Liability insurance coverage referral systems and methods

• US 20040083124A1
• Filed: 09/15/2003
• Published: 04/29/2004
• Est. Priority Date: 09/13/2002
• Status: Active Application

• Current Assignee: Brandt Gerard Cordelli
• Original Assignee: Brandt Gerard Cordelli
• Inventors: Cordelli, Brandt Gerard
• Application Number:
  US10/661,508
• Publication Number:
  US 20040083124A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Methods and systems for deterrmining which individual claims and/or suits submitted for a defense under a policy of liability insurance are best suited to be referred to a higher level of analysis, such as outside legal counsel for a coverage opinion and analysis. Particularly, those which allow, for example, a claims handler to quickly and efficiently make this determination, i.e., to make an automatic coverage referral.

Claims

1. A system for making a determination of whether a claim for a defense under a liability insurance policy should be referred to a higher review level comprising:

a tangible medium setting forth a multiplicity of categories of circumstances relevant to analyzing the claim which either apply or do not apply to the claim, and

human- or computer-executable instructions for determining, from the number of categories found to apply, and optionally also from their relative importance, whether the claim should be referred to a higher review level.

3. A system according to claim 1, wherein the instructions for determining, from the number of categories found to apply, whether the claim should be referred to a higher review level are executed by a computer.

5. A system according to claim 1, further comprising instructions for determining, from the number of categories found to apply, whether the claim should be automatically referred to a higher review level without further analysis or referred to a higher review level with qualification of an additional analysis.

7. A system according to claim 5, wherein the tangible medium contains multiple categories in a primarily prominent portion of the medium from which the determination of automatic referral is made and multiple categories in a secondarily prominent portion, the determination of qualified referral being made from the categories in both such portions.

9. A system according to claim 7, wherein the tangible medium is a paper or electronic form, the primarily prominent portion is the first or front page of the form and the secondarily prominent portion is the second or back page of the form.

12. A method according to claim 9 wherein the primarily prominent portion contains five categories.

14. A method according to claim 12 wherein the five categories in the primarily prominent portion are:

1) Preliminary Analysis Suggests Denial;

     2) Mixed Suit—

Covered and/or Potentially Covered with Uncovered Claims;

     3) Key Policyholder Counsel Tenders Claim for Defense or Independent/Cumis Counsel Involved;

     4) Misrepresentation or Omission in Application and/or Pre-existing Loss Suspected; and

one of the following;

     5) Umbrella/Excess Coverage by Company,

     6) Defense Tendered by Other than Named Insured,

     7) Latent and/or Continuous and Progressive Injury or Damage,

     8) Other Carriers Involved, or

     9) Target Claims/Damages Alleged.

16. A method according to claim 14 wherein the secondarily prominent portion contains the other categories 5) to 9) not on the primarily prominent portion plus the following categories:

10) Internet-Related Liability Issues,

     11) Potential Personal Injury or Advertising Injury,

     12) Insolvent Insurer and/or Guaranty Fund Involved or On Notice,

     13) SIR of $100,000 or More, and

     14) Employment-Related Claims.

17. A system according to claim 1 wherein at least one category also contains associated with it one or more selectable data entries which relate to bases for finding the category applicable.

20. A method according to claim 16 wherein each category also contains associated with it one or more selectable data entries which relate to bases for finding the category applicable.

21. A system according to claim 1 wherein the instructions for determining whether the claim should be referred to a higher review level are based on whether a number, n, of categories out of the total categories or a selected sub-set of categories are found applicable.

24. A method according to claim 16 wherein the instructions for determining whether the claim should be referred to a higher review level are whether tlree of the five categories in the primarily prominent portion are found applicable and, optionally, the instructions for determining whether the claim should be referred to a higher review level upon qualification are whether seven of a total of 14 categories in the total form are found applicable.

25. A system according to claim 1 wherein the instructions for determining whether the claim should be referred to a higher review level are based on a weighting system whereby each category is assigned a particular weighting and a certain threshold of the sum of weightings of the total categories or a sub-set of categories found applicable is met.

27. A system according to claim 25, wherein the instructions for determining whether the claim should be referred to a higher review level are executed by a computer.

30. A method according to claim 16 wherein the instructions for determining whether the claim should be referred to a higher review level are based on a weighting system whereby each category is assigned a particular weighting and a certain threshold of the sum of weightings of the total categories or a sub-set of categories found applicable is met.

32. A system according to claim 30, wherein the instructions for determining whether the claim should be referred to a higher review level are executed by a computer.

33. A system according to claim 1 wherein the tangible medium contains at least one data entry area for information identifying the claim.

35. A system according to claim 7 wherein the tangible medium contains the instructions for determining, from the number of categories found to apply, whether the claim should be referred to a higher review level, automatically or with qualification, on the primarily prominent portion of the form.

37. A system according to claim 1 which further includes compiling data from the tangible media prepared under the system for a multiplicity of claims and conducting a trend analysis on one or more aspects thereof.

2. A method for determining whether a claim for a defense under a liability insurance policy should be referred to a higher review level comprising:

making a determination whether each of a multiplicity of categories of circumstances relevant to analyzing the claim either apply or do not apply to the claim and indicating such in a tangible medium setting forth the categories, and

based on the determinations of how many categories apply, and optionally also from their relative importance, executing, by human or computer action, instructions provided on or with the tangible medium to determine whether the claim should be referred to a higher review level.

4. A method according to claim 2, wherein the instructions for determining, from the number of categories found to apply, whether the claim should be referred to a higher review level are executed by a computer.

6. A method according to claim 2, further comprising instructions for determining, from the number of categories found to apply, whether the claim should be automatically referred to a higher review level without further analysis or referred to a higher review level with qualification of an additional analysis.

8. A method according to claim 6, wherein the tangible medium contains multiple categories in a primarily prominent portion of the medium from which the determination of automatic referral is made and multiple categories in a secondarily prominent portion, the determination of qualified referral being made from the categories in both such portions.

10. A method according to claim 8, wherein the tangible medium is a paper or electronic form, the primarily prominent portion is the first or front page of the form and the secondarily prominent portion is the second or back page of the form.

11. A system according to claim 8 wherein the primarily prominent portion contains five categories.

13. A system according to claim 11 wherein the five categories in the primarily prominent portion are:

1) Preliminary Analysis Suggests Denial;

     2) Mixed Suit—

Covered and/or Potentially Covered with Uncovered Claims;

     3) Key Policyholder Counsel Tenders Claim for Defense or Independent/Cumis Counsel Involved;

     4) Misrepresentation or Omission in Application and/or Pre-existing Loss Suspected; and

one of the following;

     5) Umbrella/Excess Coverage by Company,

     6) Defense Tendered by Other than Named Insured,

     7) Latent and/or Continuous and Progressive Injury or Damage,

     8) Other Carriers Involved, or

     9) Target Claims/Damages Alleged.

15. A system according to claim 13 wherein the secondarily prominent portion contains the other categories 5) to 9) not on the primarily prominent portion plus the following categories:

10) Internet-Related Liability Issues,

     11) Potential Personal Injury or Advertising Injury,

     12) Insolvent Insurer and/or Guaranty Fund Involved or On Notice,

     13) SIR of $100,000 or More, and

     14) Employment-Related Claims.

18. A method according to claim 2 wherein at least one category also contains associated with it one or more selectable data entries which relate to bases for finding the category applicable.

19. A system according to claim 15 wherein each category also contains associated with it one or more selectable data entries which relate to bases for finding the category applicable.

22. A method according to claim 2 wherein the instructions for determining whether the claim should be referred to a higher review level are based on whether a number, n, of categories out of the total categories or a selected sub-set of categories are found applicable.

23. A system according to claim 15 wherein the instructions for determining whether the claim should be referred to a higher review level are whether three of the five categories in the primarily prominent portion are found applicable and, optionally, the instructions for determining whether the claim should be referred to a higher review level upon qualification are whether seven of a total of 14 categories in the total form are found applicable.

26. A system according to claim 15 wherein the instructions for determining whether the claim should be referred to a higher review level are based on a weighting system whereby each category is assigned a particular weighting and a certain threshold of the sum of weightings of the total categories or a sub-set of categories found applicable is met.

28. A system according to claim 26, wherein the instructions for determining whether the claim should be referred to a higher review level are executed by a computer.

29. A method according to claim 2 wherein the instructions for determining whether the claim should be referred to a higher review level are based on a weighting system whereby each category is assigned a particular weighting and a certain threshold of the sum of weightings of the total categories or a sub-set of categories found applicable is met.

31. A system according to claim 29 wherein the instructions for determining whether the claim should be referred to a higher review level are executed by a computer.

34. A method according to claim 2 wherein the tangible medium contains at least one data entry area for information identifying the claim.

36. A method according to claim 8 wherein the tangible medium contains the instructions for determining, from the number of categories found to apply, whether the claim should be referred to a higher review level, automatically or with qualification, on the primarily prominent portion of the form.

38. A method according to claim 2 which further includes compiling data from the tangible media prepared under the method for a multiplicity of claims and conducting a trend analysis on one or more aspects thereof.