agent8_coverage_verify.py

"""
ClaimSense — Agent 8: Coverage Verification Agent
===================================================
Verifies whether the claimed incident is covered under the policy.
- Works for both linked (submission_id present) and standalone flows
- Checks incident type vs coverage type eligibility matrix
- Checks deductible, limits, exclusions
- No ML — pure rules engine
"""

import logging
from datetime import datetime, date

log = logging.getLogger(__name__)

# ── Coverage eligibility matrix ───────────────────────────────
# Maps coverage_type → set of covered incident types
COVERAGE_MATRIX = {
    'HO-3': {
        'FIRE', 'WIND', 'HAIL', 'THEFT', 'VANDALISM',
        'LIABILITY', 'VEHICLE_IMPACT', 'WATER', 'STRUCTURAL', 'OTHER'
    },
    'HO-5': {
        'FIRE', 'WIND', 'HAIL', 'THEFT', 'VANDALISM',
        'LIABILITY', 'VEHICLE_IMPACT', 'WATER', 'STRUCTURAL',
        'EARTHQUAKE', 'OTHER'
    },
    'HO-4': {  # Renters
        'FIRE', 'THEFT', 'VANDALISM', 'LIABILITY', 'WATER', 'OTHER'
    },
    'HO-6': {  # Condo
        'FIRE', 'THEFT', 'VANDALISM', 'LIABILITY', 'WATER', 'STRUCTURAL', 'OTHER'
    },
    'DP-3': {  # Dwelling
        'FIRE', 'WIND', 'HAIL', 'VANDALISM', 'VEHICLE_IMPACT', 'OTHER'
    },
    'WC-3': {
        'LIABILITY', 'OTHER'
    },
}

# Incident types typically excluded (require endorsement)
FLOOD_EXCLUDED      = {'HO-3', 'HO-4', 'HO-5', 'HO-6', 'DP-3'}
EARTHQUAKE_EXCLUDED = {'HO-3', 'HO-4', 'HO-6', 'DP-3'}


def run_coverage_verify_agent(fnol_result: dict, submission: dict) -> dict:
    """
    Agent 8 — Coverage Verification.

    Args:
        fnol_result:  Output from Agent 7 (FNOL Intake)
        submission:   Submission/policy data dict (may be empty for standalone)

    Returns:
        result dict with coverage_status, applicable_limit, deductible, exclusions
    """
    claim_id      = fnol_result.get('claim_id', '')
    incident_type = fnol_result.get('incident_type', 'OTHER')
    policy_number = fnol_result.get('policy_number', '')

    log.info(f"[COVERAGE] Agent 8 running for {claim_id}")

    # ── Pull policy details ───────────────────────────────────
    # Works for both linked (from DB via submission) and standalone
    coverage_type = (
        submission.get('_coverage_type_code') or
        submission.get('coverage_type_code') or
        (submission.get('policy_request') or {}).get('coverage_type') or
        'HO-3'  # safe default
    )

    coverage_limit = float(
        submission.get('_requested_coverage_limit') or
        (submission.get('policy_request') or {}).get('requested_coverage_limit') or
        300000
    )
    deductible = float(
        submission.get('_requested_deductible') or
        (submission.get('policy_request') or {}).get('requested_deductible') or
        2500
    )
    estimated_damage = float(
        fnol_result.get('normalised_fields', {}).get('estimated_damage') or 0
    )

    coverage_type = str(coverage_type).upper().strip()
    exclusions    = []
    partial_notes = []

    # ── Check eligibility matrix ──────────────────────────────
    covered_perils = COVERAGE_MATRIX.get(coverage_type, COVERAGE_MATRIX['HO-3'])

    if incident_type == 'FLOOD' and coverage_type in FLOOD_EXCLUDED:
        exclusions.append(
            f"FLOOD damage is excluded under {coverage_type}. "
            "Separate flood insurance (NFIP) required."
        )
    elif incident_type == 'EARTHQUAKE' and coverage_type in EARTHQUAKE_EXCLUDED:
        exclusions.append(
            f"EARTHQUAKE is excluded under {coverage_type}. "
            "Earthquake endorsement required."
        )
    elif incident_type not in covered_perils:
        exclusions.append(
            f"Incident type {incident_type} is not a covered peril under {coverage_type}."
        )

    # ── Limit checks ─────────────────────────────────────────
    applicable_limit = coverage_limit
    if estimated_damage > coverage_limit:
        partial_notes.append(
            f"Estimated damage ${estimated_damage:,.0f} exceeds "
            f"coverage limit ${coverage_limit:,.0f}. "
            f"Maximum payable: ${coverage_limit:,.0f}."
        )

    # ── Deductible check ──────────────────────────────────────
    net_payable = max(0, min(estimated_damage, coverage_limit) - deductible)
    if estimated_damage > 0 and estimated_damage <= deductible:
        partial_notes.append(
            f"Claimed amount ${estimated_damage:,.0f} does not exceed "
            f"deductible ${deductible:,.0f}. Claim may not result in payment."
        )

    # ── Final coverage status ─────────────────────────────────
    if exclusions:
        coverage_status = 'EXCLUDED'
    elif partial_notes:
        coverage_status = 'PARTIAL'
    else:
        coverage_status = 'COVERED'

    # ── Summary ───────────────────────────────────────────────
    if coverage_status == 'COVERED':
        summary = (
            f"Incident type {incident_type} is fully covered under {coverage_type}. "
            f"Coverage limit: ${coverage_limit:,.0f}. "
            f"Deductible: ${deductible:,.0f}. "
            f"Estimated net payable: ${net_payable:,.0f}."
        )
    elif coverage_status == 'PARTIAL':
        summary = (
            f"Incident {incident_type} is covered under {coverage_type} "
            f"but with limitations. " + " ".join(partial_notes)
        )
    else:
        summary = (
            f"Incident {incident_type} is NOT covered under {coverage_type}. "
            + " ".join(exclusions)
        )

    result = {
        'claim_id':          claim_id,
        'status':            f'COVERAGE_{coverage_status}',
        'coverage_status':   coverage_status,
        'coverage_type':     coverage_type,
        'policy_number':     policy_number,
        'applicable_limit':  applicable_limit,
        'deductible':        deductible,
        'estimated_damage':  estimated_damage,
        'net_payable_est':   net_payable,
        'exclusions':        exclusions,
        'partial_notes':     partial_notes,
        'summary':           summary,
    }

    log.info(
        f"[COVERAGE] {claim_id}: {coverage_status} | "
        f"type={coverage_type} | limit=${coverage_limit:,.0f} | "
        f"exclusions={len(exclusions)}"
    )
    return result