Insurance payment operation support system and insurance payment operation support method

Abstract

To provide a mechanism for quickly making the payment of a benefit or an insurance benefit.SOLUTION: A first acquisition unit 108 acquires first claim information necessary for claiming payment of a benefit or an insurance benefit. A second acquisition unit 110 acquires second claim information necessary for claiming payment of the benefit or the insurance benefit from character data extracted from a document image obtained by photographing a document issued by a medical institution. An identification unit 112 identifies claim contents including information identifying a sickness from the first claim information and the second claim information. An assessment unit 114 calculates an amount of the benefit or the insurance benefit based on the identified claim contents and contract contents held in a contract content DB 120. The assessment unit 114 acquires payment conditions related to a moral risk associated with the information identifying the sickness included in the claim contents from a sickness assessment DB 122, and determines to pay the benefit or the insurance benefit if the claim contents satisfy the payment conditions related to the moral risk.SELECTED DRAWING: Figure 3

Description

[Technical Field]

[0001] The present invention relates to a technology for supporting payment operations at insurance companies, and more particularly to an insurance payment operation support system and an insurance payment operation support method for calculating the amount of benefits or insurance money based on the contents of insurance contracts that customers have made. [Background technology]

[0002] Patent Document 1 discloses a system for supporting insurance benefit application procedures. This insurance benefit application system extracts information contained in photographed images of medical institution certification documents and automatically determines the appropriateness of the application information by comparing the extracted information with text information entered during the application procedure and personal information registered in the insurance company's customer information database. If the automatic determination determines that the information is incorrect, the insurance benefit application system requests the applicant to re-enter the information or re-photograph the certification documents, etc., and enter the correct application information, thereby smoothly carrying out the insurance benefit application procedures and payment procedures. [Prior art documents] [Patent documents]

[0003] [Patent Document 1] Japanese Patent Publication No. 2023-31501 Summary of the Invention [Problem to be solved by the invention]

[0004] Traditionally, most of the payment assessment work to calculate the amount of benefits and insurance payments has been done manually, which has resulted in a long period of time between receiving a claim and paying the benefit or insurance payment to the customer.

[0005] The present invention has been made in consideration of these problems, and one of its purposes is to provide a system that simplifies the procedures for claiming benefits or insurance claims while quickly paying benefits or insurance claims. [Means for solving the problem]

[0006] An insurance payment support system according to one embodiment of the present invention is an insurance payment support system for calculating the amount of insurance benefits or insurance money, and includes: a contract details database storing insurance contract details; an injury / illness assessment database storing information identifying the injury or illness and payment conditions related to the moral risk of the benefit or insurance money in association with each other; a first acquisition unit acquiring first claim information required for claiming the benefit or insurance money; a second acquisition unit acquiring second claim information required for claiming the benefit or insurance money from character data extracted from a photographed document image of a document issued by a medical institution; an identification unit identifying claim details including information identifying the injury or illness from the first claim information and the second claim information; and an assessment unit calculating the amount of the benefit or insurance money based on the identified claim details and the contract details stored in the contract details database. The assessment unit acquires the payment conditions related to the moral risk associated with the information identifying the injury or illness included in the claim details from the injury / illness assessment database, and decides to pay the benefit or insurance money if the claim details satisfy the payment conditions related to the moral risk.

[0007] Another aspect of the present invention relates to an insurance payment support method for supporting insurance payment operations in an insurance payment support system including a contract content database that stores insurance contract content, and an injury / illness assessment database that stores information identifying injury or illness and payment conditions related to moral risk of benefits or insurance payments in association with each other. This insurance payment support method includes the steps of acquiring first claim information required for claiming benefits or insurance payments, extracting character data from a document image obtained by photographing a document issued by a medical institution, acquiring second claim information required for claiming benefits or insurance payments from the extracted character data, identifying claim details including information identifying injury or illness from the first claim information and the second claim information, acquiring payment conditions related to moral risk associated with the information identifying injury or illness included in the claim details from the injury / illness assessment database, determining whether the claim details satisfy the payment conditions related to moral risk, and deciding to pay the benefit or insurance payments if the claim details satisfy the payment conditions related to moral risk.

[0008] Any combination of the above components, or any conversion of the present invention between an apparatus, a computer program, or a recording medium on which a computer program is readably recorded, is also valid as an embodiment of the present invention. [Brief explanation of the drawings]

[0009] [Figure 1] FIG. 1 is a diagram showing a series of business processes for processing a claim for payment of benefits or insurance payments. [Figure 2] FIG. 10 is a diagram showing an example of a receipt. [Figure 3] FIG. 1 is a diagram showing functional blocks of an insurance system according to an embodiment. [Figure 4] FIG. 10 is a diagram illustrating an example of an input screen. [Figure 5] FIG. 10 is a diagram showing an example of an input screen for the content of an offer. [Figure 6] FIG. 10 is a diagram showing an example of a screen for inputting a reason for a request. [Figure 7] FIG. 10 is a diagram showing an example of an input screen for the name of an injury or illness. [Figure 8] FIG. 10 is a diagram showing an example of an input screen for hospitalization period. [Figure 9] FIG. 10 is a diagram showing an example of an input screen for a surgery name. [Figure 10] FIG. 10 is a diagram showing an example of a confirmation screen for input contents. [Figure 11] FIG. 10 is a diagram showing an example of an input screen for required documents and required information. [Figure 12] FIG. 10 is a diagram illustrating an example of a final confirmation screen. [Figure 13] FIG. 10 is a diagram showing billing details identified from first billing information and second billing information. [Figure 14] FIG. 10 is a flowchart illustrating an automatic appraisal process. DETAILED DESCRIPTION OF THE INVENTION

[0010] Figure 1 shows a series of business processes for processing insurance benefits or insurance claim payments. Each business process is implemented by an insurance payment support system installed in an insurance company. The insurance payment support system may be configured with multiple information processing devices, such as an OCR (Optical Character Reader) device and a server device.

[0011] (Claim Procedure) In the insurance system of the embodiment, a customer operates a terminal device such as a smartphone or tablet to carry out the procedure for claiming payment of benefits or insurance money. The customer creates a claim document by entering information required for the claim, such as the name of the injury or illness and the length of hospitalization, into an input screen displayed on the terminal device. The customer also photographs documents issued by medical institutions using a camera installed in the terminal device. The photographed document may be a receipt or a medical statement. The customer then transmits the created claim document and the payment claim, including the photographed document image, from the terminal device to the insurance company's insurance payment business support system. This claim procedure may also be carried out by an insurance company sales representative visiting the customer's home from the sales representative's terminal device.

[0012] Figure 2 shows an example of a receipt. The receipt includes the medical fee points for each medical procedure and the billing amount calculated based on the patient's share of the medical expenses. The receipt shown in Figure 2 was issued when the patient was discharged from the hospital and includes the hospital stay (October 10, 2022 to October 15, 2022) and the number of days (6 days). The receipt only includes information necessary for medical expenses payment, so it does not include the name of the disease or surgery. The medical statement (not shown) contains more detailed information than the receipt, such as the details of the treatment, tests, prescription medications, and surgery, but does not include the name of the disease. The customer takes a photo of the receipt and / or medical statement and sends the image along with the billing documents to the insurance payment support system.

[0013] (claim acceptance) The insurance payment support system accepts payment claims, including claim documents and document images, from customer terminal devices. During the claim acceptance process, an OCR device recognizes the text contained in the document images and converts them into character data.

[0014] (Payment Assessment) The insurance payment support system acquires the primary claim information required for claiming benefits or insurance money from the claim documents, and acquires the secondary claim information required for claiming benefits or insurance money from the character data extracted from the document image, thereby identifying the claim details. The insurance payment support system checks whether the identified claim details fall under the payment grounds stipulated in the insurance product's terms and conditions. If the claim details do not fall under the payment grounds stipulated in the terms and conditions, the claim is rejected and no benefits or insurance money will be paid to the customer. If the claim details fall under the payment grounds stipulated in the terms and conditions, the insurance payment support system calculates the amount of benefits or insurance money based on the contract details. For ease of explanation, benefits or insurance money will sometimes be simply referred to as "benefits" below.

[0015] Next, the insurance payment support system of the embodiment checks whether the claim content satisfies payment conditions related to moral risk. Here, moral risk in the insurance industry refers to abuse of the insurance system or moral danger (immoral behavior), such as fraudulently obtaining benefits or insurance payments. Payment conditions related to moral risk differ from payment conditions (grounds for payment) stipulated in the insurance product policy, and are conditions for determining whether a payment claim is being made fraudulently.

[0016] Health insurance coverage begins on the date when all three steps—application for the insurance contract, notification or medical examination, and first premium payment—are completed. This date is called the "liability start date," and the insurance company's contractual liability begins on this date. The insurance payment support system in the embodiment identifies the claim based on the primary claim information included in the claim documents and the secondary claim information included in the receipt and / or medical statement. However, the name of the injury or illness that is the basis for the benefit claim is not listed on the receipt or medical statement and is therefore identified by the claim documents prepared by the customer. In other words, the name of the injury or illness included in the claim is self-reported by the customer, and it is possible that the customer may enter an incorrect name (a name different from the actual injury or illness). Therefore, the insurance payment support system in the embodiment performs a process to verify whether the claim meets the payment conditions related to moral risk. This verification process will be described in detail later.

[0017] If a photograph of a medical certificate is attached to the claim, the name of the illness or injury can be identified from the characters contained in the certificate. The insurance payment support system can then cross-check the name of the illness or injury entered by the customer against the name listed on the certificate to confirm its accuracy. However, obtaining a medical certificate takes time and money, so it is preferable for insurance companies to accept benefit claims without requiring the customer to submit a medical certificate. Therefore, the insurance system of the embodiment allows customers to receive benefits by submitting photographs of receipts and / or medical statements to the insurance company. Some insurance products require the submission of a medical certificate. In such cases, the customer must have a medical institution prepare the certificate and then send a photograph of the certificate from a terminal device to the insurance payment support system.

[0018] If the claim meets the payment conditions related to moral risk, the insurance payment support system will promptly process the payment to the customer. The claim acceptance process and payment assessment process are carried out automatically by the insurance payment support system, so the process from accepting the payment claim to paying the benefit to the customer can be completed as soon as the same day, and at the latest within two business days. If the claim does not meet the payment conditions related to moral risk, automatic payment cannot be made, and the claim details will be notified to the insurance company's adjuster, who will make a decision on the payment conditions. If it is determined that the claim does not constitute a moral risk, the insurance payment support system will process the payment to the customer.

[0019] (Confirmation assessment) After the payment of benefits, the insurance payment support system automatically checks for any missed claims from customers.The insurance payment support system checks to see if any reasons for benefit payment have been overlooked.

[0020] (Billing Information) If an incomplete claim is found, the insurance payment support system will notify the customer and guide them to file a new claim. As described above, the insurance payment support system supports the efficient implementation of insurance payment operations, providing insurance services with high customer satisfaction.

[0021] FIG. 3 shows functional blocks of an insurance system 1 according to an embodiment. The insurance system 1 includes a terminal device 10 operated by a customer and an insurance payment support system 100 installed in an insurance company. The terminal device 10 and the insurance payment support system 100 are communicably connected via a network 2 such as the Internet. At least a portion of the configuration of the insurance payment support system 100 may be installed outside the insurance company.

[0022] The terminal device 10 is a device with communication capabilities, such as a smartphone or tablet, that is operated by a customer. The terminal device 10 has an input unit 12, such as a touch screen, that allows the customer to input data, a camera 14, a processing unit 16 that executes various data processing, a memory unit 18 that stores data referenced or updated by the processing unit 16, a communication unit 20 that is communicatively connected to the insurance payment operation support system 100, and a display unit 22. The display unit 22 may be a liquid crystal panel or an organic EL panel. The terminal device 10 may be a device that is personally owned by the customer, or may be a device that is owned by an insurance company representative who visits the customer's home.

[0023] Figure 4 shows the login screen of the dedicated site. When a customer enters their insurance policy number and login password on the login screen and operates the login button, their identity is verified and they are then logged in to the dedicated site. The processing unit 16 displays on the display unit 22 a list of multiple procedures that the customer can carry out with the insurance company. The customer (hereinafter also referred to as the "claimant") operates the input unit 12 to select "claim for benefits / insurance claims" from the list of procedures and begin the procedure for claiming payment of benefits.

[0024] Figure 5 shows an example of the input screen for claim details. This input screen displays options for claim details based on the claimant's contract details. In this example, the claimant has selected "hospitalization" and "surgery / radiotherapy." When the claimant clicks the "Next" button, the input screen for the reason for claim is displayed.

[0025] Figure 6 shows an example of the screen for entering the reason for claim. This screen displays options for the reason for claim, and the claimant selects "illness." When the claimant clicks the "Next" button, a screen for entering the name of the injury or illness is displayed.

[0026] Figure 7 shows an example of an input screen for the name of an illness or injury. The claimant enters the name of the illness or injury that caused "hospitalization" or "surgery / radiotherapy." The input field may be configured to display a selectable list of illness or injury names that are frequently claimed when the claimant enters part of the name of the illness or injury. For example, if "stomach" is entered in the input field, a list of illness or injury names that are likely to be entered and contain "stomach" in part, such as "gastric ulcer," "gastric polyp," "gastroenteritis," "acute gastroenteritis," "gastric cancer," "gastritis," etc., is displayed. The claimant can enter the name of the illness or injury in the input field by selecting it from the list.

[0027] Only illnesses and injuries registered in the injury and injury assessment database (DB) 122 managed by the insurance company can be entered in the input field. The insurance company's injury and injury assessment DB 122 registers master data based on the MEDIS standard master, which conforms to the International Classification of Diseases (ICD) established by the World Health Organization (WHO), and contains approximately 53,000 illness and injury names. To ensure consistent handling of illness and injury names, a system may be implemented in which, when synonyms of illness and injury names are entered in the input field, the entered synonyms are automatically converted to illness and injury names, which are part of the master data. The input field may not accept free text input by the claimant, but may instead be configured so that the claimant selects the appropriate illness or injury name from the approximately 53,000 registered illness and injury names to enter the illness or injury name in the input field. In this example, the claimant enters "cataract" as the illness or injury name. When the claimant clicks the "Next" button, a screen for entering the length of hospitalization is displayed.

[0028] Figure 8 shows an example of the hospitalization period input screen. In this example, the claimant has entered that they were hospitalized from May 15, 2023 to May 17, 2023, and have now been discharged. When the claimant clicks the "Next" button, an input screen for surgery and radiation therapy will be displayed.

[0029] Figure 9 shows an example of the surgery name input screen. The claimant enters the name of the surgery they underwent during their hospitalization. Since the name of the surgery is listed on the medical bill, the claimant can enter the name of the surgery by referring to the information on the medical bill.

[0030] Only surgery names registered in the surgery assessment database (DB) 124 managed by the insurance company can be entered in the input field. The surgery assessment DB 124 registers master data based on surgery names registered in medical treatment procedures (receipts) established by the Social Insurance Medical Fee Payment Fund, and approximately 5,500 surgery names are registered. To handle surgery names uniformly, a system may be introduced in which, when a synonym for a surgery name is entered as text in the input field, the entered synonym is automatically converted to the surgery name, which is one of the master data. Note that the input field may be configured so that the claimant does not accept free text input, but instead the surgery name is entered in the input field by the claimant selecting the appropriate surgery name from the approximately 5,500 registered surgery names.

[0031] In this example, the claimant enters "Lens reconstruction surgery (lens insertion, etc.)" as the name of the surgery and the date of surgery as May 15, 2023. They also enter that they did not receive radiation therapy during their hospitalization. When the claimant clicks the "Next" button, a screen will appear confirming the details of their hospitalization.

[0032] Figure 10 shows an example of the confirmation screen for the entered information. If the claimant finds an error in the entered information, they can correct it by pressing the "correction button." When the claimant presses the "next" button, a screen for entering the required documents and information will be displayed.

[0033] Figure 11 shows an example of the input screen for required documents and required information. The documents required for this claim are automatically determined from the information entered by the claimant up to that point, and are displayed on the input screen shown in Figure 11. The top section of this input screen indicates that receipts and / or medical details are required for the claim.

[0034] In the insurance system 1 of the embodiment, the claimant is required to take a photograph of the receipt 30 and / or medical statement 32 and send the photographed document image to the insurance company. Note that it is also possible to send only one of the receipt 30 and medical statement 32. When the claimant operates the "camera capture start button," the camera 14 is activated and the claimant takes a photograph of the receipt 30 and / or medical statement 32. Note that the photograph of the document may be taken after the creation of the claim document is completed.

[0035] On this input screen, the claimant enters their bank account and address. If the claimant has previously filed a claim, the account and address fields may default to the information they previously entered. When the claimant clicks the "Next" button, a final confirmation screen will be displayed.

[0036] FIG. 12 shows an example of the final confirmation screen. On the final confirmation screen, the claimant signs their name in kana, which completes the claim document creation process. When the claimant operates the "Complete Procedure" button, the communication unit 20 sends a payment claim including the claim document and document images to the insurance payment support system 100. Note that the receipt 30 and / or medical statement 32 may be photographed after the "Complete Procedure" button is operated. In this case, after the photographing is completed, the communication unit 20 sends a payment claim including the claim document and document images to the insurance payment support system 100.

[0037] 3 , the insurance payment operation support system 100 includes a claim reception unit 102, an OCR processing unit 104, an acquisition unit 106, an identification unit 112, an assessment unit 114, a contract content database (DB) 120, an injury / illness assessment database (DB) 122, a surgery assessment database (DB) 124, and a customer information database (DB) 126. The acquisition unit 106 includes a first acquisition unit 108 and a second acquisition unit 110.

[0038] The contract details DB120 holds the contract details of insurance products offered by insurance companies. The injury / illness assessment DB122 registers approximately 53,000 names of injuries and illnesses as master data, and the surgery assessment DB124 registers approximately 5,500 names of surgeries as master data. The customer information DB126 holds personal information of customers and the details of the insurance contracts (such as the details of insurance products and special provisions) that customers have signed up for.

[0039] The injury / illness assessment DB 122 stores information identifying an injury or illness in association with insurance products applicable to the injury or illness. The information identifying an injury or illness here may be the name of the injury or illness, or may be an identification number (injury / illness ID) assigned to the injury or illness in the injury / illness assessment DB 122. When an insurance company offers multiple types of insurance products, the injury / illness assessment DB 122 stores applicable (payable) insurance products in association with each of approximately 53,000 types of injury or illness. This makes it possible to automatically determine whether or not the benefit can be paid, for example, when a claimant files a claim for payment of benefits due to "cataracts," by determining whether the claimant has contracted an insurance product that is payable for "cataracts."

[0040] In the embodiment, the injury / illness assessment DB 122 stores information identifying an injury or illness and payment conditions related to the moral risk of benefits or insurance payments, in association with each other. As described above, the information identifying an injury or illness may be the name of the injury or illness, but it may also be an identification number (injury / illness ID) assigned to the injury or illness. Payment conditions related to moral risk will be described in detail later.

[0041] The insurance payment processing support system 100 shown in FIG. 3 includes one or more computers, and various functions shown in FIG. 3 are realized by the computers executing programs. The computer includes hardware such as a memory into which the programs are loaded, one or more processors that execute the loaded programs, auxiliary storage devices, and other LSIs. The processor is composed of multiple electronic circuits including semiconductor integrated circuits and LSIs, and the multiple electronic circuits may be mounted on a single chip or multiple chips. The functional blocks shown in FIG. 3 are realized by cooperation between hardware and software. Therefore, it will be understood by those skilled in the art that these functional blocks can be realized in various forms using hardware alone, software alone, or a combination thereof.

[0042] The claim acceptance unit 102 accepts a payment claim including a claim document and a document image. The first acquisition unit 108 acquires first claim information necessary for claiming benefits or insurance payments from the claim document. The OCR processing unit 104 recognizes text contained in the document image and converts it into character data, and the second acquisition unit 110 acquires second claim information necessary for claiming benefits or insurance payments from the character data extracted from the document image. The identification unit 112 identifies the claim content, including information identifying the injury or illness, from the first claim information and the second claim information. The information identifying the injury or illness may be the name of the injury or illness.

[0043] FIG. 13 shows the claim details identified from the first claim information and the second claim information. In this claim, the illness is "cataract." The claimant enters the hospitalization period on the input screen shown in FIG. 8, and the hospitalization period is also listed on receipt 30 and medical statement 32. The identification unit 112 then determines whether the hospitalization period included in the first claim information matches the hospitalization period included in the second claim information, and if they match, recognizes that the hospitalization period is correct. If the two do not match, the identification unit 112 determines that there is an error in the claim information and notifies the insurance company's adjuster of this fact.

[0044] In this example, the hospitalization period is from May 15, 2023 to May 17, 2023. However, if the hospitalization period spans multiple months, the claimant must submit photographed images of the receipts for each month. For example, if the hospitalization period is from May 15, 2023 to July 5, 2023, the claimant must submit photographed images of the receipts for May, June, and July. In this case, if the claimant submits photographed images of the receipts for May and June but does not submit a photographed image of the receipt for July, the identification unit 112 determines that the hospitalization period included in the first claim information does not match the hospitalization period included in the second claim information, specifically, that the second claim information does not include the hospitalization period for July.

[0045] In this case, the identification unit 112 identifies the claim content with the hospitalization period from May 15, 2023 to June 30, 2023 from the first claim information and the second claim information. In other words, the identification unit 112 identifies the period where the hospitalization period included in the first claim information and the hospitalization period included in the second claim information match (overlap) as the hospitalization period. In this case, the insurance company adjuster informs the customer that the July hospitalization was not covered by payment because the receipt for July was not attached, and that if the customer wishes to claim for July, they should resubmit the claim with the receipt for July attached.

[0046] When the identification unit 112 identifies the claim details, the assessment unit 114 calculates the amount of the benefit or insurance payment based on the identified claim details and the insurance contract details stored in the contract details DB 120. Specifically, the assessment unit 114 refers to the injury / illness assessment DB 122 to identify insurance products applicable to "cataracts," and refers to the customer information DB 126 to identify the insurance product that the customer has contracted. If the insurance product that the customer has contracted is applicable to "cataracts," the assessment unit 114 calculates the amount of the benefit or insurance payment based on the claim details and the insurance contract details. For example, in the case of an insurance product in which the benefit amount is determined based on the amount stated on a receipt or medical fee points, the assessment unit 114 calculates the benefit amount based on the amount and medical fee points included in the second claim information.

[0047] After calculating the amount, the assessment unit 114 determines whether the claim satisfies the payment conditions related to moral risk. In the embodiment, the payment conditions related to moral risk are set for each injury or illness, and the injury / illness assessment DB 122 stores, for each injury or illness, a first payment condition for the period from the start date of liability to the date the payment event occurs and a second payment condition for the hospitalization period. Note that injuries and illnesses include external injuries and illnesses (diseases), and in the embodiment, the injury / illness assessment DB 122 stores, for each illness (disease), the "early assessment period" for the first payment condition and the "maximum number of days of hospitalization" for the second payment condition. The assessment unit 114 obtains, from the injury / illness assessment DB 122, the payment conditions related to moral risk associated with information identifying the illness (disease) included in the claim, and determines to pay the benefit or insurance money if the claim satisfies the payment conditions.

[0048] 14 shows a flowchart of the automatic assessment process by the assessment unit 114. When the identification unit 112 identifies the claim content (S10), the assessment unit 114 refers to at least the injury / illness assessment DB 122 and the customer information DB 126 to determine whether the claim content falls under the payment grounds set forth in the insurance product's terms and conditions (S12). If the claim content does not fall under the payment grounds set forth in the terms and conditions (N in S12), the payment claim is rejected. If the claim content falls under the payment grounds set forth in the terms and conditions (Y in S12), the assessment unit 114 calculates the amount of benefit or insurance payment based on the insurance contract details (S14).

[0049] Next, the assessment unit 114 performs a process to check whether the content of the claim corresponds to a moral risk. First, the assessment unit 114 acquires the early assessment period set for the injury or illness included in the claim content from the injury or illness assessment DB 122 (S16). In this embodiment, since the claim is based on "cataract", the specification unit 112 acquires the early assessment period set for "cataract" in the injury or illness assessment DB 122.

[0050] As mentioned above, medical insurance coverage begins on the coverage start date, when all three steps—application for the insurance contract, notification or examination, and first premium payment—are completed. However, in cases where a customer is hospitalized for cataracts the day after the coverage start date and files a claim for benefits, it is suspected that the customer may not have properly disclosed their health condition. Therefore, in Insurance System 1, the insurance company analyzes a huge number of past assessment records and sets an early assessment period for each injury or illness to automatically identify moral risk cases, and registers the period in the injury or illness assessment database 122. The early assessment period is set as the shortest appropriate period between the coverage start date and the hospitalization date. If the period between the coverage start date and the hospitalization date is shorter than the early assessment period, the claim is identified as a moral risk case.

[0051] For example, if the early assessment period for cataracts is set to 60 days, and the hospitalization date is less than 60 days after the start of coverage, the assessment unit 114 determines that the claim for benefit payment is within the early assessment period (N in S18), notifies the insurance company's adjuster of the assessment result (S26), and terminates the automatic assessment. Upon receiving this notification, the adjuster will contact the individual or a medical institution to confirm the facts regarding the claim. If the period from the start of coverage date to the onset of illness (hospitalization) is shorter than the early assessment period, but it is confirmed that the illness did not occur before the start of coverage, the adjuster will determine that there is no problem with the early assessment period and allow payment to be made to the customer.

[0052] In this embodiment, the first payment condition is set such that the period from the liability start date to the hospitalization date is equal to or longer than the early assessment period set for the illness. The early assessment period is set for each illness by statistically processing past assessment results; for example, the early assessment period for glaucoma may be set to 40 days, and the early assessment period for diabetes may be set to 90 days. If the hospitalization date is equal to or longer than 60 days from the liability start date (Y in S18), the assessment unit 114 determines that the first payment condition is met.

[0053] Next, the assessment unit 114 obtains the upper limit of hospitalization days set for "cataract" from the injury and illness assessment DB 122 (S20). In the insurance system 1, the insurance company analyzes a huge number of past assessment records, sets an appropriate upper limit of hospitalization days for each injury or illness, and registers the set upper limit of hospitalization days in the injury and illness assessment DB 122. If the number of hospitalization days included in the claim exceeds the upper limit of hospitalization days (N in S22), it is determined that the payment claim may be inappropriate.

[0054] For example, if the maximum number of days of hospitalization for cataracts is set to four days, and the number of days of hospitalization exceeds four days, the assessment unit 114 determines that the number of days of hospitalization may be inappropriate for the benefit payment claim (N in S22), notifies the insurance company's adjuster of the determination result (S26), and terminates the automatic assessment. Upon receiving this notification, the adjuster will contact the individual or the medical institution to confirm the facts of the claim. If the number of days of hospitalization is longer than the maximum number of days of hospitalization but it is confirmed that the hospitalization was for legitimate treatment, the adjuster will determine that there is no problem with the length of hospitalization and allow payment to be made to the customer.

[0055] Thus, in this embodiment, the second payment condition is set such that the number of days of hospitalization included in the claim is equal to or less than the upper limit of hospitalization days set for the illness. The upper limit of hospitalization days is set for each injury or illness by statistically processing past assessment results; for example, the upper limit of hospitalization days for glaucoma may be set to 6 days, and the upper limit of hospitalization days for diabetes may be set to 45 days. If the number of days of hospitalization is equal to or less than the upper limit of hospitalization days (Y in S22), the assessment unit 114 determines that the second payment condition is met.

[0056] When the first and second payment conditions are met, the assessment unit 114 decides to automatically pay the benefit or insurance money (S24), and the automatic assessment ends. Thus, according to the insurance system 1, the customer can complete the claim procedure simply by entering the necessary information on the input screen to create a claim document, taking a photo of the receipt 30 and / or medical statement 32, and sending the claim document and the photo to the insurance payment support system 100. The name of the injury or illness is self-reported by the customer, but the insurance payment support system 100 can achieve fast and fair payment processing by determining the appropriateness of the payment claim using payment conditions related to moral risk set for each injury or illness.

[0057] The present invention has been described above based on the embodiments. These embodiments are merely examples, and it will be understood by those skilled in the art that various modifications are possible in the combination of each component or each treatment process, and that such modifications are also within the scope of the present invention. [Explanation of symbols]

[0058] 1 Insurance system, 2 Network, 10 Terminal device, 12 Input unit, 14 Camera, 16 Processing unit, 18 Memory unit, 20 Communication unit, 22 Display unit, 30 Receipt, 32 Medical treatment statement, 100 Insurance payment operation support system, 102 Claim acceptance unit, 104 OCR processing unit, 106 Acquisition unit, 108 First acquisition unit, 110 Second acquisition unit, 112 Identification unit, 114 Assessment unit, 120 Contract content DB, 122 Injury / illness assessment DB, 124 Surgery assessment DB, 126 Customer information DB.

Claims

1. An insurance payment support system that calculates the amount of insurance benefits or insurance money, a contract details database that stores insurance contract details; an injury / illness assessment database that stores information identifying injury or illness and payment conditions related to moral risk of benefits or insurance payments in association with each other; a first acquisition unit that acquires first claim information necessary for claiming benefits or insurance payments, the first claim information including information specifying the injury or illness and the length of hospitalization from the date of admission to the date of discharge; a second acquisition unit that acquires second claim information necessary for claiming benefits or insurance payments from character data extracted from a document image obtained by photographing a document issued by a medical institution, the second claim information including the hospitalization period from the admission date to the discharge date; an identification unit that identifies claim details including information identifying the injury or illness and the length of hospitalization from the first claim information and the second claim information; an assessment unit that calculates the amount of benefit or insurance payment based on the specified claim content and the contract content stored in the contract content database; The assessment unit acquires, from the injury / illness assessment database, payment conditions related to moral risk associated with information identifying the injury or illness included in the claim content, and determines to pay benefits or insurance money if the claim content satisfies the payment conditions related to moral risk. An insurance payment support system characterized by:

2. If the claim does not satisfy the payment conditions regarding moral risk, the assessment department notifies the insurance company's personnel of that fact.

2. The insurance payment support system according to claim 1.

3. The payment conditions for moral risk are set so that the period from the start date of liability to the date of hospitalization is equal to or longer than the period set for injury or illness.

2. The insurance payment support system according to claim 1.

4. The identification unit identifies the claim content, including the number of days of hospitalization, from the first claim information and the second claim information, The payment conditions for moral risk are set so that the number of hospital days included in the claim is less than the upper limit set for the injury or illness.

2. The insurance payment support system according to claim 1.

5. the first acquisition unit accepts first claim information input by the claimant on an input screen of a terminal device, the first claim information including information specifying the injury or illness and the length of hospitalization; 2. The insurance payment support system according to claim 1.

6. The identification unit identifies, as the hospitalization period, a period in which the hospitalization period included in the first claim information and the hospitalization period included in the second claim information match.

2. The insurance payment support system according to claim 1.

7. the second acquisition unit accepts second billing information extracted from a photographed image of a receipt; 2. The insurance payment support system according to claim 1.

8. An insurance payment support method for supporting insurance payment operations in an insurance payment support system including a contract content database that stores insurance contract content, and an injury / illness assessment database that stores information identifying injury or illness and payment conditions related to the moral risk of benefits or insurance payments in association with each other, comprising: A step of acquiring first claim information necessary for claiming benefits or insurance payments, the first claim information including information specifying the injury or illness and the length of hospitalization from the date of admission to the date of discharge; extracting character data from a document image obtained by photographing a document issued by a medical institution; acquiring, from the extracted character data, second claim information necessary for claiming benefits or insurance money, the second claim information including the hospitalization period from the admission date to the discharge date; Identifying claim details including information specifying the injury or illness and the length of hospitalization from the first claim information and the second claim information; A step of obtaining payment terms related to moral risk associated with information identifying the injury or illness included in the claim content from the injury or illness assessment database; determining whether the claim satisfies payment conditions related to moral risk; determining whether to pay a benefit or claim if the claim satisfies a payment condition regarding moral risk; 1. An insurance payment operation support method comprising:

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