Hierarchical Claims Processing System for Multiple Policies
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Solution Overview
Problem
Current insurance claims processing for multiple policies is fragmented, paper-intensive, and prone to duplication, errors, and increased interaction with external entities, leading to inefficiencies and burdens on insured individuals or their families, particularly in cases involving multiple policies with different beneficiaries and terms.
Innovation Solution
A hierarchical claims processing system that manages claims at a claim management case level, policy level, and coverage level, allowing for centralized processing and adjudication of multiple policies, with features such as a policy portfolio view, claim management case creation, and node-based association of policies, coverages, and designees, enabling unified 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 managed independently with its own beneficiaries and terms, 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 claim management case. When an insured has multiple policies with the same carrier, the system consolidates information requirements, document collection, and adjudication processes into one integrated workflow, eliminating the need for separate paper-based processing for each policy while maintaining policy-specific benefits.
Solution Approach 2:
The claim management case structure serves multiple functions simultaneously: it manages information requirements across all policies, tracks documentation status, coordinates adjudication, and handles communications with beneficiaries. This universal structure replaces multiple separate administrative processes while accommodating policy-specific variations.
2Adaptability or versatility
If separate information requirements are generated for each policy, then policy-specific needs are met, but duplication occurs and additional opportunities for error and fraud arise
Solution Approach 1:
The system merges information requirements from multiple policies into a consolidated set of unique requirements. The claim management case identifies and eliminates duplicate requests (such as requesting the same death certificate for multiple policies), maintaining only the necessary policy-specific requirements while reducing overall duplication and error opportunities.
Solution Approach 2:
The system creates a standardized template for information requirements that can be copied and applied across multiple policies. Once an information requirement is established for one policy, it can be automatically replicated for other policies with appropriate modifications, ensuring consistency and reducing manual entry errors.
3Productivity
If multiple separate checks are issued to beneficiaries for different policies, then each policy payment is tracked independently, but the process becomes more cumbersome and time consuming
Solution Approach 1:
The system merges the payment issuance process for multiple policies into a single coordinated action. When all information requirements are satisfied and adjudication is complete for multiple policies, the system can generate a single consolidated payment or coordinated payments, reducing the time required for processing compared to issuing separate checks through multiple independent workflows.
4Adaptability or versatility
If a grieving spouse receives duplicate requests for the same documentation under different policies, then policy-specific information needs are addressed, but the administrative burden on the insured or family members increases
Solution Approach 1:
The system merges all information requirement requests into a single coordinated communication with the beneficiary. Instead of sending separate requests for the same documentation under different policies, the claim management case consolidates these into one unified request, reducing the administrative burden on grieving spouses while ensuring all policy-specific information needs are met.
Data Source
AI summary
Methods and systems are provided for processing claims. A hierarchy may be created for claims specific to the insured that includes a claim management case level, a policy level, and a coverage level. The claim management case level may include a claim management case node. The policy level may include one or more policy nodes. Each of the policy nodes may relate to an insurance policy covering the insured. The one or more insurance policies covering the insured are associated with the claim management case. The coverage level may include one or more coverage nodes. Each of the coverage nodes may relate to an insurance coverage covering the insured. Each of the insurance coverages may be associated with one of the insurance policies.