How it works
From claim file to documented decision
Follow how a claim file moves through the review: from the moment it arrives to a documented recommendation with a lawyer's name behind it.
01 · The duty
Evidence on every decision, not a sample
At low volume, evidencing fair value on each claim is a discipline. At high volume it becomes a gap: quality assurance samples a fraction of the book, and the rest is assumed to be fine. The Consumer Duty does not distinguish between the files you checked and the files you did not.
The files outside the sample are the exposure. Not because the decisions were careless, but because no one can show how they were reached.
02 · The challenge moment
What the Ombudsman asks
When a decision is challenged, the Financial Ombudsman Service asks whether the reasoning was documented at the time, not reconstructed afterwards. That question lands on every line you write.
Travel claims
High volume, low value, decided quickly. Exactly the files a sampling regime rarely reaches.
Motor & home claims
Longer files, more parties, more reports. More room for the record and the decision to drift apart.
Income protection claims
Long-running and medically complex. The reasoning has to hold up months or years after it was written.
Complaints & FOS referrals
The question changes from what was decided to how it was decided, and the file has to answer.
03 · How the review works
Every claim file read end-to-end. A lawyer signs off.
A claim file arrives
Any line, any length. A travel claim of forty pages or an income protection file running to hundreds.
Every page is read
The system reads the file end-to-end, not a sample of it. The timeline is structured and the findings are set against the policy terms.
Contradictions are flagged
Anything that does not line up is surfaced: dates that conflict, a report that contradicts a statement, terms applied differently from similar files.
The rationale is drafted
A fair-value rationale for the recommendation, consistent with how similar files were handled, written to be read later.
A lawyer reviews and signs off
Nothing goes back as machine output. A lawyer works through the file, the flags and the rationale, and signs off.
The recommendation goes back to your team
Documented, signed off, and on file. The reasoning exists before anyone asks for it.
04 · What you get
A documented fair-value rationale on every file
Every claim decision leaves with a lawyer-signed rationale behind it. When a complaint is raised or the Ombudsman asks, the evidence already exists; nothing has to be reconstructed. And full-depth review finds what sampling cannot. For one of our clients, moving from partial to full review surfaced 2% of previously-approved decisions that should not have gone the way they did, worth over $11M a year.
