Unified Claims Case Management for Multi-Policy Adjudication
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Solution Overview
Problem
Current insurance claim processing for multiple policies is fragmented, paper-intensive, and prone to errors, duplication, and increased interaction with outside entities, leading to administrative burdens and opportunities for fraud, especially when handling events like death or disability claims across different policies.
Innovation Solution
A hierarchical claims processing system that manages claims at a claim management case level, policy level, and coverage level, allowing for unified processing and adjudication of multiple policies, with features like a policy portfolio view and designee management, to streamline information requirements and payments.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If claims are processed on a policy-by-policy basis, then each policy can be handled according to its specific terms and conditions, but the claims administration process becomes fragmented and paper-intensive with duplication of efforts
Solution Approach 1:
The patent merges multiple policy-level claim processes into a single unified claims administration system. The system consolidates information requirements, document collection, and correspondence generation across multiple policies into one integrated workflow, eliminating duplication while maintaining policy-specific processing capabilities through a centralized hierarchy.
Solution Approach 2:
The claims administration system is designed as a universal platform that can handle multiple policies simultaneously. It provides multi-functional capabilities to manage diverse policy types (life insurance, annuity, disability, health) through a single system interface, allowing the same system to adapt to different policy requirements without requiring separate processing systems.
2Reliability
If multiple sets of information requirements are generated for each policy, then each policy's specific documentation needs are met, but duplication occurs and additional opportunities for error and fraud arise
Solution Approach 1:
The system merges information requirements across multiple policies into a unified set of documentation requests. By consolidating duplicate requirements (such as a single death certificate for multiple policies), the system reduces information duplication and associated errors while maintaining the ability to track which documents satisfy which policy requirements through its hierarchical structure.
3Manufacturing precision
If multiple checks are issued to beneficiaries for different policies, then each policy's benefit is paid correctly, but the process becomes more time-consuming and administratively burdensome
Solution Approach 1:
The system merges the payment issuance process for multiple policies into a coordinated workflow. It can consolidate payments to the same beneficiary across multiple policies into a single transaction when appropriate, or coordinate multiple payments through a unified system that tracks and manages all payment activities, reducing administrative time while maintaining accurate payment distribution.
4Adaptability or versatility
If additional interaction is required with outside persons and entities for each policy, then specific policy requirements are fulfilled, but the insured or insured family members bear additional burdens
Solution Approach 1:
The system merges correspondence and communication requirements across multiple policies into unified interactions with outside entities and the insured. It consolidates requests for the same information (such as a single death certificate request) into one communication, reducing the burden on insured family members while still fulfilling all necessary policy requirements through coordinated information gathering.
Data Source
AI summary
Methods and systems are provided for processing claims. A claim management case is created for an insured in response to a notice of a claim. One or more insurance policies covering the insured are associated with the claim management case. At least one process is performed at a claim management case level to fulfill an information requirement that applies to at least two of the insurance policies associated with the claim management case. Claims are adjudicated under the one or more of the insurance policies covering the insured.