["Antibiotics", "Bronchodilators"]
          },
          "bill": {
            "consultation_fee": 1500,
            "medicines": 3000
          }
        }
      },
      "expected_output": {
        "decision": "APPROVED",
        "approved_amount": 3600,
        "cashless_approved": true,
        "network_discount": 900,
        "confidence_score": 0.93
      }
    }
  ],
  "validation_notes": {
    "scoring_guidelines": [
      "Each test case should complete within 5 seconds",
      "Confidence scores should be provided for all decisions",
      "System should handle edge cases gracefully",
      "Clear reasoning should be provided for rejections"
    ],
    "bonus_test_scenarios": [
      "Handle illegible/blurry document images",
      "Process handwritten prescriptions",
      "Detect forged/modified documents",
      "Handle claims in regional languages",
      "Process multiple receipts in single claim"
    ]
  }
}