Real-Time Coverage Prediction for Multi-Policy Insurance Claims
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Solution Overview
Problem
Insured individuals often miss opportunities for insurance claim reimbursement due to a lack of understanding of the complex coverage limitations across multiple insurance policies, leading to incorrect submissions or missed claims.
Innovation Solution
A machine-learning driven system that analyzes policy and claim information, converts it to a standardized format, and uses trained models to predict which insurer is likely to cover specific claims, providing real-time recommendations for optimal claim submission.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If the insured manually analyzes multiple insurance policies to determine coverage, then understanding of policy details may be improved, but time consumption and complexity increase significantly
Solution Approach 1:
The patent replaces the manual mechanical analysis process with an automated machine learning system. The ML model automatically ingests policy documents, extracts coverage information, and determines appropriate coverage without human intervention, thereby eliminating time loss while maintaining or improving accuracy through consistent pattern recognition.
Solution Approach 2:
The patent introduces an intermediary layer between the insured and the insurance policies - a machine learning-based coverage analysis system. This intermediary automatically processes the complex policy information and provides clear coverage determinations, shielding the insured from the complexity while delivering accurate results quickly.
2Loss of information
If the insured studies the minutiae of each insurance policy to understand coverage, then coverage understanding improves, but the complexity and difficulty of operation increase
Solution Approach 1:
The patent replaces the complex manual process of studying policy minutiae with an automated machine learning system that performs the analysis. The ML model handles the complexity of parsing and understanding policy language, while presenting simplified coverage information to the user, thereby retaining all necessary information without requiring the user to engage with the complexity.
Solution Approach 2:
The patent creates a simplified copy or representation of the complex policy information through the ML system's analysis output. Instead of requiring users to read and understand the full policy documents, the system generates condensed coverage determinations that capture the essential information in an easily consumable format.
3Productivity
If automated systems are used to analyze claims and policies, then processing speed and productivity improve, but system complexity increases
Solution Approach 1:
The patent segments the complex automated analysis task into distinct functional modules: document ingestion, text extraction, ML model processing, and result generation. Each module handles a specific aspect of the analysis, making the overall system more manageable and maintainable while achieving high processing speeds through specialized optimization of each segment.
Data Source
AI summary
A data processing system for insurance claims analysis and adjudication implements obtaining policy coverage information for each of a plurality of insurance policies and insurance claim information associated with a plurality of insurance claims associated with an insured user, analyzing the insurance claim information using a first machine learning to obtain event-related claim grouping information; analyzing the event-related claim grouping information and the standardized policy information using the second machine learning model to obtain coverage prediction information comprising a prediction, for each event of the one or more events, identifying a respective insurance policy of the plurality of insurance policies likely to cover the one or more claims associated with each event, the second machine learning model being trained using second training data formatted according to the standard schema; and providing, via a network connection, the coverage prediction information to a computing device associated with the insured user.