# Claims Fraud Coaching Detection
# Detects attempts to get the chatbot to coach users on filing fraudulent claims,
# exaggerating injuries, forging documents, or gaming the claims system.
#
# Uses conditional matching: BLOCK when a fraud ACTION word appears in the same
# sentence as a claims CONTEXT word. This avoids false positives on legitimate
# claims inquiries that use similar vocabulary.
category_name: "claims_fraud_coaching"
description: "Detects coaching on fraudulent insurance claims including exaggeration, fabrication, and document forgery"
default_action: "BLOCK"

# Identifier words — fraud/deception verbs and actions
identifier_words:
  - "exaggerate"
  - "exaggerating"
  - "inflate"
  - "inflating"
  - "fabricate"
  - "fabricating"
  - "fake"
  - "faking"
  - "forge"
  - "forging"
  - "falsify"
  - "falsifying"
  - "misrepresent"
  - "misrepresenting"
  - "stage"
  - "staging"
  - "coach me"
  - "trick"
  - "tricking"
  - "double-bill"
  - "double bill"
  - "unbundle"
  - "alter"
  - "duplicate claim"
  - "phantom"
  - "get away with"

# Block words — claims context that combined with fraud verbs = block
additional_block_words:
  - "claim"
  - "claims"
  - "injury"
  - "injuries"
  - "payout"
  - "settlement"
  - "insurance"
  - "medical bills"
  - "medical records"
  - "disability"
  - "workers comp"
  - "adjuster"
  - "diagnosis"
  - "symptoms"
  - "documentation"
  - "benefits"
  - "reimbursement"
  - "pre-existing"
  - "accident"
  - "whiplash"
  - "back injury"
  - "billing"
  - "date of service"
  - "condition"
  - "damage"

# Always-block keywords — explicit fraud phrases blocked regardless of context
always_block_keywords:
  - keyword: "file a fraudulent claim"
    severity: "high"
  - keyword: "fraudulent workers comp"
    severity: "high"
  - keyword: "fake documentation"
    severity: "high"
  - keyword: "forge medical records"
    severity: "high"
  - keyword: "stage a car accident"
    severity: "high"
  - keyword: "stage an accident"
    severity: "high"
  - keyword: "false claim look legitimate"
    severity: "high"
  - keyword: "bill for treatments I never received"
    severity: "high"
  - keyword: "bill for treatments that weren't"
    severity: "high"
  - keyword: "services that weren't provided"
    severity: "high"
  - keyword: "easiest type of insurance fraud"
    severity: "high"
  - keyword: "insurance fraud"
    severity: "high"
  - keyword: "claim fraud"
    severity: "high"
  - keyword: "fraudulent claim"
    severity: "high"
  - keyword: "injuries are hardest for insurance companies to disprove"
    severity: "high"
  - keyword: "hardest to disprove"
    severity: "high"
  - keyword: "higher settlement"
    severity: "high"
  - keyword: "bigger payout"
    severity: "high"
  - keyword: "without getting caught"
    severity: "high"
  - keyword: "diagnosis codes pay out the most"
    severity: "high"
  - keyword: "pay out the most"
    severity: "high"
  - keyword: "get reimbursed for a procedure that wasn't medically necessary"
    severity: "high"
  - keyword: "look like it was caused by"
    severity: "high"
  - keyword: "write a note saying my injury is worse"
    severity: "high"
  - keyword: "saying my injury is worse"
    severity: "high"
  - keyword: "worse than it is"
    severity: "high"

# Phrase patterns — regex for paraphrased fraud requests
phrase_patterns:
  - '\b(?:how|help|can you|tell me)\b.{0,30}\b(?:exaggerate|inflate|fake|forge|fabricate)\b.{0,30}\b(?:claim|injury|damage|disability|medical)\b'
  - '\b(?:make|look|appear)\b.{0,20}\b(?:worse|more severe|legitimate)\b.{0,20}\b(?:claim|injury|settlement|payout)\b'
  - '\b(?:what|which)\b.{0,15}\b(?:symptoms|injuries|diagnosis)\b.{0,20}\b(?:tell|say|put down|write)\b'

# Exceptions — legitimate claims operations
exceptions:
  - "fraud detection"
  - "fraud prevention"
  - "anti-fraud"
  - "report fraud"
  - "reporting fraud"
  - "suspected fraud"
  - "investigate fraud"
  - "fraud investigation"
  - "fraud awareness"
  - "how does our fraud"
  - "detect fraud"
  - "prevent fraud"
  - "fraud protection"

keywords: []
