Method of expediting insurance claims

• US 20070150319A1
• Filed: 02/22/2007
• Published: 06/28/2007
• Est. Priority Date: 12/18/2003
• Status: Abandoned Application

• Current Assignee: Ultimate Claim Solutions Incorporated
• Original Assignee: Ultimate Claim Solutions Incorporated
• Inventors: Menendez, Dale
• Application Number:
  US11/709,649
• Publication Number:
  US 20070150319A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method and apparatus are provided for processing an insurance claim. The method includes the steps of receiving a claim for a loss from an insured through an Internet connection and determining a policy type from the claim. The method further includes the steps of retrieving a set of keywords based upon the policy type, matching the retrieved set of keywords with words contained within the received claim, assigning an adjuster to the claim when any matched words of the matching step meets a predetermined criteria and paying the claim without assigning the claim to an adjuster when the matching does not meet the predetermined criteria and any auxiliary criteria.

Claims

1. A method of processing an insurance claim such method comprising the steps of:

storing in memory plural sets of keywords, wherein each set of keywords is associated with at least one of a plurality of policy types and wherein the keywords in said plural set of keywords are descriptive of damages covered by the plurality of policy types;

receiving a claim from an insured through an Internet connection wherein the received claim contains a description of loss for determining a who, what and why about how the loss occurred;

determining a policy type of the plurality of policy types from said received claim;

identifying an insurance criteria based on said determined policy type for evaluating the loss, wherein the insurance criteria is based upon insuring agreements, exclusions, coverage limits and terms and conditions selected from the group consisting of all risk of loss, named perils, accident to object, supplemental coverage, consequential loss, coverage extensions, exclusions, limitations and property not covered or limited;

retrieving from said memory a predetermined set of that are associated with said determined policy type and with said identified insurance criteria;

matching said retrieved set of keywords with words contained within the description of loss of said received and

assigning the claim to an adjuster when any matched words of said matching step meets a predetermined criteria; and

paying the claim without assigning the claim to an adjuster when said matching step does not meet the predetermined criteria and any auxiliary criteria.

2. The method of processing said claim as in claim 1 further comprising defining the predetermined criteria as a match between any word of the retrieved set of keywords and any word within said received claim.

3. The method of processing said claim as in claim 2 wherein the matching step further comprises selecting a description of how a loss occurred and matching said retrieved set of keywords with a text of said description.

4. The method of processing said claim as in claim 2 wherein the matching step further comprises retrieving and matching a set of keywords of covered property and property not covered.

5. The method of processing said claim as in claim 1 further comprising defining the predetermined criteria as an absence of a match between any keyword of covered property, property not covered and/or exclusions and any word within the received claim.

6. The method of processing said claim as in claim 5 wherein the matching step further comprises selecting a description of how a loss occurred and matching the retrieved set of keywords with a text of that description.

7. The method of processing said claim as in claim 5 wherein the matching step further comprises selecting a description of building damage and matching the retrieved set of keywords with a text of the description.

8. The method of processing said claim as in claim 1 further comprising assigning the claim to an adjuster and/or investigator and/or other vendor/entity when the claim indicates that a third or other party may be responsible.

9. The method of processing said claim as in claim 1 further comprising assigning the claim to an adjuster and/or other vendors/resources when the claim indicates that emergency services are required.

10. The method of processing said claim as in claim 1 further comprising assigning the claim to an adjuster and/or investigator and/or other vendor/entity when the claim indicates potential employee dishonesty.

11. The method of processing said claim as in claim 1 further comprising assigning the claim to an adjuster when the policy type and/or keyword matching/mismatching indicates a claim for damages with no coverage and/or a different deductible than claimed.

12. The method of processing said claim as in claim 1 further comprising assigning the claim to an adjuster when the claim indicates that a time period greater than a predetermined threshold has passed since the loss occurred/date of loss.

13. The method of processing said claim as in claim 1 further comprising assigning the claim to an adjuster when the claim indicates that it exceeds a predetermined set of criteria for the number of claims previously submitted for a predetermined time period.

14. The method of processing said claim as in claim 1 further comprising assigning the claim to an adjuster or investigator when the claim meets a predetermined criteria used to identify potential fraudulent claims.

15. The method of processing said claim as in claim 1 further comprising assigning the claim to an adjuster when a total dollar value of the claim and/or subtotals exceed predetermined threshold limit values for building, personal property and/or expense.

16. The method of processing said claim as in claim 1 further comprising assigning the claim to an adjuster when the a time period between the loss and completion of a damages and/or proof of loss section of the claim exceeds a predetermined time threshold value.

17. The method of processing said claim as in claim 1 further comprising providing an online record, log and report allowing review of the claim and processing of payment or assigning an adjuster and further allowing servers/computers to exchange and query data to automate the payment and assignment process.

42. The method of processing said claim as in claim 1 further comprising an insured and claimants, including their agents, brokers and others submitting claims under a number of different formats including but not limited to, commercial lines, personal lines insurance, self insurance which includes self insured retentions, and deductibles.

43. The method of processing said claim as in claim 1 further utilizing an “

Emergency”

icon that allows the insured or claimant to request emergency services across many disciplines including but not limited to disaster restoration services for fire, water, smoke, a salver or salvage team, an investigation expert, building repair contractor, etc. Upon completion of the electronic claim form an email, text or other electronic message is sent for each service requested immediately notifying that service vendor to respond as an emergency.

44. The method of processing said claim as in claim 1 further comprising utilizing claim forms for various classes of damages including at least one from the group consisting of:

(1) building and tenant improvement type damages, (2) Contents, merchandise, furniture, fixtures and equipment, and (3) extra expense, additional living expense, and in-house labor (4) Sworn Statement in Proof of Loss and wherein if the claim is accepted and is to be paid or is not assigned to an adjuster after initially being reported, the adjusting rules and claim criteria for coverage and damages continue an approval/recommendation for payment process by pending the claim within a specified time allowed until the insured or claimant enters all dollar damages and information/documentation for the various classes of damages claimed e.g. building, contents, extra expense per the forms online in the claim submission process.

45. The method of processing said claim as in claim 44 further comprising the system continuing to use key word matching and mismatching from the plural sets of keywords stored in memory from the policy type initially identified once the insured or claimant enters the damages, which may include entering specific, itemized and detailed costs for the damages claimed to complete further analysis on the claim for covered damages, covered property and/or property not covered.

46. The method of processing said claim as in claim 45 further comprising the insured entering and completing the claim including entering classes of damages and when substantially all damages have been documented with information and dollar damages and estimates of dollar damages to repair or replace said property, including any extra expense and loss of net business earning and the total value of each class of damage along with the date and time of loss, a detailed description of how the loss occurred is recovered from the claim data previously entered to create a “

Sworn Statement in Proof of Loss”

document which requires the insured or claimant'"'"'s electronic signature to subscribe and affirm that all statements and damages are true and correct to the best of their knowledge and belief and acknowledge their understanding that making a false claim may result in serious consequences including denial of the claim.

18. An apparatus for processing an insurance claim related to property damage on a property and casualty insurance policy, except personal automobile and commercial automobile, as defined by the NAIC Uniform Property and Casualty Product Coding Matrix, such apparatus comprising:

plural sets of keywords stored in memory, wherein each set of keywords is associated with at least one policy type and wherein the keywords in said plural set of keywords are descriptive damages covered by the at least one policy type;

means for receiving a claim from an insured for a loss to property, but not automobile property and not a health care claim, through an Internet connection wherein the received claim contains a description of loss for determining a who, what and why about how the loss occurred;

means for determining a policy type from said received claim;

means for identifying an insurance criteria based upon said determined policy type for evaluating the loss, wherein the insurance criteria is based upon insuring agreements, exclusions, coverage limits and terms and conditions selected from the group consisting of all risk of loss, named perils, accident to object, supplemental coverage, consequential loss, coverage extensions, exclusions, limitations and property not covered or limited;

means for retrieving from said memory a predetermined set of keywords that are associated with said determined policy type and with said identified insurance criteria;

means for matching said retrieved set of keywords with words contained within the description of loss of said received claim;

means for assigning the claim to an adjuster when the words matched by said means for matching meet a predetermined criteria; and

means for paying the claim without assigning the claim to an adjuster when the matched words do not meet the predetermined criteria.

19. The apparatus for processing said claim as in claim 18 wherein the predetermined criteria further comprises a match between any word of the retrieved set of keywords and any word within said received claim.

20. The apparatus for processing said claim as in claim 19 wherein means for matching further comprises means for selecting a description of how a loss occurred and matching said retrieved set of keywords with a text of that description of how the loss occurred.

21. The apparatus for processing said claim as in claim 19 wherein the means for matching further comprises means for selecting a set of keywords of covered property, property not covered and/or exclusions.

22. The apparatus for processing said claim as in claim 18 further comprising defining the predetermined criteria as the absence of a match between any word of the retrieved set of keywords for property not covered covered proper, exclusions and any word within the received claim.

23. The apparatus for processing said claim as in claim 22 wherein the means for matching further comprises means for selecting a description of how a loss occurred and matching the retrieved set of keywords with a text of that description.

24. The apparatus for processing said claim as in claim 22 wherein the means for matching further comprises means for selecting a description of building damage and matching the retrieved sets of keywords with a text of that description.

25. The apparatus for processing said claim as in claim 18 further comprising means for assigning the claim to an adjuster and/or investigator and/or other vendor/entity when the claim indicates that a third or other party may be responsible.

26. The apparatus for processing said claim as in claim 18 further comprising means for assigning the claim to an adjuster and/or other vendors/resources when the claim indicates that emergency services are required.

27. The apparatus for processing said claim as in claim 18 further comprising means for assigning the claim to an adjuster and/or investigator and/or other vendor/entity when the claim indicates potential employee dishonesty.

28. The apparatus for processing said claim as in claim 18 further comprising means for assigning the claim to an adjuster when the policy type indicates a claim for damages with no coverage and/or a different deductible than claimed.

29. The apparatus for processing said claim as in claim 18 further comprising means for assigning the claim to an adjuster when the claim indicates that a time period greater than a predetermined threshold has passed since the loss occurred.

30. The apparatus for processing said claim as in claim 18 further comprising means for assigning the claim to an adjuster when the claim indicates that it exceeds a predetermined set of criteria for the number of claims submitted for a predetermined time period.

31. The apparatus for processing said claim as in claim 18 further comprising means for assigning the claim to an adjuster when the claim meets a predetermined criteria used to identify potential fraudulent claims.

32. The apparatus for processing said claim as in claim 18 further comprising means for assigning the claim to an adjuster when a total dollar value of the claim and/or subtotals exceed predetermined threshold limit values for building, personal property and/or expense.

33. The apparatus for processing said claim as in claim 18 further comprising means for assigning the claim to an adjuster when the a time period between the loss and completion of a damages and/or proof of loss section of the claim exceeds a predetermined time threshold value.

34. The apparatus for processing said claim as in claim 18 further comprising means for providing an online record, log and report allowing review of the claim and processing of payment or assigning an adjuster and further allowing servers/computers to exchange and query data to automate said claim payment and assignment process.

47. The apparatus as in claim 18 further comprising an insured and claimants, including their agents, brokers and others submitting claims under a number of different formats including but not limited to, commercial lines, personal lines insurance, self insurance which includes self insured retentions, and deductibles.

48. The apparatus as in claim 18 further utilizing an “

Emergency”

icon that allows the insured or claimant to request emergency services across many disciplines including but not limited to disaster restoration services for fire, water, smoke, a salver or salvage team, an investigation expert, building repair contractor, etc. Upon completion of the electronic claim form an email, text or other electronic message is sent for each service requested immediately notifying that service vendor to respond as an emergency.

49. The apparatus as in claim 18 further comprising utilizing claim forms for various classes of damages including at least one from the group consisting of:

(1) building and tenant improvement type damages, (2) Contents, merchandise, furniture, fixtures and equipment, and (3) extra expense, additional living expense, and in-house labor (4) Sworn Statement in Proof of Loss and wherein if the claim is accepted and is to be paid or is not assigned to an adjuster after initially being reported, the adjusting rules and claim criteria for coverage and damages continue an approval/recommendation for payment process by pending the claim within a specified time allowed until the insured or claimant enters all dollar damages and information/documentation for the various classes of damages claimed e.g. building, contents, extra expense per the forms online in the claim submission process.

50. The apparatus as in claim 49 further comprising the system continuing to use key word matching and mismatching from the plural sets of keywords stored in memory from the policy type initially identified once the insured or claimant enters the damages, which may include entering specific, itemized and detailed costs for the damages claimed to complete further analysis on the claim for covered damages, covered property and/or property not covered.

51. The apparatus as in claim 50 further comprising the insured entering and completing the claim including entering classes of damages and when substantially all damages have been documented with information and dollar damages and estimates of dollar damages to repair or replace said property, including any extra expense and loss of net business earning and the total value of each class of damage along with the date and time of loss, a detailed description of how the loss occurred is recovered from the claim data previously entered to create a “

Sworn Statement in Proof of Loss”

document which requires the insured or claimant'"'"'s electronic signature to subscribe and affirm that all statements and damages are true and correct to the best of their knowledge and belief and acknowledge their understanding that making a false claim may result in serious consequences including denial of the claim.

35. An apparatus for processing an insurance claim related to property damage on a property and casualty insurance policy, except personal automobile and commercial automobile, as defined by the NAIC Uniform Property and Casualty Product Coding Matrix, such apparatus comprising:

plural sets of keywords stored in memory, wherein each set of keywords is associated with at least one policy type and wherein the keywords in said plural set of keywords are descriptive damages covered by the at least one policy type;

a website adapted to receive a claim from an insured for a loss to property, but not automobile property and not a health care claim, through an Internet connection wherein the received claim contains a description of loss for determining a who, what and why about how the loss occurred;

a policy processor adapted to determine a policy type from said received claim;

said policy processor being further adapted to identify an insurance criteria based upon the determined policy type for evaluating the loss, wherein the insurance criteria is based upon insuring agreements, exclusions, coverage limits and terms and conditions selected from the group consisting of all risk of loss, named perils, accident to object, supplemental coverage, consequential loss, coverage extensions, exclusions, limitations and property not covered or limited;

a predetermined set of keywords retrieved from said memory that are associated with said determined policy type and with said identified insurance criteria;

a matching processor adapted to match said retrieved set of keywords with words contained within the description of loss of said received claim

a criteria processor adapted to assign said received claim to an adjuster when the words matched by the matching processor meet a predetermined criteria; and

a payment processor adapted to authorize payment of the claim without assigning the claim to an adjuster when the matched words does not meet the predetermined criteria and any auxiliary criteria.

36. The apparatus for processing said claim as in claim 35 wherein the predetermined criteria further comprises a match between any word of the retrieved set of keywords and a word within said received claim.

37. The apparatus for processing said claim as in claim 35 wherein the words contained within the received claim matched by the matching processor further comprises a description of how a loss occurred.

38. The apparatus for processing said claim as in claim 35 wherein the set of keywords further comprises a set of keywords that describe covered property, property not covered, exclusions and any word within said received claim.

39. The apparatus for processing said claim as in claim 35 wherein the predetermined criteria used by the criteria processor further comprises the absence of a match between any word of the retrieved set of keywords and any word within the received claim.

40. The apparatus for processing said claim as in claim 39 wherein the words contained within the received claim matched by the matching processor further comprises a description of how a loss occurred.

41. The apparatus for processing said claim as in claim 35 wherein the words contained within the received claim matched by the matching processor further comprises description of building damage and matching the retrieved set of keywords with a text of the description.

52. The apparatus as in claim 35 further comprising an insured and claimants, including their agents, brokers and others submitting claims under a number of different formats including but not limited to, commercial lines, personal lines insurance, self insurance which includes self insured retentions, and deductibles.

53. The apparatus as in claim 35 further utilizing an “

Emergency”

icon that allows the insured or claimant to request emergency services across many disciplines including but not limited to disaster restoration services for fire, water, smoke, a salver or salvage team, an investigation expert, building repair contractor, etc. Upon completion of the electronic claim form an email, text or other electronic message is sent for each service requested immediately notifying that service vendor to respond as an emergency.

54. The apparatus as in claim 35 further comprising utilizing claim forms for various classes of damages including at least one from the group consisting of:

(1) building and tenant improvement type damages, (2) Contents, merchandise, furniture, fixtures and equipment, and (3) extra expense, additional living expense, and in-house labor (4) Sworn Statement in Proof of Loss and wherein if the claim is accepted and is to be paid or is not assigned to an adjuster after initially being reported, the adjusting rules and claim criteria for coverage and damages continue an approval/recommendation for payment process by pending the claim within a specified time allowed until the insured or claimant enters all dollar damages and information/documentation for the various classes of damages claimed e.g. building, contents, extra expense per the forms online in the claim submission process.

55. The apparatus as in claim 54 further comprising the system continuing to use key word matching and mismatching from the plural sets of keywords stored in memory from the policy type initially identified once the insured or claimant enters the damages, which may include entering specific, itemized and detailed costs for the damages claimed to complete further analysis on the claim for covered damages, covered property and/or property not covered.

56. The apparatus as in claim 55 further comprising the insured entering and completing the claim including entering classes of damages and when substantially all damages have been documented with information and dollar damages and estimates of dollar damages to repair or replace said property, including any extra expense and loss of net business earning and the total value of each class of damage along with the date and time of loss, a detailed description of how the loss occurred is recovered from the claim data previously entered to create a “

Sworn Statement in Proof of Loss”

document which requires the insured or claimant'"'"'s electronic signature to subscribe and affirm that all statements and damages are true and correct to the best of their knowledge and belief and acknowledge their understanding that making a false claim may result in serious consequences including denial of the claim.