Critical Illness · CI
Critical Illness claims, checked against diagnosis, recurrence, and relationship rules
A Critical Illness benefit is a single, often large payment governed by the diagnosis, whether it is a first or subsequent occurrence, the time since a prior covered diagnosis, and whose coverage it is. Trestl checks those conditions before payment and can review the supporting clinical documentation.
Where errors hide
What goes wrong in Critical Illness claims
Most payment errors in fixed-benefit lines are not fraud. They are small mismatches between the claim and the plan, repeated across a book.
- A diagnosis outside the covered conditions
- A recurrence paid before the separation period ends
- A subsequent diagnosis paid at the first-occurrence rate
- Spouse or child benefits paid at the employee percentage
What Trestl checks
Critical Illness checks, before payment
Each check is configured to your plans. Applicability depends on your policy wording and the reference data available, which we confirm during discovery.
Covered diagnosis
Diagnosis codes are checked against the conditions the plan covers.
Recurrence separation
Confirms the required separation period since a prior covered diagnosis.
Subsequent-diagnosis rates
Validates the benefit percentage applied to subsequent diagnoses.
Relationship percentages
Spouse and child benefits are checked against the configured percentage of the employee amount.
Benefit amounts
Cancer benefit amounts are recalculated from the plan. Overpayments and underpayments are both flagged.
Clinical document review
AI-assistedPathology and clinical documents are compared with the claimed diagnosis to surface mismatches for analyst review.
Findings are presented for review with the rule and evidence behind them. Your team, or your authorized TPA, keeps claim adjudication, appeal, and payment authority.
Frequently asked questions
- Does Trestl replace our claims adjudication system?
- No. Trestl reviews claims before payment and presents findings to your analysts or returns them to your system. Your team, or your authorized TPA, keeps claim adjudication, appeal, and payment authority.
- Is an AI-assisted flag a denial?
- No. AI-assisted checks surface items for an analyst to review. An alert is not a final denial or a confirmed saving; people make the decision and the decision is recorded.
- Is clinical documentation used to train AI models?
- No. Documents are analyzed with Google Cloud Vertex AI inside our Google Cloud business associate agreement. Google Cloud’s service terms prohibit using customer content to train or fine-tune its models.
- Which Critical Illness conditions are covered by the checks?
- The diagnosis check uses the covered-condition list configured for your plans; the amount and clinical document checks currently focus on cancer benefits. We confirm coverage against your policy wording during discovery.
Start with your Critical Illness book
Start with a conversation about your book, the claim decisions that need attention, and who owns them. We will show the platform on synthetic data and agree whether a scoped review makes sense.