Data processing system for accurately calculating a policyholder's discount in a medical insurance plan and a method therefor

• US 20060041454A1
• Filed: 07/26/2005
• Published: 02/23/2006
• Est. Priority Date: 07/26/2004
• Status: Active Grant

• Current Assignee: Vitality Group International, Inc. (Discovery Limited)
• Original Assignee: Discovery Holdings Limited (Prudential PLC)
• Inventors: Matisonn, Shaun, Greenblatt, Samuel Shlomo, Berghorst, Timothy
• Granted Patent: US 8,145,500 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/00 Administration; Management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment

Abstract

A data processing system for accurately calculating a discount in a medical insurance plan comprises a premiums module adapted to access data regarding the amount of premiums paid by a policyholder of the medical insurance plan for a predetermined period. A claims module is adapted to access data regarding the amount of claims paid by the medical insurance plan to the policyholder for the predetermined period, the claims module being further adapted to access data to determine if there have been any claims submitted by a policyholder which have not yet been paid, and if so to apply a set of rules to each submitted claim which has not been paid to determine if it is likely to be paid, and if the claim is likely to be paid then adding the amount of the claim to the amount of claims already paid for the predetermined period. Finally, a discount module adapted to receive data from the premiums module and the claims module and to use the data to calculate a discount amount.

Claims

1. A data processing system for accurately calculating a discount in a medical insurance plan, the system comprising:

a premiums module adapted to access data regarding the amount of premiums paid by a policyholder of the medical insurance plan for a predetermined period,

a claims module adapted to access data regarding the amount of claims paid by the medical insurance plan to the policyholder for the predetermined period, the claims module being further adapted to access data to determine if there have been any claims submitted by a policyholder which have not yet been paid, and if so to apply a set of rules to each submitted claim which has not been paid to determine if it is likely to be paid, and if the claim is likely to be paid then adding the amount of the claim to the amount of claims already paid for the predetermined period; and

a discount module adapted to receive data from the premiums module and the claims module and to use the data to calculate a discount amount.

2. A system according to claim 1 further comprising an incentive scheme module adapted to access data regarding the level of the policyholder in an incentive scheme and to use this data to calculate the discount amount.

3. A system according to claim 1 wherein the discount module is adapted to check the data received from the premiums module and the claims module.

4. A system according to claim 1 wherein the claims module is further adapted to determine if there have been any claims authorised for a policyholder which have not yet been claimed, and if so to apply a set of rules to determine the likely amount of the authorised claim and then add the likely amount of the claim to the amount of claims already paid for the predetermined period.

5. A system according to claim 1 wherein the premiums module is adapted to determine if the amount of premiums paid by the policyholder of the medical insurance plan for the predetermined period was a discounted amount, and if so to calculate a notional amount being the amount the policyholder would have paid if they were not awarded a discount, wherein the notional amount is used to calculate the discount amount.

6. A system according to claim 1 wherein the claims module is adapted to compare the number of claims submitted by a policyholder to the number of claims submitted by a policyholder in a previous time period as a further error check.

7. A system according to claim 1 wherein the premium module is adapted to use the calculated discount to calculate a premium for the policyholder for the coming year.

8. A machine-readable medium comprising instructions, which when executed by a machine, cause the machine to perform a method of calculating a discount in a medical insurance plan, the method comprising:

accessing premiums data regarding the amount of premiums paid by a policyholder of the medical insurance plan for a predetermined period,

accessing claims data regarding the amount of claims paid by the medical insurance plan to the policyholder for the predetermined period;

accessing further claims data to determine if there have been any claims submitted by a policyholder which have not yet been paid, and if so to apply a set of rules to each submitted claim which has not been paid to determine if it is likely to be paid, and if the claim is likely to be paid then adding the amount of the claim to the amount of claims already paid for the predetermined period; and

using the data accessed to calculate a discount amount.

9. A machine-readable medium according to claim 8 comprising instructions, which when executed by a machine, cause the machine to perform a method of calculating a discount in a medical insurance plan, the method further comprising accessing data regarding the level of the policyholder in an incentive scheme and using this data to calculate the discount amount.

10. A machine-readable medium according to claim 8 comprising instructions, which when executed by a machine, cause the machine to perform a method of calculating a discount in a medical insurance plan, the method further comprising checking the data received from the premiums module and the claims module.

11. A machine-readable medium according to claim 8 comprising instructions, which when executed by a machine, cause the machine to perform a method of calculating a discount in a medical insurance plan, the method further comprising determining if there have been any claims authorised for a policyholder which have not yet been claimed, and if so to apply a set of rules to determine the likely amount of the authorised claim and then adding the likely amount of the claim to the amount of claims already paid for the predetermined period.

12. A machine-readable medium according to claim 8 comprising instructions, which when executed by a machine, cause the machine to perform a method of calculating a discount in a medical insurance plan, the method further comprising determining if the amount of premiums paid by the policyholder of the medical insurance plan for the predetermined period was a discounted amount, and if so to calculate a notional amount being the amount the policyholder would have paid if they were not awarded a discount, wherein the notional amount is used to calculate the discount amount.

13. A machine-readable medium according to claim 8 comprising instructions, which when executed by a machine, cause the machine to perform a method of calculating a discount in a medical insurance plan, the method further comprising comparing the number of claims submitted by a policyholder to the number of claims submitted by a policyholder in a previous time period as a further error check.

14. A method of calculating a discount in a medical insurance plan, the method comprising:

accessing premiums data regarding the amount of premiums paid by a policyholder of the medical insurance plan for a predetermined period,

accessing claims data regarding the amount of claims paid by the medical insurance plan to the policyholder for the predetermined period;

accessing further claims data to determine if there have been any claims submitted by a policyholder which have not yet been paid, and if so to apply a set of rules to each submitted claim which has not been paid to determine if it is likely to be paid, and if the claim is likely to be paid then adding the amount of the claim to the amount of claims already paid for the predetermined period; and

using the data accessed to calculate a discount amount.

15. A method according to claim 14 further comprising accessing data regarding the level of the policyholder in an incentive scheme and using this data to calculate the discount amount.

16. A method according to claim 14 further comprising checking the data received from the premiums module and the claims module.

17. A method according to claim 14 further comprising determining if there have been any claims authorised for a policyholder which have not yet been claimed, and if so to apply a set of rules to determine the likely amount of the authorised claim and then adding the likely amount of the claim to the amount of claims already paid for the predetermined period.

18. A method according to claim 14 further comprising determining if the amount of premiums paid by the policyholder of the medical insurance plan for the predetermined period was a discounted amount, and if so to calculate a notional amount being the amount the policyholder would have paid if they were not awarded a discount, wherein the notional amount is used to calculate the discount amount.

19. A method according to claim 14 further comprising comparing the number of claims submitted by a policyholder to the number of claims submitted by a policyholder in a previous time period as a further error check.