An individual risk claim settlement maximum payout implementation method

Abstract

The application discloses an individual risk claim maximum payment implementation method, which comprises the following steps: 1) responsibility matching; 2) amount calculation; 3) sequence determination; 4) amount allocation; 5) circulation settlement; and 6) result verification. Through the dynamic sorting logic of 'the minimum payment amount is given priority to', the application reduces the early deduction loss of high-value responsibility, ensures the maximization of the total payment amount after the superposition of multiple responsibilities, solves the problem that the traditional fixed sequence settlement cannot realize optimal payment, and improves user satisfaction. Through fine processing of the sharing and deduction rules between responsibilities, the payment amount is split according to the payment type, so that the deduction logic is accurate; through the layer-by-layer promotion of multiple settlement formulas, segmented payment rules, limit and premium accounting, the amount calculation is accurate and error-free, and the risk of claim dispute is reduced.

Description

Technical Field

[0001] This invention relates to the field of insurance claims, specifically a method for maximizing individual insurance claims payouts. Background Technology

[0002] In existing individual insurance claims processing, indemnity insurance typically involves the overlapping configuration of multiple insurance liabilities. The same claim document may match multiple applicable liabilities, and there are related rules between liabilities such as amount deduction, limit sharing, and deductible apportionment. Traditional claims calculation methods often use a fixed order (such as by liability effective date, policy number, etc.) to calculate one by one, without considering the impact of differences in compensation amounts, coverage limits, and compensation ratios of different liabilities on the total compensation amount.

[0003] This fixed-order claims settlement model has significant drawbacks: Firstly, it may lead to high-coverage, high-proportion liabilities failing to fully realize their compensation potential due to unreasonable deductions of lower-priority liabilities in the early stages, resulting in users receiving less than the theoretical maximum compensation. Secondly, the handling of inter-liability association rules lacks refined logic, easily leading to issues such as duplicate deductions, deductible or coverage sharing calculation errors. This not only affects the accuracy of claims results but may also trigger user complaints, increasing the insurance company's operating costs and reputational risks. Furthermore, the traditional claims settlement process lacks robust verification and retry mechanisms for abnormal situations, making it difficult to efficiently correct claims settlement errors, further reducing the reliability and efficiency of claims processing.

[0004] Therefore, it is essential to propose a method for maximizing individual insurance claims payouts. Summary of the Invention

[0005] The purpose of this invention is to provide a method for realizing the maximum compensation in individual insurance claims, so as to generate an efficient and accurate scheme for the maximum compensation amount, thereby solving the existing technical defects and unmet technical requirements.

[0006] To achieve the above objectives, the present invention provides the following technical solution: a method for maximizing individual insurance claims payout, comprising the following steps: 1) Liability Matching: The system uses a loop to match all applicable indemnity insurance liabilities for each indemnity in a cyclical manner, while reading the preset sharing rules between these liabilities (such as amount deduction, limit sharing, and other related configurations) to obtain the matched list of indemnity liabilities, configuration information of each liability (including claims formula, claim type, etc.), and shared configuration information between liabilities. (ii) Amount Calculation: Based on all the information obtained in step one), calculate the compensation amount for each liability in the list of uncompensated liabilities in the cyclical compensation liability list according to the preset logic, and obtain the final compensation amount data for each liability. (iii) Sequence determination: Based on the final compensation amount data of each liability obtained in step two, select the liability with the smallest compensation amount as the first compensation liability of the bill, and obtain the current compensation liability identifier and the corresponding compensation amount; (iv) Amount apportionment: Based on the liability identification and compensation amount obtained in step (iii), the compensation amount is broken down and calculated according to the compensation type configured for the current compensation liability, the proportion of each compensation type is determined, and the proportion of each compensation type and the cumulative apportionment result are obtained. 5) Cyclic Settlement: Based on the cumulative allocation result obtained in step 4), determine whether there are any unsettled liabilities in the compensation liability list obtained in step 1). If there are, return the cumulative allocation result and the unsettled liability list to step 2), triggering step 2) to be re-executed until the settlement result of all liabilities is obtained. If there are no unsettled liabilities, obtain the settlement result of all liabilities. VI) Result Verification: Verify the calculation results of all responsibilities in step V) to ensure that they meet the preset verification rules.

[0007] Preferably, the specific content of step one) is as follows: 1.1) Process each claim invoice individually, matching each invoice with all applicable indemnity insurance liabilities; 1.2) Read the preset sharing rules between matched responsibilities; 1.3) Obtain the matched list of compensatory responsibilities, configuration information for each responsibility, and shared configuration information between responsibilities; The compensation type of the aforementioned indemnifying liability includes at least one of the following: self-payment type 1, self-payment type 2, and out-of-pocket expense; and deductions between liabilities only apply to liabilities with the same compensation type. In this application, it is necessary to further explain that the core purpose of step one) is to clarify the basic claim information for each invoice, avoiding omissions or mismatches of liability. Processing invoices one by one ensures the accuracy of liability matching for a single invoice and is suitable for multi-invoice claim scenarios. The reading of shared rules directly affects the deduction and apportionment logic in subsequent amount calculations and must be clarified in advance to ensure calculation accuracy. Limiting deductions between liabilities to the same type of compensation is to avoid interference between compensation amounts of different natures. For example, the compensation amount for "self-payment 1" liability should not deduct the compensation amount for "self-payment" liability, ensuring the rationality of the deduction logic, while reducing calculation complexity and improving process efficiency.

[0008] Additionally, it is necessary to explain the different categories of medical insurance reimbursement: co-payment 1, co-payment 2, and out-of-pocket expenses. I. Basic Concepts and Relationships Total medical expenses = Medical insurance payment + Personal co-payment + Personal out-of-pocket expenses.

[0009] Out-of-pocket expenses: Expenses within the scope of medical insurance that need to be borne by the individual, including out-of-pocket expense one and out-of-pocket expense two.

[0010] Out-of-pocket expenses: Expenses that are not covered by medical insurance and must be paid in full by the individual.

[0011] II. Compensation payment is one-third of the cost (one-third of the cost is paid by the employee). Definition: The portion of medical insurance reimbursement that is outside the reimbursement ratio.

[0012] Contents include: Expenses below the medical insurance deductible (the amount you have to pay out of pocket before medical insurance starts reimbursing).

[0013] Expenses exceeding the medical insurance cap (the portion exceeding the maximum medical insurance reimbursement limit).

[0014] For Category A drugs and items covered by medical insurance, the portion that individuals are required to pay according to a certain percentage (e.g., 90% covered by medical insurance, with the remaining 10% paid out of pocket).

[0015] Features: The "mandatory deduction" within the medical insurance catalog is the fixed personal burden after medical insurance reimbursement.

[0016] III. Compensation payable by the employee (Self-payment of 2%) Definition: A fixed percentage of costs that individuals must initially bear for Category B drugs, examinations, treatments, and materials covered by medical insurance.

[0017] Features: This applies only to Category B projects (Category A projects do not have this self-payment requirement).

[0018] You need to pay a certain percentage (usually 10%-30%) first, and then the remaining part will go through the medical insurance reimbursement process.

[0019] For example, if a Class B drug costs 1000 yuan and the co-payment ratio is 20%, then the second co-payment is 200 yuan, and the remaining 800 yuan will be reimbursed according to the medical insurance ratio.

[0020] Identification: Drugs or projects with only "co-payment 1" are Class A drugs; drugs with both "co-payment 1" and "co-payment 2" are Class B drugs.

[0021] IV. Self-funded Definition: Medical expenses that are completely outside the scope of medical insurance coverage and must be paid in full by the individual.

[0022] Preferably, the specific content of step two is as follows: 2.1) Receive all the information from step 1.3) and the cumulative allocation result returned in step 5) (when not in the first loop); 2.2) Based on the compensation liability list obtained in the first cycle in step 1.3), and the unresolved liability list and abnormal liability list after verification failure in step 5), for each liability, call the corresponding compensation formula to calculate the initial reimbursable amount. If it is not the first cycle and there is a deduction relationship between the current liability and the already compensated liability, include the apportioned amount of the already compensated liability in the deduction item and generate the initial reimbursable amount and deduction association description. If it is the first cycle, only the initial reimbursable amount is generated and no deduction association description is generated. 2.3) Based on the initial claimable amount and deduction association instructions, adjust the initial claimable amount according to the preset script rules to generate the adjusted claimable amount; (the deduction association instructions are only used to record the deduction logic and do not affect the amount adjustment calculation) 2.4) Based on the adjusted claimable amount, extract the corresponding deductible from the liability configuration information in step one). If there is a deductible sharing rule between liabilities, the deductible amount of the already claimed liability sharing needs to be deducted. Deduct the deductible from the adjusted claimable amount. If the amount after deduction is less than zero, it is calculated as zero and the amount after deduction is generated. 2.5) Based on the amount after deduction, read the compensation ratio and segmentation rules of the liability from the liability configuration information in step one). If no segmentation rules are configured, directly multiply the amount after deduction by the compensation ratio. If segmentation rules are configured, split the amount according to the rules and multiply each by the corresponding ratio, then sum them to obtain the proportional calculation amount and generate the proportional calculation amount. 2.6) Based on the proportional calculation of the amount, read the advanced information limit rules of the responsibility from the responsibility configuration information in step one), deduct the historical used amount of the responsibility, and take the smaller value between the remaining available amount and the proportional calculation amount as the limit amount to generate the limit amount; 2.7) Based on the amount after the limit, read the total sum insured for this liability from the liability configuration information in step one). If there is a sum insured sharing rule between liabilities, the sum insured amount of the shared liability that has already been settled needs to be deducted. The remaining sum insured = total sum insured - historical payout amount for this liability - deduction of shared sum insured amount. Take the smaller value between the amount after the limit and the remaining sum insured as the final payout amount for this liability and send it to step three).

[0023] Further explanation is needed in this application regarding step two, which is the core step in amount calculation. Seven detailed steps are used to accurately derive the final compensation amount from the initial amount. Multiple calculation formulas are designed to adapt to different types of compensation, ensuring that the initial amount calculation complies with the liability agreement. Including the apportioned amount of already calculated liabilities in non-first-time cycles is to implement the deduction rules between liabilities and avoid duplicate payments. Pre-set script rules can flexibly handle special claim scenarios (such as additional compensation for specific diseases, increased emergency rescue costs, etc.), improving the flexibility of calculation. The layered calculation of deductible, reimbursement ratio, advanced limit, and total sum insured is to strictly adhere to the insurance contract, protecting the legitimate rights and interests of the insurance company while ensuring that users receive the compensation they deserve. Separate recording of deduction-related explanations enables traceability of the calculation logic, facilitating subsequent verification and problem investigation.

[0024] Preferably, in step 2.2), the calculation formula includes: Formula 1: Initial recoverable base amount = Total bill amount - Amount covered by this insurance - Amount paid by third parties; Formula 2: Initial recoverable base amount = Total bill amount - Amount covered by this insurance - Third-party payment amount - Self-paid amount; Formula 3: Initial recoverable base amount = Total bill amount - Amount covered by this insurance - Amount paid by third parties - Amount paid by the second party - Amount paid by the third party.

[0025] In this application, it is necessary to further explain that the three settlement formulas mentioned above correspond to different indemnification liabilities with different coverage scopes. The choice of formula is determined by the compensation type in the liability configuration information. Formula 1 is applicable to liabilities with coverage including Deductible 1, Deductible 2, and Out-of-Pocket Expenses, deducting only the amount not covered by the insurance and the amount paid by third parties; Formula 2 is applicable to liabilities with coverage including Deductible 1 and Out-of-Pocket Expenses, deducting Deductible 2; Formula 3 is applicable to liabilities with coverage including Deductible 1, deducting Deductible 2 and Out-of-Pocket Expenses. By accurately matching the formulas with the liability compensation type, it is ensured that the calculation of the initial claimable amount conforms to the contractual agreement, avoiding deviations in amount due to unclear coverage scope.

[0026] Furthermore, the formulas above are just a few common examples. The actual compensation formula is dynamically configured according to the policy's compensation rules, and this configuration can support compensation in almost all situations. For example, if the compensation amount for liability A is to be deducted from liability B, the formula might be: Total invoice amount - Amount covered by this insurance - Third-party payment amount - Amount of the corresponding category allocated from the compensation amount for liability A.

[0027] In addition, regarding the explanation of each formula, the total amount of the invoice - the amount covered by this insurance - the amount paid by the third party = the amount of reimbursement for self-payment 1, self-payment 2, or self-paid amount.

[0028] The amount covered by this insurance = the total amount reimbursed by medical insurance, i.e., the portion reimbursed by national medical insurance. Third-party payment amount = Amount already paid out through other compensation channels After deducting the two amounts mentioned above from the bill amount, the remaining amount is the portion of the bill that can be claimed under the policy (Self-payment 1, Self-payment 2, Out-of-pocket expenses). The specific type of claim is subject to the policy rules.

[0029] Preferably, in step 2.5), the segmented comparison rule is as follows: the recoverable amount is divided into at least two consecutive amount intervals, each amount interval corresponds to an independent compensation ratio, and the amount is calculated by the sum of the products of "amount of each interval × corresponding compensation ratio".

[0030] In this application, it is necessary to further explain the dynamic sorting logic of "prioritizing the lowest payout amount," which is crucial for achieving maximum payout. Traditional fixed-order claims processing may result in high-coverage, high-percentage liabilities not being fully compensated due to early deductions. Prioritizing liabilities with lower payout amounts reduces the impact of deductions on subsequent high-value liabilities, ensuring that high-value liabilities can maximize their compensation role and ultimately maximizing the total payout amount after all liabilities are combined. Simultaneously, generating a unique identifier ensures accurate liability identification, providing a clear direction for subsequent amount allocation and cyclical claims processing.

[0031] Preferably, the specific content of step three is as follows: 3.1) Receive the final compensation amount data for all unclaimed liabilities generated in step two); 3.2) Sort all unclaimed liabilities in ascending order of compensation amount; 3.3) Select the liability with the smallest payout amount after sorting and determine it as the first payout liability for this bill; 3.4) Generate a unique identifier for the first claim liability and the corresponding final claim amount, and pass it to step four.

[0032] In this application, it is necessary to further explain that the purpose of step four) is to break down the current liability's compensation amount by compensation type, providing an accurate basis for subsequent liability deductions. Since deductions between liabilities only apply to the same compensation type, it is necessary to clearly define the percentage amount for each compensation type to ensure that subsequent liabilities only deduct the amount for the corresponding type, avoiding calculation errors caused by cross-type deductions. For example, if a liability simultaneously pays for both self-payment and out-of-pocket expenses, its compensation amount needs to be split into two parts. Subsequent liabilities that only pay for self-payment only need to deduct that percentage amount, without affecting subsequent compensation for the out-of-pocket expenses, thus ensuring the accuracy of the deduction logic.

[0033] Preferably, the specific content of step four is as follows: 4.1) Receive the unique identifier of the current compensation liability generated in step 3), associate the liability configuration information in step 1 with the identifier, read the compensation type of the liability configuration, clarify the compensation type and corresponding amount to be shared, and generate a list of sharing types and corresponding basic amounts; 4.2) Receive the list of apportionment types and corresponding basic amounts generated in step 4.1), accumulate the total amount of all apportionment types as the denominator, and the amount of a single apportionment type as the numerator. Calculate the percentage of each apportionment type by "numerator ÷ denominator" to generate the percentage data of each apportionment type. 4.3) Receive the percentage data of each compensation type generated in step 4.2) and the final compensation amount of the current compensation liability generated in step 3). Multiply the final compensation amount by the percentage of each compensation type to obtain the percentage amount corresponding to each compensation type. Generate the percentage amount of each compensation type and the cumulative apportionment result (i.e., the sum of each percentage amount) to step 5.

[0034] In this application, further explanation is needed regarding step five, which utilizes a cyclical iterative mechanism to comprehensively calculate all responsibilities, ensuring no omissions. The first loop processes all uncalculated responsibilities, while subsequent loops only process the remaining uncalculated responsibilities, improving calculation efficiency. Receiving and recalculating a list of abnormal responsibilities after verification failures forms a closed-loop correction mechanism, allowing for timely correction of calculation errors. Continuous feedback of cumulative allocation results ensures that subsequent responsibilities can obtain deduction data for already calculated responsibilities in real time during calculation, guaranteeing the consistency and accuracy of deduction logic between responsibilities, ultimately achieving complete accounting for all applicable responsibilities.

[0035] Preferably, the specific content of step five is as follows: 5.1) Receive the percentage amount and cumulative apportionment results of each compensation type generated in step four), or the verification failure message and current settlement result returned in step six; 5.2) Based on the compensation responsibility list obtained in step one), remove the responsibilities that have completed the settlement process in steps two to four, and generate an unsettled responsibility list. If the received message is a verification failure message, generate an abnormal responsibility list according to the abnormal responsibility identifier in the message. 5.3) Determine if the list of unresolved responsibilities or the list of abnormal responsibilities is empty: If not empty, the cumulative allocation result (or abnormal responsibility identifier) ​​and the list of unpaid responsibilities (or abnormal responsibility list) will be sent back to step two, triggering step two to only calculate unpaid responsibilities (or abnormal responsibilities); If empty, summarize the payment results of all settled liabilities to form the settlement results of all liabilities, and send them to step six.

[0036] In this application, it is necessary to further explain that step six) is a crucial step in ensuring the legality, compliance, and accuracy of the claims settlement results. The preset verification rules cover core risk points in the claims process, such as preventing the total compensation amount from exceeding the invoice amount and preventing the single-liability compensation amount from exceeding the insured amount (in accordance with contractual agreements). Detailed information on anomaly alerts helps to accurately pinpoint the root cause of the problem, providing a clear direction for recalculation. The retry mechanism can automatically correct some temporary calculation deviations or data errors, improving the process's fault tolerance. Limiting the number of retries and terminating the process avoids resource waste caused by infinite loops, while the generation of complete anomaly data facilitates manual intervention for verification, ensuring the efficiency and reliability of claims processing.

[0037] Preferably, the specific content of step six is ​​as follows: 6.1) Receive all liability settlement results generated in step five; 6.2) Verify each item of the calculation results according to the preset verification rules; 6.3) If the verification passes, the final claim settlement result will be generated directly; 6.4) If the verification fails, a verification failure message will be generated, which includes the abnormal type (such as exceeding the invoice amount, exceeding the liability coverage, abnormal deduction amount) and abnormal data (such as exceeding the limit amount, and the liability identifier of the matter). 6.5) Send the verification failure message and the current calculation result back to step five), triggering steps two through six to be re-executed; 6.6) Record the number of retries. When the verification still fails after 3-5 retries, generate a final failure message and complete exception data, and terminate the calculation process.

[0038] Preferably, in step 2.6), the advanced information limit rules include at least one of monthly payout limit, quarterly payout limit, annual payout limit, and cumulative payout limit.

[0039] Preferably, the preset verification rules in step six) include: Rule 1: The total amount of claims for all liabilities under the same invoice shall not exceed the total amount of the invoice. Rule 2: The total claim amount for all bills under the same liability shall not exceed the total insured amount for that liability; Rule 3: The cumulative deduction amount under the same compensation type shall not exceed the compensation amount of the corresponding liability.

[0040] Compared with the prior art, the beneficial effects of the present invention are: 1. This application uses a dynamic sorting logic of "lowest compensation amount first" to reduce the upfront deduction losses of high-value liabilities, ensure the maximum total compensation amount after multiple liabilities are combined, solve the problem that traditional fixed-order claims settlement cannot achieve optimal compensation, and improve user satisfaction.

[0041] 2. This application refines the sharing and deduction rules among liabilities, and splits the apportionment amount according to the type of compensation to ensure accurate deduction logic; multiple sets of calculation formulas, segmented compensation rules, and the step-by-step advancement of limit and sum assured calculation achieve accurate amount calculation and reduce the risk of claims disputes.

[0042] 3. This application achieves comprehensive coverage of all responsibilities through a cyclical claims settlement mechanism. The closed-loop verification and retry mechanism can automatically correct some calculation anomalies. At the same time, the generation of detailed anomaly data facilitates manual verification, thereby improving the fault tolerance and reliability of claims processing.

[0043] 5. Supports complex claims scenarios with multiple invoices, multiple liabilities, and multiple shared rules. It can be flexibly adapted to different types of indemnity insurance products without the need to develop separate claims logic for specific products, thus reducing the system development and maintenance costs for insurance companies.

[0044] 6. This application strictly adheres to the terms of the insurance contract and industry compliance requirements. All calculation steps, deduction logic, and verification results are clearly recorded, enabling full traceability of the claims process and facilitating regulatory verification and problem tracing. Attached Figure Description

[0045] Figure 1 This is a schematic diagram of the overall process of the present invention. Detailed Implementation

[0046] The following will refer to the appendices in the embodiments of the present invention. Figure 1 The technical solutions in the embodiments of the present invention are clearly and completely described herein. Obviously, the described embodiments are only a part of the embodiments of the present invention, and not all of the embodiments. Based on the embodiments of the present invention, all other embodiments obtained by those of ordinary skill in the art without creative effort are within the scope of protection of the present invention.

[0047] Please see Figure 1 Embodiments of the present invention: Example: like Figure 1 The following is a method for maximizing individual insurance claims payouts, comprising the following steps: 1) Liability Matching: The system iterates through each invoice to match all applicable indemnity insurance liabilities for each invoice, while reading the preset sharing rules between these liabilities to obtain the matched list of indemnity liabilities, configuration information for each liability, and shared configuration information between liabilities. 1.1) Process each claim invoice individually, matching each invoice with all applicable indemnity insurance liabilities; Processing each invoice individually avoids confusion of responsibility caused by mixing and matching multiple invoices, ensuring that the applicable responsibility for each invoice is not omitted or mismatched, thus laying the foundation for accurate settlement in the future.

[0048] 1.2) Read the preset sharing rules between matched responsibilities; Clearly define the rules for deductions, shared coverage amounts, and shared deductibles between liabilities in advance to avoid logical confusion caused by missing rules during subsequent amount calculations and ensure the smoothness of the claims process.

[0049] 1.3) Obtain the matched list of compensatory responsibilities, configuration information for each responsibility, and shared configuration information between responsibilities; The compensation type of the indemnifying liability is at least one of the following: self-payment type 1, self-payment type 2, and out-of-pocket expenses, and the deduction between liabilities only applies to liabilities with the same compensation type.

[0050] By integrating basic data to form a complete data source for claims settlement, and by defining deduction rules between the same type of claims, the calculation error of cross-type deductions is reduced, and the accuracy of amount calculation is improved.

[0051] In this embodiment, step one) achieves a precise association between the invoice and the insurance liability through the liability matching step, clarifies the core association rules between liabilities, and provides complete and accurate basic data for subsequent steps such as amount calculation and order sorting, avoiding calculation deviations caused by missing data or matching errors. At the same time, the subsequent calculation logic is simplified by the deduction restrictions of the compensation type.

[0052] (ii) Amount Calculation: Based on all the information obtained in step one), calculate the compensation amount for each liability in the list of uncompensated liabilities in the cyclical compensation liability list according to the preset logic, and obtain the final compensation amount data for each liability. 2.1) Receive all the information from step 1.3) and the cumulative allocation result returned in step 5) (when not in the first loop); 2.2) Based on the compensation liability list obtained in the first cycle in step 1.3), and the unresolved liability list and abnormal liability list after verification failure in step 5), for each liability, call the corresponding compensation formula to calculate the initial reimbursable amount. If it is not the first cycle and there is a deduction relationship between the current liability and the already compensated liability, include the apportioned amount of the already compensated liability in the deduction item and generate the initial reimbursable amount and deduction association description. If it is the first cycle, only the initial reimbursable amount is generated and no deduction association description is generated. The formula for calculation includes: Formula 1: Initial recoverable base amount = Total bill amount - Amount covered by this insurance - Amount paid by third parties; Formula 2: Initial recoverable base amount = Total bill amount - Amount covered by this insurance - Third-party payment amount - Self-paid amount; Formula 3: Initial recoverable base amount = Total bill amount - Amount covered by this insurance - Amount paid by third parties - Amount paid by the second party - Amount paid by the third party.

[0053] The settlement formula is matched with the liability to ensure that the initial amount calculation complies with the contract; non-first-time cycles are included in the deduction items to implement the compensation principle between liabilities and avoid double payment; the records of deduction-related explanations make the settlement logic traceable.

[0054] 2.3) Based on the initial claimable amount and deduction association instructions, adjust the initial claimable amount according to the preset script rules to generate the adjusted claimable amount; (the deduction association instructions are only used to record the deduction logic and do not affect the amount adjustment calculation) By adapting script rules to special claims scenarios, the flexibility of claims processing is improved, ensuring that special agreements (such as additional compensation, limit adjustments, etc.) are accurately implemented.

[0055] 2.4) Based on the adjusted claimable amount, extract the corresponding deductible from the liability configuration information in step one). If there is a deductible sharing rule between liabilities, the deductible amount of the already claimed liability sharing needs to be deducted. Deduct the deductible from the adjusted claimable amount. If the amount after deduction is less than zero, it is calculated as zero and the amount after deduction is generated. Strictly implement the deductible and sharing rules to avoid payment discrepancies caused by incorrect deductible calculations, while protecting the legitimate rights and interests of insurance companies by charging zero deductibles.

[0056] 2.5) Based on the amount after deduction, read the compensation ratio and segmentation rules of the liability from the liability configuration information in step one). If no segmentation rules are configured, directly multiply the amount after deduction by the compensation ratio. If segmentation rules are configured, split the amount according to the rules and multiply each by the corresponding ratio, then sum them to obtain the proportional calculation amount and generate the proportional calculation amount. The segmented comparison rule is as follows: the claimable amount is divided into at least two consecutive amount intervals, each with an independent payout ratio. The amount is calculated by summing the products of "amount in each interval × corresponding payout ratio".

[0057] Accurately implement the compensation ratio and segmentation agreement to ensure that the compensation calculation for different amount ranges complies with the contract requirements and improve the rationality and compliance of the claims results.

[0058] 2.6) Based on the proportional calculation of the amount, read the advanced information limit rules of the responsibility from the responsibility configuration information in step one), deduct the historical used amount of the responsibility, and take the smaller value between the remaining available amount and the proportional calculation amount as the limit amount to generate the limit amount; The advanced information limit rules include at least one of the following: monthly payout limit, quarterly payout limit, annual payout limit, and cumulative payout limit.

[0059] Strictly adhere to the phased or frequency-based limit agreements to avoid overpayment, ensure the insurance company's risk is controllable, and at the same time ensure that users receive full compensation within the limit.

[0060] 2.7) Based on the amount after the limit, read the total sum insured for this liability from the liability configuration information in step one). If there is a sum insured sharing rule between liabilities, the sum insured amount of the shared liability that has already been settled needs to be deducted. The remaining sum insured = total sum insured - historical payout amount for this liability - deduction of shared sum insured amount. Take the smaller value between the amount after the limit and the remaining sum insured as the final payout amount for this liability and send it to step three).

[0061] By calculating the total sum insured and the shared rules, the final amount of compensation is determined, ensuring that it does not exceed the maximum sum insured stipulated in the contract, while providing accurate monetary data for subsequent sorting steps.

[0062] In this embodiment, step two, through seven detailed steps, achieves accurate calculation from the initial amount to the final compensation amount. It strictly follows the various rules stipulated in the insurance contract (such as deductible, compensation ratio, sum insured, limit, etc.) and adapts to the logic of special scenarios and the relationship between liabilities, ensuring that the compensation amount for each liability is calculated accurately, and providing core data support for achieving the maximum compensation target in the future.

[0063] (iii) Sequence determination: Based on the final compensation amount data of each liability obtained in step two, select the liability with the smallest compensation amount as the first compensation liability of the bill, and obtain the current compensation liability identifier and the corresponding compensation amount; 3.1) Receive the final compensation amount data for all unclaimed liabilities generated in step two); 3.2) Sort all unclaimed liabilities in ascending order of compensation amount; By dynamically sorting and filtering the optimal calculation order, a path is provided for implementing the core logic of "minimum amount first".

[0064] 3.3) Select the liability with the smallest payout amount after sorting and determine it as the first payout liability for this bill; Prioritize the settlement of lower-value liabilities to reduce the impact of deductions on subsequent higher-value liabilities, thus laying the foundation for maximizing the total compensation amount.

[0065] 3.4) Generate a unique identifier for the first claim liability and the corresponding final claim amount, and pass it to step four.

[0066] In this embodiment, step three) breaks through the limitations of the traditional fixed-order claims settlement by dynamic sorting and optimal liability selection, realizes intelligent optimization of the claims settlement order, fundamentally solves the problem of insufficient compensation for high-value liabilities, and provides key guarantee for ultimately achieving the maximum compensation target.

[0067] (iv) Amount apportionment: Based on the liability identification and compensation amount obtained in step (iii), the compensation amount is broken down and calculated according to the compensation type configured for the current compensation liability, the proportion of each compensation type is determined, and the proportion of each compensation type and the cumulative apportionment result are obtained. 4.1) Receive the unique identifier of the current compensation liability generated in step 3), associate the liability configuration information in step 1 with the identifier, read the compensation type of the liability configuration, clarify the compensation type and corresponding amount to be shared, and generate a list of sharing types and corresponding basic amounts; By configuring related liability information, the types of claims and their corresponding basic amounts can be accurately identified, providing a clear basis for subsequent apportionment calculations.

[0068] 4.2) Receive the list of apportionment types and corresponding basic amounts generated in step 4.1), accumulate the total amount of all apportionment types as the denominator, and the amount of a single apportionment type as the numerator. Calculate the percentage of each apportionment type by "numerator ÷ denominator" to generate the percentage data of each apportionment type. The compensation amount is split proportionally to ensure the accurate calculation of the proportion of each type of compensation, providing precise data for subsequent cross-liability deductions.

[0069] 4.3) Receive the percentage data of each compensation type generated in step 4.2) and the final compensation amount of the current compensation liability generated in step 3). Multiply the final compensation amount by the percentage of each compensation type to obtain the percentage amount corresponding to each compensation type. Generate the percentage amount of each compensation type and the cumulative apportionment result (i.e., the sum of each percentage amount) to step 5.

[0070] Generate accurate percentage amounts and cumulative results for each type to ensure that subsequent deductions only apply to amounts of the same type, avoiding cross-type deduction errors and ensuring the consistency of the claims process.

[0071] In this embodiment, step four) clarifies the scope and amount of deductions from the current liability to subsequent liabilities by splitting the apportionment amount according to the type of compensation. This solves the problem of ambiguous deduction logic between liabilities in traditional claims settlement, ensures the accuracy of cross-liability deductions, and provides clear data support for the smooth progress of cyclic claims settlement.

[0072] 5) Cyclic Settlement: Based on the cumulative allocation result obtained in step 4), determine whether there are any unsettled liabilities in the compensation liability list obtained in step 1). If there are, return the cumulative allocation result and the unsettled liability list to step 2), triggering step 2) to be re-executed until the settlement result of all liabilities is obtained. If there are no unsettled liabilities, obtain the settlement result of all liabilities. 5.1) Receive the percentage amount and cumulative apportionment results of each compensation type generated in step four), or the verification failure message and current settlement result returned in step six; 5.2) Based on the compensation responsibility list obtained in step one), remove the responsibilities that have completed the settlement process in steps two to four, and generate an unsettled responsibility list. If the received message is a verification failure message, generate an abnormal responsibility list according to the abnormal responsibility identifier in the message. By iteratively calculating all responsibilities, and by returning an exception list to correct errors, the completeness and accuracy of the calculation results are ensured.

[0073] 5.3) Determine if the list of unresolved responsibilities or the list of abnormal responsibilities is empty: If not empty, the cumulative allocation result or abnormal liability identifier, as well as the list of unpaid liabilities or abnormal liabilities, will be sent back to step two, triggering step two to calculate the amount of unpaid liabilities or abnormal liabilities; If empty, summarize the payment results of all settled liabilities to form the settlement results of all liabilities, and send them to step six.

[0074] In this embodiment, step five) achieves one-to-one calculation and data linkage of multiple responsibilities through a cyclical calculation mechanism, ensuring that all applicable responsibilities can be accurately calculated without omission or duplication; at the same time, the closed-loop correction mechanism for abnormal responsibilities improves the fault tolerance of the process, effectively solves the problem of low efficiency in abnormal handling in traditional calculation, and ensures the reliability and integrity of the calculation process.

[0075] VI) Result Verification: Verify the calculation results of all responsibilities in step V) to ensure that they meet the preset verification rules.

[0076] 6.1) Receive all liability settlement results generated in step five; 6.2) Verify each item of the calculation results according to the preset verification rules; 6.3) If the verification passes, the final claim settlement result will be generated directly; 6.4) If the verification fails, a verification failure message will be generated, which includes the abnormal type (such as exceeding the invoice amount, exceeding the liability coverage, abnormal deduction amount) and abnormal data (such as exceeding the limit amount, and the liability identifier of the matter). 6.5) Send the verification failure message and the current calculation result back to step five), triggering steps two through six to be re-executed; 6.6) Record the number of retries. When the verification still fails after 3-5 retries, generate a final failure message and complete exception data, and terminate the calculation process.

[0077] This avoids resource waste caused by infinite loops, while generating complete anomaly data to facilitate manual intervention and verification, ensuring the controllability of the process.

[0078] In this embodiment, step six) ensures that the final claims settlement result complies with the contract and industry compliance requirements through a comprehensive verification and closed-loop correction mechanism, effectively avoiding risks such as overpayment and logical errors; the limitation on the number of retries and the recording of abnormal data balance process efficiency and processing quality, which not only improves the automation processing capability, but also provides a clear basis for manual intervention, ensuring the accuracy and reliability of the claims settlement result.

[0079] Specifically, this embodiment takes a medical insurance claim as an example. There is one or more receipts in a case. Each receipt can be matched with one or more policies and one or more liabilities. There is a deduction relationship between related liabilities. That is, the claim amount of this liability will be deducted from the claim amount of the previous related liability. Suppose there are two receipts A and B in a case. They can both be claimed under medical liabilities D, E and F under policy C. Among them, D pays out-of-pocket expenses 1, out-of-pocket expenses 2 and out-of-pocket expenses, E pays out-of-pocket expenses and F pays out out-of-pocket expenses 2. This embodiment can be understood as follows: 1. First, calculate the claimable amount according to the liability configuration formula. The formula may be: total amount - within the scope of this medical insurance - third-party payment, or total amount - within the scope of this medical insurance - third-party payment - co-payment 2, total amount - within the scope of this medical insurance - third-party payment - co-payment 2 - out-of-pocket expenses, etc. The specific formula varies depending on the type of liability compensation.

[0080] 2. Adjust the claimable amount according to the script. Special rules may result in overpayment or underpayment, thus obtaining a second claimable amount.

[0081] 3. If there is a deductible, the claimable amount will be deducted based on the deductible. For example, if the claimable amount is 100 yuan and the deductible is 200 yuan, then the claimable amount will be 0.

[0082] 4. Next, determine if there are segmented proportions for liability. If not, directly multiply the claimable amount by the reimbursement ratio. If there are, then according to the segmentation rules of the liability configuration, split the claimable amount into different segments multiplied by different reimbursement ratios. For example, the segmentation rules for liability A are: 0-100 yuan, reimbursement ratio is 1; 101 yuan-1000 yuan, reimbursement ratio is 0.5. Assuming the claimable amount is 200 yuan, the calculation logic is (100*1) + (200-100)*0.5 = 150 yuan.

[0083] 5. Advanced information limits are supplementary clauses for configuring liability. For example, it might specify that the liability can only be compensated 500 yuan per month, or that there can only be a certain number of compensations in total. Assuming the rule is: Liability A can only be compensated 500 yuan per month, the calculation rule is to find all claims data for this person under this liability between October 1st and October 31st, add the claim amounts to get a historical usage limit, then subtract the historical usage limit from 500 to get the available limit for this liability, and then compare this with the claimable amount for this liability to calculate the payable amount. If the historical usage limit is 450 yuan, then the available limit is 50 yuan. If the claimable amount for this liability is 150 yuan, then the limited payable amount is 50 yuan.

[0084] The liability coverage amount is calculated in a similar way to the advanced information limit. However, the liability coverage amount is the total amount that can be paid out under this liability clause, while the advanced information limit is an additional clause outside of the liability coverage and has some additional rules and restrictions.

[0085] Comparative Example 1: The difference between this embodiment and Example 1 is that: The normal claims settlement rule is to process claims in the order of liability, cycling through each liability and sorting by date. This involves first settling claims for bill A under liability D, then bill B, then bills A and B under liability E, and finally bills A and B under liability F, until all bills are settled. However, a fixed claims settlement order may not necessarily satisfy the insurer's principle of maximizing payouts.

[0086] For example: Assume receipt A has an amount of 200 yuan, the amount covered by medical insurance is 100 yuan, and the third-party payment is 0 yuan. Assume the claim formula for liabilities D, E, and F is ABC, i.e., receipt amount - amount covered by medical insurance - third-party payment amount. The insured amount for liabilities E and F is 100 yuan, and the insured amount for liability D is 50 yuan. The reimbursement ratios for liabilities are 0.8, 0.5, and 0.1, respectively. Then, according to the calculation order, first calculate liability D: the claimable amount * reimbursement ratio = (200 - 100 - 0) * 0.8 = 80 > 50 = 50 yuan. The second calculation is for liability E: the claimable amount * reimbursement ratio = (200 - 100 - 50) * 0.5 = 25 yuan. The third calculation is for liability F: the claimable amount * reimbursement ratio = (200 - 100 - 75) * 0.1 = 2.5 yuan. Therefore, the final reimbursement amount is 50 + 25 + 2.5 = 77.5 yuan.

[0087] Comparative Example 2: The difference between this embodiment and Example 1 is that: If the claim calculation order is E, D, F, then according to the claim calculation order, the first claim is for liability E, the claimable amount * reimbursement ratio = (200-100-0) * 0.5 = 50 yuan. The second claim is for liability D, the claimable amount * reimbursement ratio = (200-100-50) * 0.8 = 40 < 50 = 40 yuan. The third claim is for liability F, the claimable amount * reimbursement ratio = (200-100-90) * 0.1 = 1 yuan. Therefore, the final compensation amount is 50 + 40 + 1 = 91 yuan.

[0088] The simple example above illustrates that during the claims process, when there are variables such as the insured amount and different payout ratios, different payout orders will lead to different total payout amounts. In normal individual insurance claims logic, the calculation formula, script limit, deductible, payout ratio, segmented deduction rules, advanced information limit rules, and the variable of the insured amount may all be inconsistent. Too many variables mean that, in order to satisfy the principle of maximum payout, the order of liability calculation for each policy needs to be different.

[0089] The foregoing has shown and described the basic principles, main features, and advantages of the present invention. It will be apparent to those skilled in the art that the invention is not limited to the details of the exemplary embodiments described above, and that the invention can be implemented in other specific forms without departing from its spirit or essential characteristics. Therefore, the embodiments should be considered illustrative and non-limiting in all respects, and the scope of the invention is defined by the appended claims rather than the foregoing description. Thus, all variations falling within the meaning and scope of equivalents of the claims are intended to be included within the scope of the invention. No reference numerals in the claims should be construed as limiting the scope of the claims.

[0090] Furthermore, it should be understood that although this specification describes embodiments, not every embodiment contains only one independent technical solution. This narrative style is merely for clarity. Those skilled in the art should consider the specification as a whole, and the technical solutions in each embodiment can also be appropriately combined to form other embodiments that can be understood by those skilled in the art.

Claims

1. A method for maximizing individual insurance claims payout, characterized in that, Includes the following steps: 1) Liability Matching: The system iterates through each invoice to match all applicable indemnity insurance liabilities for each invoice, while reading the preset sharing rules between these liabilities to obtain the matched list of indemnity liabilities, configuration information for each liability, and shared configuration information between liabilities. (ii) Amount Calculation: Based on all the information obtained in step one), calculate the compensation amount for each liability in the list of uncompensated liabilities in the cyclical compensation liability list according to the preset logic, and obtain the final compensation amount data for each liability. (iii) Sequence determination: Based on the final compensation amount data of each liability obtained in step two, select the liability with the smallest compensation amount as the first compensation liability of the bill, and obtain the current compensation liability identifier and the corresponding compensation amount; (iv) Amount apportionment: Based on the liability identification and compensation amount obtained in step (iii), the compensation amount is broken down and calculated according to the compensation type configured for the current compensation liability, the proportion of each compensation type is determined, and the proportion of each compensation type and the cumulative apportionment result are obtained. 5) Cyclic Settlement: Based on the cumulative allocation result obtained in step 4), determine whether there are any unsettled liabilities in the compensation liability list obtained in step 1). If there are, return the cumulative allocation result and the unsettled liability list to step 2), triggering step 2) to be re-executed until the settlement result of all liabilities is obtained. If there are no unsettled liabilities, obtain the settlement result of all liabilities. VI) Result Verification: Verify the calculation results of all responsibilities in step V) to ensure that they meet the preset verification rules.

2. The method for realizing maximum compensation in individual insurance claims according to claim 1, characterized in that, The specific content of step one is as follows: 1.1) Process each claim invoice individually, matching each invoice with all applicable indemnity insurance liabilities; 1.2) Read the preset sharing rules between matched responsibilities; 1.3) Obtain the matched list of compensatory responsibilities, configuration information for each responsibility, and shared configuration information between responsibilities; The compensation type of the indemnifying liability is at least one of the following: self-payment type 1, self-payment type 2, and out-of-pocket expenses, and the deduction between liabilities only applies to liabilities with the same compensation type.

3. The method for realizing maximum compensation in individual insurance claims according to claim 2, characterized in that, The specific content of step two is as follows: 2.1) Receive all the information from step 1.3) and the cumulative allocation result returned in step 5); 2.2) Based on the compensation liability list obtained in the first cycle in step 1.3), and the unresolved liability list and abnormal liability list after verification failure in step 5), for each liability, call the corresponding compensation formula to calculate the initial reimbursable amount. If it is not the first cycle and there is a deduction relationship between the current liability and the already compensated liability, include the apportioned amount of the already compensated liability in the deduction item and generate the initial reimbursable amount and deduction association description. If it is the first cycle, only the initial reimbursable amount is generated and no deduction association description is generated. 2.3) Based on the initial claimable amount and deduction association description, adjust the initial claimable amount according to the preset script rules to generate the adjusted claimable amount; 2.4) Based on the adjusted claimable amount, extract the corresponding deductible from the liability configuration information in step one). If there is a deductible sharing rule between liabilities, the deductible amount of the already claimed liability sharing needs to be deducted. Deduct the deductible from the adjusted claimable amount. If the amount after deduction is less than zero, it is calculated as zero and the amount after deduction is generated. 2.5) Based on the amount after deduction, read the compensation ratio and segmentation rules of the liability from the liability configuration information in step one). If no segmentation rules are configured, directly multiply the amount after deduction by the compensation ratio. If segmentation rules are configured, split the amount according to the rules and multiply each by the corresponding ratio, then sum them to obtain the proportional calculation amount and generate the proportional calculation amount. 2.6) Based on the proportional calculation of the amount, read the advanced information limit rules of the responsibility from the responsibility configuration information in step one), deduct the historical used amount of the responsibility, and take the smaller value between the remaining available amount and the proportional calculation amount as the limit amount to generate the limit amount; 2.7) Based on the amount after the limit, read the total sum insured for this liability from the liability configuration information in step one). If there is a sum insured sharing rule between liabilities, the sum insured amount of the shared liabilities that have already been settled needs to be deducted. The remaining sum insured = total sum insured - historical payout amount for this liability - deduction of shared sum insured amount. Take the smaller value between the amount after the limit and the remaining sum insured as the final payout amount for this liability and send it to step three).

4. The method for realizing maximum compensation in individual insurance claims according to claim 3, characterized in that, In step 2.2), the calculation formula includes: Formula 1: Initial recoverable base amount = Total bill amount - Amount covered by this insurance - Amount paid by third parties; Formula 2: Initial recoverable base amount = Total bill amount - Amount covered by this insurance - Third-party payment amount - Self-payment amount; Formula 3: Initial recoverable base amount = Total bill amount - Amount covered by this insurance - Third-party payment amount - Self-paid amount - Out-of-pocket amount.

5. The method for realizing maximum compensation in individual insurance claims according to claim 4, characterized in that, In step 2.5), the segmented comparison rule is as follows: the claimable amount is divided into at least two consecutive amount intervals, each amount interval corresponds to an independent compensation ratio, and the amount is calculated by the sum of the products of "amount of each interval × corresponding compensation ratio".

6. The method for realizing maximum compensation in individual insurance claims according to claim 5, characterized in that, The specific content of step three is as follows: 3.1) Receive the final compensation amount data for all unclaimed liabilities generated in step two); 3.2) Sort all unclaimed liabilities in ascending order of compensation amount; 3.3) Select the liability with the smallest payout amount after sorting and determine it as the first payout liability for this bill; 3.4) Generate a unique identifier for the first claim liability and the corresponding final claim amount.

7. The method for realizing maximum compensation in individual insurance claims according to claim 6, characterized in that, The specific content of step four is as follows: 4.1) Receive the unique identifier of the current compensation liability generated in step 3), associate the liability configuration information in step 1 with the identifier, read the compensation type of the liability configuration, clarify the compensation type and corresponding amount to be shared, and generate a list of sharing types and corresponding basic amounts; 4.2) Receive the list of apportionment types and corresponding basic amounts generated in step 4.1), accumulate the total amount of all apportionment types as the denominator, and the amount of a single apportionment type as the numerator. Calculate the percentage of each apportionment type by "numerator ÷ denominator" to generate the percentage data of each apportionment type. 4.3) Receive the percentage data of each compensation type generated in step 4.2) and the final compensation amount of the current compensation liability generated in step 3). Multiply the final compensation amount by the percentage of each compensation type to obtain the percentage amount corresponding to each compensation type. Generate the percentage amount of each compensation type and the cumulative apportionment result to step 5.

8. The method for realizing maximum compensation in individual insurance claims according to claim 7, characterized in that, The specific content of step five is as follows: 5.1) Receive the percentage amount and cumulative apportionment results of each compensation type generated in step four), or the verification failure message and current settlement result returned in step six; 5.2) Based on the compensation responsibility list obtained in step one), remove the responsibilities that have completed the settlement process in steps two to four, and generate an unsettled responsibility list. If the received message is a verification failure message, generate an abnormal responsibility list according to the abnormal responsibility identifier in the message. 5.3) Determine if the list of unresolved responsibilities or the list of abnormal responsibilities is empty: If not empty, the cumulative allocation result or abnormal liability identifier, as well as the list of unpaid liabilities or abnormal liabilities, will be sent back to step two, triggering step two to calculate the amount of unpaid liabilities or abnormal liabilities; If empty, summarize the payment results of all settled liabilities to form the settlement results of all liabilities, and send them to step six.

9. The method for realizing maximum compensation in individual insurance claims according to claim 8, characterized in that, The specific content of step six is ​​as follows: 6.1) Receive all liability settlement results generated in step five; 6.2) Verify each item of the calculation results according to the preset verification rules; 6.3) If the verification passes, the final claim settlement result will be generated directly; 6.4) If the verification fails, generate a verification failure message containing the exception type and exception data; 6.5) Send the verification failure message and the current calculation result back to step five), triggering steps two through six to be re-executed; 6.6) Record the number of retries. When the verification still fails after 3-5 retries, generate a final failure message and complete exception data, and terminate the calculation process.

10. A method for realizing maximum compensation in individual insurance claims according to claim 3, 4, 5, 6, 7, 8 or 9, characterized in that, In step 2.6), the advanced information limit rules include at least one of the following: monthly payout limit, quarterly payout limit, annual payout limit, and cumulative payout limit.

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