Fast medical review method and system based on small personal injury of car insurance

Abstract

This invention discloses a rapid medical review and settlement method and system for minor personal injury claims in auto insurance, comprising: a medical database for storing injury mechanisms, standardized injury decision trees, and compensation standards; a receiving module for receiving injury images uploaded by vehicle surveyors; an injury image judgment module for determining the compensation amount based on the minimum compensation standard if the injury image shows no signs of injury or if the injury is obscured; if the injury image shows signs of injury, a preliminary diagnosis is determined based on the injury mechanism, and then the severity of the injury (mild, moderate, or severe) is determined based on the preliminary diagnosis, the injury image, and the standardized injury decision tree; a compensation suggestion module is used to determine the compensation amount corresponding to the injury diagnosis based on the compensation standards; and an output module is used to output the injury diagnosis and the corresponding compensation amount. This enables rapid and accurate medical review and claims settlement, reducing labor costs.

Description

Technical Field

[0001] This invention belongs to the field of data processing, specifically relating to a rapid claims medical review method and system for minor personal injury claims in auto insurance. Background Technology

[0002] According to industry data, personal injury cases account for 5% to 10% of all liability insurance (including car insurance and non-car liability insurance) claims, but the amount of compensation for personal injury cases accounts for more than 70% of all claims, and small claims with a claim amount of less than 5,000 yuan account for more than 84%.

[0003] In on-site accidents, personal injury cases vary greatly due to the wide range of ages, health conditions, injuries, and family circumstances of the injured, resulting in even more diverse compensation standards for minor personal injury cases. The main pain points for insurance companies in managing minor personal injury cases include: First, weak basic control: inconsistent on-site service procedures and standards for minor cases, incomplete implementation of operational processes and standard actions, and an incomplete frontline performance evaluation system, leading to inconsistent small-claim payout outcomes; Second, weak professional skills: insufficient medical professionals in personal injury positions, generally low skill levels among claims adjusters, resulting in a passive ability to handle minor accidents, prolonged claims processes, and wasted human resources; Third, difficulty in controlling time costs: low payout efficiency for minor cases results in the squeezing of time resources in personal injury departments and slow turnover of outstanding claims funds.

[0004] In the rapid medical review process for minor personal injury claims under car insurance, such as Figure 1 As shown, the complete vehicle personal injury claims process involves several stages: accident reporting, investigation, damage assessment, pricing, verification, settlement, and payment. Small-amount claims refer to cases where a vehicle involved in a traffic accident causes personal injury to a third party and the loss amount is less than a certain upper limit. The upper limit for small-amount claims varies among different insurance companies, regions, and insurance institutions of different levels, generally ranging from below 3,000 yuan to above 500 yuan. For small-amount personal injury cases, especially minor traffic injuries, insurance companies have a "fast settlement and fast payment" requirement if the parties involved are willing to settle in a one-time negotiation, involving on-site damage assessment and rapid payment.

[0005] Vehicle surveyors are the first point of contact at the accident scene. Rapid compensation requires vehicle surveyors to have a systematic understanding of basic personal injury knowledge, to be able to provide reasonable compensation amounts for different injuries, and, within a reasonable scope, to use communication skills and personal injury knowledge to negotiate and mediate with the parties involved.

[0006] However, in practice, the professional competence of vehicle surveyors varies greatly. Most surveyors are unable to provide relatively professional compensation standards for personal injury claims. Therefore, medical reviewers are still the core personnel for injury assessment in small-amount cases.

[0007] In conclusion, it is particularly necessary to standardize and improve the operational capabilities of vehicle surveyors in small-scale practical operations. Summary of the Invention

[0008] In view of the above, the purpose of this invention is to provide a rapid medical review method and system for minor personal injury claims in auto insurance, so as to achieve rapid and accurate medical review and claims processing.

[0009] To achieve the above-mentioned objectives, an embodiment provides a rapid medical review system for minor personal injury claims in auto insurance, comprising: a medical database, a receiving module, an injury image judgment module, a compensation suggestion module, and an output module;

[0010] The medical database is used to store injury mechanisms, standardized injury decision trees, and compensation standards;

[0011] The receiving module is used to receive injury photos uploaded by vehicle surveyors;

[0012] The injury image judgment module is used to determine the compensation amount according to the minimum compensation standard when there are no signs of injury in the injury image or the injury image is obscured; when there are signs of injury in the injury image, it determines the preliminary diagnosis corresponding to the signs of injury shown in the injury image according to the injury mechanism, and then determines the mild, moderate or severe injury diagnosis according to the preliminary diagnosis or injury image and the standardized injury decision tree.

[0013] The compensation suggestion module is used to determine the compensation amount corresponding to the injury diagnosis based on the compensation standards;

[0014] The output module is used to output the injury diagnosis and the corresponding compensation amount.

[0015] Preferably, before receiving the injury images uploaded by the vehicle surveyor, the receiving module also provides an injury selection function, allowing the vehicle surveyor to select the injured area on the human anatomy diagram before uploading the injury images.

[0016] Preferably, the injury mechanism includes diagnostic terms determined according to the injury mode. These diagnostic terms are clinically common diagnostic terms that are configured with different injury modes for different parts of the body based on ICD-10 data and commonly used emergency diagnostic names.

[0017] Preferably, the standardized injury decision includes two branches based on the injured part: single-site injury and multiple-site injury. Then, for each branch, based on the minor injury diagnosis, the injury diagnosis includes three levels: mild, moderate, and severe, according to the injured area. For the multiple-site injury branch, it also includes a unified classification and a non-unified classification for each injury diagnosis level.

[0018] Preferably, when the injured area is less than 5cm or the injured area is less than 10cm 2 If so, the injury diagnosis level is mild;

[0019] When the injury area is 5cm-10cm or the injury area is 10cm 2 -20cm 2 If so, the injury diagnosis level is moderate;

[0020] When the injury area is greater than 10cm or the injury area is greater than 20cm 2 If the injury is severe, then the diagnosis level is considered severe.

[0021] Preferably, in the injury image judgment module, determining the injury diagnosis as mild, moderate, or severe based on the preliminary diagnosis or injury image and a standardized injury decision tree includes:

[0022] First, determine whether the injury is single or multiple based on the injury images, and then determine the corresponding decision branch in the standardized injury decision tree based on the number of injured parts.

[0023] Then, based on the initial diagnosis of minor injury, the level of injury diagnosis is determined according to the extent or area of ​​injury, or the level of injury diagnosis and the uniformity of the level are determined.

[0024] Preferably, in the compensation recommendation module, determining the compensation amount corresponding to the injury diagnosis based on the compensation standard includes:

[0025] When it is a single injured part, the compensation amount is determined directly according to the compensation standard corresponding to the injury diagnosis level;

[0026] When there are multiple injured parts and the injury diagnosis level is the same, the compensation standard for the injury diagnosis level of the multiple injured parts is determined by adding them together after conversion;

[0027] When there are multiple injured parts and the injury diagnosis levels are not uniform, the compensation standards for the different injury diagnosis levels of the multiple injured parts are directly added together to determine the compensation amount.

[0028] Preferably, the system further includes a treatment plan recommendation module;

[0029] The medical database is also used to store the mapping relationship between diagnoses and treatment plans;

[0030] The treatment plan recommendation module is used to determine and recommend the preliminary diagnosis, injury diagnosis and level, and corresponding treatment plan determined by the injury image judgment module based on the mapping relationship between diagnosis and treatment plan.

[0031] Preferably, the system further includes a medical expense recommendation module;

[0032] The medical database is also used to store the cost standards for various medical procedures;

[0033] The medical expense recommendation module is used to configure and recommend corresponding medical expenses for treatment plans based on the cost standards of each medical item.

[0034] Preferably, the system further includes an offline claims adjuster assessment module, which is used to receive the offline claims amount and offline claims time of the claims adjuster, and compare the offline claims amount and offline claims time with the online claims amount and claims time to assess the difference in claims amount, case processing time, claims adjuster on-site rate, and the difference between on-site claims and online claims.

[0035] Preferably, the system further includes a risk management and alarm module, which is used to identify the possibility of fraud and issue an alarm when multiple claims are made by the same industry, the same institution, the same case, or the same injured party.

[0036] To achieve the above-mentioned objectives, an embodiment also provides a rapid medical review method for minor personal injury claims in auto insurance. The method uses the aforementioned system and includes the following steps:

[0037] Vehicle surveyors collect photos of injuries at the scene and upload them to the rapid claims medical review system for minor personal injury claims under vehicle insurance.

[0038] The receiving module receives injury photos uploaded by vehicle surveyors;

[0039] If the injury image assessment module determines that there are no signs of injury in the injury image or that the injury is obscured, the compensation amount will be determined according to the minimum compensation standard. If the injury image shows signs of injury, the preliminary diagnosis corresponding to the signs of injury shown in the injury image will be determined according to the injury mechanism. Then, the injury diagnosis of mild, moderate or severe injury level will be determined based on the preliminary diagnosis or injury image and the standardized injury decision tree.

[0040] The compensation suggestion module is used to determine the compensation amount corresponding to the injury diagnosis based on the compensation standards.

[0041] The output module outputs the injury diagnosis and the corresponding compensation amount.

[0042] Compared with the prior art, the beneficial effects of the present invention include at least the following:

[0043] By using a pre-built medical database that includes injury mechanisms, standardized injury decision trees, and compensation standards, when a claim is needed, as long as the vehicle surveyor uploads the collected injury photos to the system as required, the system will diagnose the injury and determine the compensation amount according to the procedural small-amount personal injury assessment process and standards. This greatly reduces the labor costs of small-amount personal injury cases and also improves the efficiency of loss assessment at the scene of small-amount personal injury cases. Attached Figure Description

[0044] To more clearly illustrate the technical solutions in the embodiments of the present invention or the prior art, the drawings used in the description of the embodiments or the prior art will be briefly introduced below. Obviously, the drawings described below are only some embodiments of the present invention. For those skilled in the art, other drawings can be obtained based on these drawings without creative effort.

[0045] Figure 1 This is a flowchart of the personal injury assessment process in existing technology;

[0046] Figure 2 This is a structural diagram of the rapid claims medical review system for minor personal injury in auto insurance provided in this embodiment of the invention;

[0047] Figure 3 This is a schematic diagram of the structure of a standardized injury decision tree provided in an embodiment of the present invention;

[0048] Figure 4 This is a schematic diagram of the human anatomy provided in an embodiment of the present invention;

[0049] Figure 5 This is a structural diagram of another fast claims medical review system based on minor personal injury in auto insurance provided by an embodiment of the present invention;

[0050] Figure 6 This is a roadmap of the rapid claims medical review method for minor personal injury in auto insurance provided by an embodiment of the present invention. Detailed Implementation

[0051] To make the objectives, technical solutions, and advantages of this invention clearer, the invention will be further described in detail below with reference to the accompanying drawings and embodiments. It should be understood that the specific embodiments described herein are merely illustrative of the invention and do not limit the scope of protection of this invention.

[0052] To address the issues of low efficiency and high labor costs in the current rapid claims and medical review processes for minor personal injury cases in auto insurance, this embodiment provides a rapid claims and medical review system for minor personal injury cases in auto insurance. This system is designed for use by vehicle surveyors, enabling fast claims processing for minor personal injury cases. Specifically, after collecting basic information about the injured party and photos of the injuries at the scene, the vehicle surveyor uploads the relevant materials to the rapid claims and medical review system. This information technology replaces the original medical review process. After uploading, the system intelligently assesses the situation and directly provides the compensation amount and negotiation basis on-site, offering support for the surveyor's damage assessment and negotiation.

[0053] Figure 2 This is a structural diagram of the rapid claims medical review system for minor personal injury claims in auto insurance provided by an embodiment of the present invention. Figure 2As shown, the fast medical review system 100 provided in this embodiment includes: a medical database 110, a receiving module 120, an injury image judgment module 130, a compensation suggestion module 140, and an output module 150.

[0054] In this embodiment, the medical database 110 is self-constructed and used to store injury mechanisms, standardized injury decision trees, and compensation standards. The injury mechanism is constructed by licensed physicians and determines diagnostic terms based on the injury mode. These diagnostic terms are clinically commonly used diagnostic terms for different injury modes in different parts of the body, configured with ICD-10 data and different emergency department diagnostic names. These clinically commonly used diagnostic terms mainly refer to the "Clinical Diagnosis and Treatment Guidelines for Road Traffic Accident Injuries" and related publications such as "Diagnostics," "Emergency Medicine," "Surgery," and "Emergency Clinical Diagnosis and Treatment Guidelines." Injury modes mainly involve minor open and closed injuries, including lacerations, abrasions, contusions, hematomas, lacerations, avulsions, cuts, and some puncture wounds. A preliminary diagnosis is made based on the injury mechanism.

[0055] A standardized injury decision tree is the basis for determining the severity of an injury in advance based on the location and area of ​​the injury. For example... Figure 3 As shown, the standardized injury decision-making process includes two branches based on the injured location: single-site injury and multiple-site injury. For each branch, based on the minor injury diagnosis, severity is further classified, specifically into three levels: mild, moderate, and severe, according to the injured area. The branch for multiple-site injuries also includes both standardized and non-standardized classifications for each injury diagnosis level. Because the calculation method for claims differs depending on the injured site, it is divided into two branches based on the injured area. Since the entire system is used for small-amount personal injury claims in auto insurance, it only handles minor injuries. Therefore, constraints are set for the minor injury diagnosis, which is determined based on the injury mechanism.

[0056] The severity of an injury, or the determination of its diagnostic grade, is based on the extent and area of ​​the injury. Specifically, this includes injuries where the injured area is less than 5cm or the injured area is less than 10cm. 2 If the injury is 5cm-10cm or the injured area is 10cm, then the injury level is considered mild; 2 -20cm 2 If the injury is less than 10cm or the injured area is greater than 20cm, the injury level is considered moderate; 2 If the injury is severe, then the diagnosis level is considered severe.

[0057] For injuries to multiple parts of the body, a unified or standardized classification should be established for each injury diagnosis level. This will facilitate the use of different calculation methods for compensation amounts later.

[0058] In this embodiment, the receiving module 120 is used to receive injury images uploaded by vehicle surveyors. To ensure the accuracy of the injured parts in the uploaded injury images, an injury selection function is provided before uploading the images, based on the vehicle surveyor's selection of the injured part. Figure 4 The human anatomy diagram shown allows users to select the injured area before uploading an image of the injury. This provides a basis for licensed physicians to judge the accuracy of the injured area and the corresponding injury image.

[0059] The injury image assessment module 130 determines the compensation amount based on the minimum compensation standard if the injury image shows no physical signs of injury or if the injury is obscured. Physical signs of injury refer to the presence of physical damage. This compensation method is the simplest and most standardized.

[0060] The injury image assessment module 130 is also used to determine the preliminary diagnosis corresponding to the injury signs shown in the injury image based on the injury mechanism when the injury image contains injury signs. Then, based on the preliminary diagnosis or injury image and the standardized injury decision tree, the injury diagnosis of mild, moderate or severe level is determined, specifically including the following steps:

[0061] First, determine whether the injury is single or multiple based on the injury images, and then determine the corresponding decision branch in the standardized injury decision tree based on the number of injured parts.

[0062] Then, based on the initial diagnosis of minor injury, the level of injury diagnosis is determined according to the extent or area of ​​injury, or the level of injury diagnosis and the uniformity of the level are determined.

[0063] In this embodiment, the compensation suggestion module 140 is used to determine the compensation amount corresponding to the injury diagnosis based on the compensation standard. Specifically, this includes: when there is a single injured part, the compensation amount is directly determined according to the compensation standard corresponding to the injury diagnosis level; when there are multiple injured parts and the injury diagnosis levels are the same, the compensation amount is determined by adding the compensation standards of the injury diagnosis levels of the multiple injured parts after conversion; when there are multiple injured parts and the injury diagnosis levels are not the same, the compensation amount is determined by directly adding the compensation standards of the different injury diagnosis levels of the multiple injured parts.

[0064] In this embodiment, the output module 150 is used to output the injury diagnosis and the corresponding compensation amount.

[0065] Figure 5 This is a structural diagram of another rapid claims medical review system based on minor personal injury claims in auto insurance, provided by an embodiment of the present invention. Figure 5As shown, the fast claims medical review system provided in this embodiment also includes a treatment plan recommendation module 510. At this time, the medical database 110 is also used to store the mapping relationship between diagnosis and treatment plan. The treatment plan recommendation module 510 is used to determine and recommend the preliminary diagnosis, injury diagnosis and level and corresponding treatment plan determined by the injury image judgment module according to the mapping relationship between diagnosis and treatment plan.

[0066] In this embodiment, licensed Western medicine practitioners and licensed traditional Chinese medicine practitioners simulated the outpatient and emergency department disease treatment process, selecting medications, treatments, and consumables corresponding to the diagnosis to form a treatment plan. The plan primarily referenced the *Clinical Treatment Guidelines for Injured Persons in Road Traffic Accidents*, *Diagnostics*, *Emergency Medicine*, *Surgery*, *Emergency Clinical Treatment Guidelines*, and *Guidelines for the Clinical Application of Antibacterial Drugs*. The treatment plan followed insurance claim regulations, considering the injury location, injury mechanism, and severity, and configured a mapping table between treatment plans for mild and severe cases and diagnoses. The accuracy of the treatment plan was confirmed through big data analysis and comparison (sample size of 4 million medical records).

[0067] like Figure 5 As shown, the fast claims medical review system provided in this embodiment also includes a medical expense recommendation module 520. At this time, the medical database 110 is also used to store the cost standards of each medical item. The medical expense recommendation module 520 is used to configure and recommend corresponding medical expenses for the treatment plan according to the cost standards of each medical item.

[0068] In this embodiment, the local tertiary medical institution outpatient and emergency fee standards are used to configure the diagnostic-related project fees. The average project fees are extracted from big data (4 million medical records) to configure the medical fee standards. Based on this, the corresponding medical fees are configured according to the treatment plan.

[0069] like Figure 5 As shown, the fast claims medical review system provided in the embodiment also includes an offline surveyor assessment module 530, which is used to receive the offline claims amount and offline claims time of the surveyor, and compare the offline claims amount and offline claims time with the online claims amount and claims time to assess the difference in claims amount, case processing time, surveyor on-site rate, and the difference between on-site claims and online claims.

[0070] like Figure 5 As shown, the fast claims medical review system provided in the embodiment also includes a risk management and alarm module 540, which is used to identify the risk of fraud and issue an alarm when multiple claims occur in the same industry, the same institution, the same case, and the same injured party.

[0071] like Figure 6 As shown, the embodiment also provides a rapid medical review method for minor personal injury claims in auto insurance, which is described in the claims as follows. Figure 2Or the system shown in Figure 5, the method includes the following steps:

[0072] Step 1: The vehicle surveyor collects photos of the injuries at the scene and uploads them to the fast claims medical review system;

[0073] Step 2: Receive the injury photos uploaded by the vehicle surveyor using the receiving module;

[0074] Step 3: If the injury image judgment module determines that there are no signs of injury in the injury image or that the injury is obscured, the compensation amount shall be determined according to the minimum compensation standard; if the injury image shows signs of injury, the preliminary diagnosis corresponding to the signs of injury shown in the injury image shall be determined according to the injury mechanism, and then the injury diagnosis of mild, moderate or severe injury shall be determined according to the preliminary diagnosis or injury image and the standardized injury decision tree.

[0075] Step 4: Use the compensation suggestion module to determine the compensation amount corresponding to the injury diagnosis based on the compensation standards;

[0076] Step 5: Use the output module to output the injury diagnosis and the corresponding compensation amount.

[0077] The examples also provide scenarios for small-amount personal injury claims in the industry, including: (1) Establishing a fast-track process for small-amount personal injury claims within the insurance company. After receiving a small-amount claim, the personal injury medical review post uses the fast-track process to improve the efficiency of on-site investigation and review. (2) Online investigation. By establishing online communication channels, investigators and medical reviewers can be summoned at the same time through online communication or online video investigation, but the labor cost is high. (3) GPS dispatch. Based on the established intelligent dispatch process, investigators are dispatched to the nearest location according to the accident site, reducing the time investigators spend on the road and improving the efficiency of on-site dispatch. (4) Intelligent damage assessment for vehicles. Through technologies such as image recognition and machine learning algorithms, users are guided to take photos correctly, and the vehicle's exterior damage is automatically assessed.

[0078] Compared with the above four claims settlement methods, the advantages of this invention are as follows:

[0079] (1) The compensation amount is specified, providing a strong basis for negotiation.

[0080] Due to varying skill levels and insufficient medical knowledge among surveyors, they are often unable to determine the specific compensation amount corresponding to the injury. In most cases, they can only compensate according to the company's standard compensation rate, lacking negotiating leverage. This can lead to unreasonable demands from difficult accident victims, ultimately resulting in compensation far exceeding the average. The system, with its massive database and the application of artificial intelligence and other technologies, can accurately assess injuries and determine corresponding compensation amounts, providing surveyors with a basis for negotiation. By using this information to negotiate, surveyors can effectively improve the accuracy of compensation amounts, thereby reducing the insurance company's claims costs.

[0081] (2) Reduce hospital visits and expedite case closure

[0082] Most injuries in minor personal injury cases fall under the category of minor injuries that do not require hospitalization, such as abrasions, contusions, hematomas, and lacerations (data support: top number of diagnoses; top payout amounts). However, insurance clients' situations vary greatly. Driven by the pursuit of personal gain, some injured individuals, despite having minor injuries, still request hospital examinations and treatment, resulting in substantial unnecessary medical expenses. The system, relying on a massive diagnostic and medical database, supports rapid on-site diagnosis and injury assessment. Based on this information, claims adjusters negotiate with the injured parties, recommending expedited settlement and claims processing for minor injuries. This significantly reduces the likelihood of these injured individuals seeking hospitalization, thereby lowering unnecessary medical expenses, shortening the claims settlement cycle, achieving rapid processing of personal injury claims, improving customer satisfaction, and reducing the probability of lawsuits filed by injured parties.

[0083] (3) Accurately identify risky injuries and fraudulent injuries to prevent insurance fraud.

[0084] Personal injury claims involve numerous steps, complex processes, and cumbersome documentation, making them prone to insurance fraud and challenging to control. Leveraging massive amounts of data and clinical diagnostic experience, this system supports accurate identification of risky injuries and fraudulent claims, providing corresponding negotiation criteria to achieve anti-fraud risk management. This effectively prevents personal injury claims fraud, reduces claims costs, and enhances risk control capabilities.

[0085] (4) Reduce personal injury claims management costs and break down professional barriers in personal injury claims.

[0086] Insurance services often involve specialized technical knowledge from multiple disciplines and fields. However, the professional capabilities and claims service resources of insurance company personnel are always limited. Relying solely on personnel to handle various issues leads to a mismatch between claims service capabilities and actual needs, thus restricting the development of the insurance business. Artificial intelligence, with its ever-expanding interdisciplinary knowledge base, massive data processing capabilities, and continuously improving intelligent computing models, can break down the professional barriers in personal injury claims and continuously empower personal injury claims management. Applying AI technology to auto insurance personal injury claims management can significantly improve the automation and standardization of personal injury claims management, reduce human error, lower the threshold for professional skills required for claims management personnel, effectively reduce labor costs, thereby improving the overall efficiency of personal injury claims operations and reducing personal injury operating costs.

[0087] (5) Improve the assessment system for surveyors and achieve effective resource allocation.

[0088] Claim adjusters are the frontline contacts in claims processing and one of the most critical determinants of claims quality. The system's backend leverages massive amounts of historical data to support refined performance evaluation of claim adjusters, including discrepancies in compensation amounts for the same injury, differences between compensation amounts and negotiated amounts, average case processing time, claim adjuster on-site arrival rate, and differences between on-site and online claims processing. Insurance companies can use this data to conduct detailed evaluations of claim adjusters, providing standardized training for those with weaker performance and granting more claims processing privileges or assigning more cases to those with stronger capabilities, thereby achieving effective resource allocation and improving overall claims processing quality.

[0089] (6) Supports remote damage assessment by surveyors without requiring them to visit the site.

[0090] Investigations reveal that it's common for accident investigators to be unable to reach the scene due to weather, traffic congestion, or resource shortages. In such cases, the injured party, the driver at fault, or a police auxiliary officer typically take photos of their injuries and send them to the investigator, who then determines the compensation amount based on the images. However, verifying the authenticity of the injury photos and ensuring timely case processing are challenging in this process. A system that allows accident-related parties to upload their own injury photos, enabling automatic diagnosis and damage assessment, significantly improves the efficiency and quality of claims processing.

[0091] (7) Big data intelligent analysis to provide business breakthroughs

[0092] This initiative aims to help insurance companies establish a monitoring indicator system for small-amount claims services, thereby promoting the improvement of such services. Key indicators include average case processing time, average daily case volume, average estimated loss per case, total estimated loss, top-ranked diagnostic numbers, top-ranked medical expenses, top-ranked transportation expenses, and top-ranked lost wages. By mining and analyzing historical case data, the initiative seeks to identify and refine key business opportunities, providing a basis for future decisions regarding small-amount personal injury claims standards and the assessment system for claims adjusters.

[0093] (8) Big data risk management and intelligent case early warning

[0094] Big data analysis is used for risk management, including targeting individuals in the same industry, the same organization, the same case, and the same injured party. For example, if the same case number, the same ID number, or the same name appears more than three times on the platform, the system will alert the injured party to the risk of fraud and recommend that they report the incident to the police.

[0095] (9) Supports comparison of historical cases and visualization of product loss reduction.

[0096] The platform supports testing of historical cases from insurance companies, thus demonstrating the effectiveness of the product's loss reduction capabilities.

[0097] The specific embodiments described above illustrate the technical solution and beneficial effects of the present invention in detail. It should be understood that the above description is only the most preferred embodiment of the present invention and is not intended to limit the present invention. Any modifications, additions, and equivalent substitutions made within the scope of the principles of the present invention should be included within the protection scope of the present invention.

Claims

1. A rapid claims medical review system for minor personal injury claims in auto insurance, characterized in that, include: Medical database, receiving module, injury image judgment module, compensation suggestion module, output module; The medical database is used to store injury mechanisms, standardized injury decision trees, and compensation standards; The receiving module is used to receive injury photos uploaded by vehicle surveyors; The injury image judgment module is used to determine the compensation amount according to the minimum compensation standard when there are no signs of injury in the injury image or the injury image is obscured; when there are signs of injury in the injury image, it determines the preliminary diagnosis corresponding to the signs of injury shown in the injury image according to the injury mechanism, and then determines the injury diagnosis of mild, moderate or severe level based on the preliminary diagnosis or injury image and the standardized injury decision tree. The standardized injury decision tree includes two branches based on the injured part: single-site injury and multiple-site injury. Then, for each branch, based on the diagnosis of minor injury, the injury diagnosis includes three levels: mild, moderate, and severe, according to the injured area. For the branch with multiple-site injury, it also includes a unified classification and a non-unified classification for each injury diagnosis level. The compensation suggestion module is used to determine the compensation amount corresponding to the injury diagnosis based on the compensation standards; The output module is used to output the injury diagnosis and the corresponding compensation amount.

2. The rapid claims medical review system for minor personal injury in auto insurance as described in claim 1, characterized in that, Before receiving the injury images uploaded by the vehicle surveyor, the receiving module also provides an injury selection function, allowing the vehicle surveyor to select the injured area on the human anatomy diagram before uploading the injury images.

3. The rapid claims medical review system for minor personal injury in auto insurance as described in claim 1, characterized in that, The injury mechanism includes diagnostic terms determined according to the injury mode. These diagnostic terms are clinically common diagnostic terms that are assigned to different injury modes at different locations based on ICD-10 data and commonly used emergency diagnostic names.

4. The rapid claims medical review system for minor personal injury in auto insurance as described in claim 1, characterized in that, When the injury range is less than 5 cm or the injury area is less than 10 cm 2 The injury is diagnosed as a minor injury. When the injury range is 5 cm-10 cm or the injury area is 10 cm 2 -20 cm 2 The injury is diagnosed as moderate. When the injury area is greater than 10 cm or the injury area is greater than 20 cm 2 If the injury is severe, then the diagnosis level is considered severe.

5. The rapid claims medical review system for minor personal injury in auto insurance as described in claim 1, characterized in that, The injury image assessment module determines the injury level (mild, moderate, or severe) based on the preliminary diagnosis or injury images and a standardized injury decision tree, including: First, determine whether the injury is single or multiple based on the injury images, and then determine the corresponding decision branch in the standardized injury decision tree based on the number of injured parts. Then, based on the initial diagnosis of minor injury, the level of injury diagnosis is determined according to the extent or area of ​​injury, or the level of injury diagnosis and the uniformity of the level are determined.

6. The rapid claims medical review system for minor personal injury in auto insurance as described in claim 1, characterized in that, The compensation recommendation module determines the compensation amount corresponding to the injury diagnosis based on the compensation standards, including: When it is a single injured part, the compensation amount is determined directly according to the compensation standard corresponding to the injury diagnosis level; When there are multiple injured parts and the injury diagnosis level is the same, the compensation standard for the injury diagnosis level of the multiple injured parts is determined by adding them together after conversion; When there are multiple injured parts and the injury diagnosis levels are not uniform, the compensation standards for the different injury diagnosis levels of the multiple injured parts are directly added together to determine the compensation amount.

7. The rapid claims medical review system for minor personal injury in auto insurance as described in any one of claims 1-6, characterized in that, The system also includes a treatment plan recommendation module and a medical expense recommendation module. The medical database is also used to store the mapping relationship between diagnoses and treatment plans, as well as the cost standards for each medical procedure. The treatment plan recommendation module is used to determine and recommend the preliminary diagnosis, injury diagnosis and level, and corresponding treatment plan determined by the injury image judgment module based on the mapping relationship between diagnosis and treatment plan. The medical expense recommendation module is used to configure and recommend corresponding medical expenses for treatment plans based on the cost standards of each medical item.

8. The rapid claims medical review system for minor personal injury in vehicle insurance as described in any one of claims 1-6, characterized in that, The system also includes an offline claims adjuster assessment module, which is used to receive the offline claims amount and offline claims time of the claims adjuster, and compare the offline claims amount and offline claims time with the online claims amount and claims time to assess the difference in claims amount, case processing time, claims adjuster on-site rate, and the difference between on-site claims and online claims. The system also includes a risk management and alarm module, which is used to identify fraud risk and issue an alarm when multiple claims are made by the same industry, the same institution, the same case, or the same injured party.

9. A rapid medical review method for minor personal injury claims in auto insurance, characterized in that, The method uses the system according to any one of claims 1-8, and the method includes the following steps: Vehicle surveyors collect photos of injuries at the scene and upload them to the rapid claims medical review system for minor personal injury claims under vehicle insurance. The receiving module receives injury photos uploaded by vehicle surveyors; If the injury image assessment module determines that there are no signs of injury in the injury image or that the injury is obscured, the compensation amount will be determined according to the minimum compensation standard. If the injury image shows signs of injury, the preliminary diagnosis corresponding to the signs of injury shown in the injury image will be determined according to the injury mechanism. Then, the injury diagnosis of mild, moderate or severe injury level will be determined based on the preliminary diagnosis or injury image and the standardized injury decision tree. The compensation suggestion module is used to determine the compensation amount corresponding to the injury diagnosis based on the compensation standards. The output module outputs the injury diagnosis and the corresponding compensation amount.

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