GB2465766A

GB2465766A - Insurance claim assessment

Info

Publication number: GB2465766A
Application number: GB0821695A
Authority: GB
Inventors: Julian Stainton
Original assignee: WESTERN PROVIDENT ASS Ltd
Current assignee: WESTERN PROVIDENT ASS Ltd
Priority date: 2008-11-27
Filing date: 2008-11-27
Publication date: 2010-06-02
Also published as: GB0821695D0

Abstract

Apparatus (10) for assessing an insurance claim, the apparatus (10) comprising: a claim receiving element (14) operative to receive details of a claim to be assessed; a claim interpretation element (18) operative to generate clinical findings information based on the details received; a condition information element (22) operative to generate condition information from the clinical findings information generated by the claim interpretation element (18); and a claim processing element (26) operative to process the claim in accordance with predefined rules relating to the claim details, clinical findings information and condition information to produce a decision to accept or refer the claim. The details of a claim may relate to symptoms, observational findings, medical disorders or other medical information. The claim interpretation element (18) preferably gives one or a number of possible diagnosis or diagnoses or conditions linked to the received details. The condition information element (22) preferably identifies body structures linked to the condition, so that fingers would be linked to the hand and the hand linked to the arm. The claim processing element (26) may use data from the body structure identification to decide whether previous or pre-existing conditions or illnesses suffered by the claimant that might affect the claim.

Description

CLAIM ASSESSMENT

The present invention relates to an apparatus and method for assessing an insurance claim to produce a decision to accept or refer the claim.

When an insurance claim is made it is typically assessed against predefined criteria in order to provide a decision to accept or refuse the claim. For example, medical insurance policies typically include policy conditions relating to pre-existing medical conditions whereby pre-existing conditions are not covered by the medical insurance policy and claims related to such conditions will be refused.

Many insurance providers use automatic claim assessment systems to facilitate processing of claims. Such systems may be accessed via a web interface or automated telephone system, so that they can be accessed conveniently by policy holders and can provide a decision quickly without a lengthy consultation with a human operator.

Typically such systems operate by receiving a unique identifier which identifies the policy holder to permit access to the claim assessment system, which receives details of the claim. The claim details are then compared to the conditions of policy holder's insurance policy and a decision to accept or reject the claim, or to refer the claim to a human claims assessor, is made.

A difficulty with systems of this type is that the decision making process can be rather unsophisticated, in that the range of claim details recognised by the systems can is limited, which can lead to claims being incorrectly rejected or accepted, or claims being unnecessarily referred to a human claims assessor, which defeats the object of the system to provides fast decisions without the need for lengthy discussions. Additionally, known systems for assessing medical insurance claims cannot recognise claim details such as symptoms which could relate to pre-existing conditions, and thus may indicate that a claim has been accepted, which claim may then be rejected at a later stage in the procedure when it is discovered that the symptoms to which the claim relates are related to a pre-existing condition which is excluded by the policy.

According to a first aspect of the invention there is provided apparatus for assessing a claim, the apparatus comprising a claim receiving element operative to receive details of a claim to be assessed, a claim interpretation element operative to generate symptom information based on the details received, a condition information element operative to generate condition information from the clinical findings information generated by the claim interpretation element and a claim processing element operative to process the claim in accordance with one or more predefined rules relating to the claim details, clinical findings information and condition information to produce a decision to accept or refer the claim.

The apparatus of the present invention is able to interpret claim details provided by a claimant, and to determine whether the claim details received describe, for example, a condition related to a pre-existing condition of the claimant which may be excluded by the claimant's policy. Thus, a more informed decision to accept or refer the claim can be made automatically, without requiring significant additional information or time from the claimant.

The condition information element may be operative to identify a body structure associated with the clinical findings information.

The condition information element may be operative to identify body structures linked to the body structure associated with the clinical findings information.

The condition information element may be operative to identify clinical findings information associated with the linked body structures.

The apparatus may further comprise a claimant identification element operative to receive identification details of the claimant and to compare the received identification details to stored permitted claimant details to permit or refuse access to the claim receiving element.

The claim receiving element and the claimant identification element may be operative to cause data input web pages to be activated.

The claim receiving element, the claim interpretation element, the condition information element, the claim processing element and the claimant identification element may comprise one or more software programs which run on a data processing system.

According to a second aspect of the invention there is provided a method for assessing a claim, the method comprising the steps of receiving details of a claim to be assessed, generating clinical findings information based on the details received, generating condition information from the clinical findings information so generated and processing the claim in accordance with one or more predefined rules relating to the claim details, clinical findings information and condition information to produce a decision to accept or refer the claim.

Generating the condition information may comprise identifying a body structure associated with the clinical findings information.

Generating the condition information may comprise identifying body structures linked to the body structure associated with the clinical findings information.

Generating the condition information may comprise identifying clinical findings information associated with the linked body structures.

The method may further comprise receiving identification details of the claimant and comparing the received identification details to stored permitted claimant details to permit or refuse details of the claim to be assessed to be received.

Receiving details of the claim and the receiving details of the claimant may comprise receiving data from data input web pages.

Receiving details of the claim, generating clinical findings information based on the details received, generating condition information from the clinical findings information so generated, processing the claim, receiving identification details of the claimant and comparing the received identification details to stored permitted claimant details may be performed by one or more software programs running on a data processing element.

According to a third aspect of the invention there is provided a computer program for performing the method of the second aspect.

Embodiments of the invention will now be described, strictly by way of example only, with reference to the accompanying drawings, of which Figure 1 is a schematic illustration showing functional blocks of an apparatus for assessing a claim; arid Figure 2 is a flow diagram illustrating the operation of the apparatus of Figure 1.

Referring firstly to Figure 1, an apparatus for assessing a claim is shown in schematic form at 10. It is to be understood that the functional blocks shown in Figure 1 do not necessarily represent actual components of an apparatus, but that the apparatus 10 is illustrated in this way for the purpose of describing the invention only.

The apparatus 10 in this example is configured to assess a medical insurance claim, and comprises a claimant identification element 12, which is configured to receive from a claimant identification details such as a unique policy number of an insurance policy held by the claimant, a personal identification number (PiN) and/or the claimant's name, address, postcode, date of birth or other relevant information. The claimant identification element 12 may, for example, cause a web page with appropriate data entry sections to be activated and displayed to prompt the claimant to provide the required claimant identification details.

The claimant identification details are compared by the claimant identification element 12 to a database 14 of policy holder details. The database 14 may be stored on a hard disc, or in memory of the apparatus 10, as will be understood by those skilled in the relevant art. If the claimant identification details received by the claimant identification element 12 are correct, in that they correspond to details in the database 14 identifying the claimant, a claim receiving element 16 is activated. If the claimant identification details received by the claimant identification element 12 are incorrect, the claimant identification element 12 is reactivated to prompt the claimant to enter correct identification details.

When the claim receiving element 16 is activated, the claimant is prompted to enter details of the claim. The claim receiving element 16 may, for example, cause a web page with appropriate data entry sections to be activated and displayed to prompt the claimant to provide the required claim details, such as, in the case of a medical insurance claim, details of clinical findings such as symptoms experienced, medical disorders, observational findings and the like, as well as other relevant details such as the date on which symptoms were first experienced, the date on which a medical practitioner was consulted, details of a specialist or therapist to whom the claimant has been referred and the like.

On receiving the required claim details, the claim receiving element 16 passes them on to a claim interpretation element 18, which is operative to interpret the claim details provided by the claimant to generate clinical findings information containing a list of alternative terms for the clinical findings provided by the claimant.

In this example the claim interpretation element 18 is linked to a database 20, stored on a hard disc, memory or the like of the apparatus 10, which contains a list of standardised terms for clinical findings, with each entry in the database 20 being linked to entries which are conceptually similar. The database 20 acts as a thesaurus, such that the claimant need not provide a medically accurate description of clinical findings to the claim receiving element 16 for the apparatus 10 to recognise the clinical findings and provide a decision to accept or refer the claim. For example, the terms "stiffness", "degeneration of bone", "osteoarthritis", and "musculoskeletal" may be linked in the database 20, such that on receiving the clinical finding "stiffness of left knee" from the claim receiving element 16 the claim interpretation element 18 would generate a list of terms including "osteoarthritis of left knee", "bone degeneration of left knee", "musculoskeletal, left knee".

The clinical findings information generated by the claim interpretation element 18 is passed to a condition information element 22, which is operative to generate condition information by identifying body structures related to the clinical findings information generated by the claim interpretation element 18. The condition information element 22 is linked to a database 24 which maps clinical findings and conditions to relevant body structures and links body structures to related body structures. For example, the condition "finger stiffness" may be associated with the body structure "hand", which is linked in turn to the body structure "arm". Alternatively, a lower level of granularity may be employed, such that the condition "finger stiffness" is associated with the body structure "hand". This mapping of clinical findings and conditions to relevant body structures and the linking of related body structures enables the apparatus to identify clinical findings provided by the claimant to the claim receiving element 16 which may be related to pre-existing conditions which may be excluded by the claimant's policy.

On receiving clinical findings information from the claim interpretation element 18 the condition information element 22 refers to the database 24 to generate condition information including details of a body structure associated with the clinical findings information. The condition information also includes details of linked body structures and of clinical findings and conditions associated with the linked body structures, which details are extracted by the condition information element 22 from the database 24.

For example, if the claimant provides the clinical findings "stiffness of left fingers", the claim interpretation element 18 generates appropriate clinical findings information including "osteoarthritis of fingers of left hand", "degeneration of fingers of left hand".

These terms are associated in the database 24 with the body structure "left hand", which is linked to the body structure "left arm". On receiving this clinical findings information, the condition information element 22 reads the body structure "left hand" and the linked body structure "left arm" from the database 24, and reads the clinical findings information associated with the body structure "left arm" from the database 24. In this example, the clinical findings information associated with the body structure "left arm" may include the terms "broken radius" and "fractured ulna". Thus, by reading the clinical findings information from linked body structures, the condition information element is able to generate condition information including a list of clinical findings or conditions which may be linked to the clinical finding or condition to which the claim submitted by the claimant relates.

The condition information is passed by the condition information element 22 to a claim processing element 26 which is operative to assess the claim, in accordance with predefined terms and rules set out in the claimant's policy, on the basis of the condition information provided by the condition information element 22 and the claim receiving element 16 and to provide a decision to accept the claim or to refer the claim to a human claims assessor.

The claim processing element 26 is linked to a database 28 containing details of policy terms, which database 28 is linked to the database 14 of policy holder details such that the database 28 of policy terms contains information relating to the insurance policy of the claimant identified by the claimant identification element 12. The database 28 contains details of policy terms such a pre-existing medical conditions to which the policy is not applicable and well as the date on which the policy came into effect.

For example, the policy terms in the database 28 may specify that a policy holder who had suffered a broken arm prior to commencing his policy would not receive policy benefits for conditions related to this prior injury.

On receiving the condition information from the condition information element 22, the claim processing element 26 processes the claim by reading the details of the claimant's policy from the database 28, and compares the condition information to any exclusions in the claimant's policy. The claim processing element also compares the claim details received by the claim receiving element 16 to the claimant's policy to determine if the clinical findings to which the claim relates occurred after the policy commenced. If the claim processing element 26 determines, based on the condition information, the claim details and the policy details that the claim cannot be accepted without further information from the claimant, the claim processing element 26 produces a decision to refer the claim to a human claims assessor, and advises the claimant accordingly. For example, the claim processing element 26 may cause a web page to be displayed showing a telephone number for the claimant to call, or may display a web page including appropriate data entry sections to allow the claimant to enter a convenient time and date for a claims assessor to call to discuss the claim.

If the claim processing element 26 determines, on the basis of the condition information, claim details and policy information, that the claim is acceptable, the claim is accepted and is passed for further processing. The claimant is advised of the acceptance of his claim. For example, the claim processing element 26 may cause a web page to be displayed showing a message indicating that the claim has been accepted.

An example of the operation of the system will now be provided, with reference to the flow diagram of Figure 2.

At step 40, the process of assessing a claim is commenced, and the claimant identifier element 12 prompts a claimant to enter identification details, by causing a web page with appropriate data entry sections to be displayed.

The claimant enters his policy number, name and postcode (for example), and at step 42 these details are compared by the claimant identifier element 12 to details stored in the database 14.

If the details entered by the claimant are incorrect, the claimant identifier prompts the claimant to enter correct identification details, by causing the web page to be re-displayed, at step 46.

If the identification details entered by the claimant are correct, the claim receiving element 16 causes a web page with appropriate data entry sections to be displayed to prompt the claimant to provide the required claim details, including details of clinical findings experienced, the date on which symptoms were first experienced, the date on which a medical practitioner was consulted, details of a specialist or therapist to whom the claimant has been referred and the like.

The details entered by the claimant are received at step 48 and are processed by the claim interpretation element 18 at step 50 to produce clinical findings information. In this case, the claimant enters the clinical findings "stiffness left finger", which is interpreted by the claim interpretation element 16, with reference to the database 18, to produce clinical findings information including the terms "osteoarthritis of fingers of left hand" and "degeneration of fingers of left hand".

The clinical findings information is passed to the condition information element 22, which, at step 52, generates condition information by referring to the database 24 to identify body structures related to the terms included in the clinical findings information and linked body structures, and to identify conditions and clinical findings related to the linked body structures. In this example, the condition information element identifies the body structure "left hand" as being related to the terms included in the clinical findings information. This body structure is related to the body structure "left arm", which is associated with the terms "fracture left radius" and "break left ulna". These body structures and their associated terms are included in the condition information which is passed by the condition information element to the claim processing element 26.

At step 54, the claim processing element 26 processes the claim by comparing the terms included in the condition information to the policy details contained in the database 28. In this example, the claimant's policy includes an exclusion for conditions and clinical findings related to a broken left arm suffered prior to the date of commencement of the policy. The claim processing element 26 identifies that the terms "fracture left radius" and "break left ulna" relate to the policy exclusion, and thus deems that the claim is unacceptable at step 56. The claim is referred to a claims assessor at step 58, and the claimant is advised accordingly.

In an alternative example, if the claimant enters the term "headaches" as a clinical finding, the condition information passed by the condition information element 22 to the claim processing element 24 includes details of body structures related to the head and associated clinical findings and conditions. As the head and the arm are not related, no clinical findings or conditions related to the exclusion in the claimant's policy is included in the condition information, and thus the claim processing element 26 deems the claim to be acceptable at step 56. The claim is accepted at step 60 and passed for further processing, and the claimant is advised accordingly.

In the embodiment described above, the apparatus 10 is provided on a data processing system such as a server, with the functional elements described above being provided as a software program or as individual interconnected software programs. In this embodiment, the apparatus 10 provides a web interface by means of which a claimant may submit a claim to be assessed.

The apparatus 10 may equally be embodied in an alternative data processing system such as a PC, with a human operator being employed to enter details received from the claimant over a telephone connection, such that if decision to refer the claim is produced the claimant can immediately be transferred to a claims assessor.

Alternatively, the apparatus 10 may be embodied in an alternative data processing system such as an automated telephone system including one or more speech recognition elements, such that a claimant may enter details such as his policy holder identifier and claim details verbally, with the details so entered being interpreted by the speech recognition elements and, after appropriate verification by the claimant, used to assess the claim.

Claims

CLAIMSApparatus for assessing a claim, the apparatus comprising: i. a claim receiving element operative to receive details of a claim to be assessed; ii. a claim interpretation element operative to generate clinical findings information based on the details received; iii. a condition information element operative to generate condition information from the clinical findings information generated by the claim interpretation element; and iv. a claim processing element operative to process the claim in accordance with one or more predefined rules relating to the claim details, clinical findings information and condition information to produce a decision to accept or refer the claim.
2. Apparatus according to claim 1 wherein the condition information element is operative to identify a body structure associated with the clinical findings information.
3. Apparatus according to claim 2 wherein the condition information element is operative to identify body structures linked to the body structure associated with the clinical findings information.
4. Apparatus according to claim 3 wherein the condition information element is operative to identify clinical findings information associated with the linked body structures.
5. Apparatus according to any one of claims 1 to 4 further comprising a claimant identification element operative to receive identification details of the claimant and to compare the received identification details to stored permitted claimant details to permit or refuse access to the claim receiving element.
6. Apparatus according to claim 5 wherein the claim receiving element and the claimant identification element are operative to cause data input web pages to be activated.
7. Apparatus according to claim 5 or claim 6 wherein the claim receiving element, the claim interpretation element, the condition information element, the claim processing element and the claimant identification element comprise one or more software programs which run on a data processing system.
8. Apparatus substantially as hereinbefore described with reference to the accompanying drawings.
9. A method for assessing a claim, the method comprising the steps of i. receiving details of a claim to be assessed; ii. generating clinical findings information based on the details received; iii. generating condition information from the clinical findings information so generated; and v. processing the claim in accordance with one or more predefined rules relating to the claim details, clinical findings information and condition information to produce a decision to accept or refer the claim.
10. A method according to claim 9 wherein generating the condition information comprises identifying a body structure associated with the clinical findings information.
11. A method according to claim 10 wherein generating the condition information comprises identifying body structures linked to the body structure associated with the clinical findings information.
12. A method according to claim 11 wherein generating the condition information comprises identifying clinical findings information associated with the linked body structures.
13. A method according to any one of claims 9 to 12 further comprising receiving identification details of the claimant and comparing the received identification details to stored permitted claimant details to permit or refuse details of the claim to be assessed to be received.
14. A method according to claim 13 wherein receiving details of the claim and the receiving details of the claimant comprise receiving data from data input web pages.
15. A method according to claim 13 or claim 14 wherein receiving details of the claim, generating clinical findings information based on the details received, generating condition information from the clinical findings information so generated, processing the claim, receiving identification details of the claimant and comparing the received identification details to stored permitted claimant details are performed by one or more software programs running on a data processing element.
16. A method substantially as hereinbefore described with reference to the accompanying drawings.
17. A computer program for performing the method of any one of claims 9 to 15.