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Automated claims processing system

A technology of automation system and processing system, which is applied in the field of insurance policy claim processing, and can solve problems such as rising insurance premiums

Inactive Publication Date: 2010-12-22
ASSURANT INC
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  • Summary
  • Abstract
  • Description
  • Claims
  • Application Information

AI Technical Summary

Problems solved by technology

At the same time, insurers and lenders bear the high costs associated with this rigorous claims investigation process, which puts upward pressure on insurance premiums

Method used

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Examples

Experimental program
Comparison scheme
Effect test

example 1

[0122] An application example of the ALV processing tool of the present invention is Figure 5 Life insurance policy claim shown. For life insurance policy claims 150 , ALV processing pre-assigns two sources of corroborating data: the Social Security Death Index (“SSDI”) 152 and the Obituary Index 154 administered by the Federal Social Security Administration.

[0123] The rules engine of the ALV processing tool contains a TCL conversion table 156 pre-built by the insurance company issuing the life insurance policy. The table indicates that for a life insurance policy of the type that is the subject of a benefit claim, a Risk Assessment Score ("RAS") 158 equal to 1 translates to a TCL Score 159 equal to 30% to validate the claimed loss. On the other hand, a RAS equal to 2 requires a TCL score equal to 40%. Under the exemplary ALV treatment, the corresponding RAS values ​​of 3, 4, and 5 converted to required TCL scores of 75%, 85%, and 100%, respectively.

[0124] According ...

example 2

[0129] Figure 6 An example of applying the ALV processing of the present invention to an inactive unemployment insurance ("IUI") claim is provided. The rules engine has pre-assigned the TALX TPA Occupational Verification Database 172 as a source of corroborating data for verifying IUI claims. This database will be accessed by all clients who file unemployment claims. Not all employers are part of the database, so the ALV process first checks the TALX TPA occupation verification against the employer name. The match did not contribute confidence to the claim's AVV, allowing ALV processing to proceed.

[0130] Next, the ALV process checks the TALX TPA database against the unemployed person's name, social security number, and termination date. If this information in the database record matches that provided by the claimant, ALV processing contributes a 100% confidence value to the claim's AVV score. In this case, the claim will be verified (despite the claim's RAS score of 17...

example 3

[0133] Figure 7 An example of applying the ALV processing of the present invention to a disability insurance policy claim is provided. Disability insurance policy claim 190 is associated with a lookup table 192 containing predetermined RAS scores 194 and associated TCL values ​​196 . Insurance companies also provide multiple sources of substantiated data for the purpose of verifying disability insurance policies under ALV processing198.

[0134] For example, physicians and other medical service providers providing services to patients may have access to the medical provider listing database 200 . A 30% confidence level is contributed to the claim's AVV score if the health care provider's name and phone number match the information provided by the claimant. In this case, claims with an RAS score of 1 will be verified, while claims with an RAS score of 2-5 will require additional contributing sources to prove the veracity of these claims.

[0135] The ICD9 diagnosis / speciali...

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PUM

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Abstract

A computer system-based automated loss verification system for evaluating the validity of claims filed under an insurance policy or debt protection contract is provided by this invention. Instead of requiring the claimant to contact the insurance company or lender to file the claim and provide exhaustive documentary proof of the validity of the claimed loss, the system pre-scores the relative risk of the claim using a risk assessment tool based upon predictive modeling and a number of potential risk factors. The associated automated loss verification tool uses this risk score and other information connected with the claim to assign a relative confidence level of proof of valid loss that must be satisfied before the claim can be approved through the adjudication process, and assigns a third-party supplied source or combination of sources of proof that can be automatically accessed by the system to validate the claim.

Description

[0001] Cross References to Related Applications [0002] This application claims priority to US Provisional Application 61 / 004,587, filed November 28, 2007, the entire disclosure of which is hereby incorporated by reference. technical field [0003] This application relates generally to the processing of insurance policy claims submitted by policyholder customers, and more particularly to a system for the automated processing of such claims by insurance companies through a validation process that relies on trusted Personal data provided by third parties. Background technique [0004] Insurance represents a means of providing protection against financial loss in a variety of situations. For example, life insurance helps compensate families for loss of income in the event of the death of a wage earner parent. Health insurance helps pay for medical expenses in the event of an employee or family member getting sick. Fire insurance pays for all or part of the loss if the insur...

Claims

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Application Information

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Patent Type & Authority Applications(China)
IPC IPC(8): G06Q40/00
CPCG06Q10/087G06Q40/08
Inventor 曼纽尔·贝切拉马里亚·C·曼杜莱
Owner ASSURANT INC
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