AUTOMATED INSURANCE ENROLLMENT, UNDERWRITING, AND CLAIMS ADJUSTING

• US 20100017234A1
• Filed: 11/14/2006
• Published: 01/21/2010
• Est. Priority Date: 06/21/1999
• Status: Active Grant

• Current Assignee: Pets Best Insurance Services LLC (Synchrony Financial)
• Original Assignee: Pets Best Insurance Services LLC (Synchrony Financial)
• Inventors: Brown, Jeff, Emmen, Brian, Crandall, Daniel W., Stephens, Jack
• Granted Patent: US 8,762,179 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

An insurance enrollment and underwriting method includes providing a first user interface with one or more controls for enabling a user to specify one or more health conditions in an enrollment application for pet health insurance. Data representing one or more health conditions specified through the first user interface is received. That data is electronically processed. Each condition is electronically flagged as a condition that is acceptable, precluded, or for manual review. A dollar limit of coverage for each of a plurality of diagnoses in lieu of one or more exclusions is calculated. The plurality of diagnoses include one or more diagnoses related to one or more of the health conditions. Where all conditions are and flagged as acceptable or determined to be acceptable following a manual review, an active policy is packaged to include coverage for each of the plurality of diagnoses up to each diagnosis'"'"' corresponding dollar limit of coverage.

Claims

1. An insurance enrollment and underwriting method, comprising:

providing a first user interface with one or more controls for enabling a user to specify one or more health conditions in an enrollment application for pet health insurance;

receiving data representing one or more health conditions specified through the first user interface;

electronically processing the data representing the one or more health conditions and electronically flagging each condition as a condition that is acceptable, precluded, or for manual review;

calculating, a dollar limit of coverage for each of a plurality of diagnoses in lieu of one or more exclusions, the plurality of diagnoses including one or more diagnoses related to one or more of the health conditions;

where all conditions are and flagged as acceptable or determined to be acceptable following a manual review, packaging an active policy to include coverage for each of the plurality of diagnoses up to each diagnosis'"'"' corresponding dollar limit of coverage.

2. The method of claim 1, further comprising:

returning a second user interface presenting information indicating declined enrollment if at least one of the conditions is flagged as precluded;

returning a third user interface presenting information indicating approved enrollment, if all of the conditions are flagged as acceptable; and

returning a fourth user interface presenting information indicating the need for a manual review if none of the conditions is flagged as precluded and at least one of the conditions is flagged manual review.

3. The method of claim 2, further comprising following a return of the third user interface establishing an electronic record associated with the active policy for pet health insurance, the electronic record containing the data representing one or more health conditions specified through the first user interface and data representing an effective date for the policy.

4. The method of claim 1, further comprising calculating a geographic insurance rating, and wherein calculating a dollar limit of coverage includes calculating a dollar limit of coverage for each of the plurality of diagnosis based at least in part on the geographic insurance rating.

5. The method of claim 4, wherein calculating a geographic insurance rating includes:

identifying a location associated with the pet;

identifying a geographic risk zone;

comparing the location to the geographic risk zone to determine if the location is at least partially within the risk zone; and

calculating an insurance rating according to the comparison.

6. The method of claim 3, further comprising:

providing a fifth user interface having controls for enabling a user to submit a claim with respect to the active policy, the controls enabling the user to specify a diagnosis for which coverage is requested;

receiving data representing the diagnosis;

electronically processing the data representing the diagnosis with the electronic record associated with the active policy comparing the data representing the diagnosis with the data representing one or more health conditions specified through the first user interface and comparing a date of the claim with the data representing the effective date of the active policy.

7. The method of claim 6, wherein electronically processing includes

flagging the diagnosis as limited where the comparison of the data representing the diagnosis with the data representing one or more health conditions reveals that the diagnosis is for a condition identified by the data representing one or more health conditions;

and

otherwise determining if the diagnosis is for a suspect condition or a non-suspect condition and;

flagging the diagnosis as covered if the diagnosis is for a non-suspect condition;

flagging the diagnosis for manual review if the diagnosis is for a suspect condition.

10. The method of claim 7, further comprising:

returning a sixth user interface presenting information indicating claim approval if the diagnosis is flagged approved;

returning a seventh user interface presenting information indicating claim limitation, if the diagnosis is flagged limited; and

returning an eighth user interface presenting information indicating the need for a manual claim review if the diagnosis is flagged for manual review.

8. The method of claim 8, wherein determining comprises:

determining the diagnosis to be for a non-suspect condition if a difference between the date of the claim and the effective date of the active policy exceeds a predetermined duration;

otherwise determining the diagnosis to be for a non-suspect condition.

9. The method of claim 8 comprising selecting the predetermined duration according to the diagnosis.

11. An insurance enrollment and underwriting method, comprising:

providing client computing devices for use by each of a plurality of pet health care providers, each client computing device being operable to display user interfaces and to receive and transmit user input;

providing a selected one of the client computing devices with a first user interface with one or more controls for enabling a user to specify one or more health conditions in an enrollment application for pet health insurance;

receiving data representing one or more health conditions specified through user input received at the selected one of the client computing devices in response to a display of the first user interface; and

electronically processing the data representing the one or more health conditions and electronically flagging each as a condition that is acceptable, precluded, or manual review;

returning a second user interface to the selected one of the client computing devices if at least one of the conditions is flagged as precluded, the second user interface presenting information indicating declined enrollment;

returning a third user interface to the selected one of the client computing devices if all of the conditions are flagged as acceptable, the third user interface presenting information indicating approved enrollment;

returning a fourth user interface to the selected one of the client computing devices if none of the conditions is flagged as precluded and at least one of the conditions is flagged manual review, the fourth user interface presenting information indicating the need for a manual review; and

where all conditions are and flagged as acceptable or determined to be acceptable following a manual review, calculating, a dollar limit of coverage for each of a plurality of diagnoses in lieu of one or more exclusions, the plurality of diagnoses including one or more diagnoses related to one or more of the health conditions and packaging an active policy to include coverage for each of the plurality of diagnoses up to each diagnosis'"'"' corresponding dollar limit of coverage.

12. The method of claim 11, further comprising following a return of the third user interface establishing an electronic record associated with an active policy for pet health insurance, the electronic record containing the data representing one or more health conditions specified through the first user interface and data representing an effective date for the policy.

13. The method of claim 12, further comprising:

providing a fifth user interface to a selected one of the client computing devices, the fifth user interface having controls for enabling a user to submit a claim with respect to the active policy, the controls enabling the user to specify a diagnosis for which coverage is requested;

receiving data representing the diagnosis specified through user input received at the selected one of the client computing devices in response to a display of the fifth user interface;

electronically processing the data representing the diagnosis with the electronic record associated with the active policy comparing the data representing the diagnosis with the data representing one or more health conditions specified through the first user interface and comparing a date of the claim with the data representing the effective date of the active policy;

flagging the diagnosis, wherein flagging comprises;

selecting a predetermined duration according to the diagnosis;

determining the diagnosis to be for a pre-existing condition where the comparison of the data representing the diagnosis with the data representing one or more health conditions reveals that the diagnosis is for a condition identified by the data representing one or more health conditions;

determining the diagnosis to be for a non-suspect condition if a difference between the date of the claim and the effective date of the active policy exceeds the predetermined duration;

determining the diagnosis to be for a suspect condition if a difference between the date of the claim and the effective date of the active policy does not exceed the predetermined duration;

flagging the diagnosis as limited if the diagnosis is determined to be for a pre-existing condition;

flagging the diagnosis as covered if the diagnosis is determined not to be for a pre-existing condition and is also determined to be non-suspect;

flagging the diagnosis for manual review if the diagnosis is determined not to be for a pre-existing condition and is also determined to be suspect;

returning a sixth user interface to the selected one of the client computing devices if the diagnosis is flagged approved, the sixth user interface presenting information indicating claim approval;

returning a seventh user interface to the selected one of the client computing devices if the diagnosis is flagged limited, the seventh user interface presenting information indicating claim limitation; and

returning an eighth user interface to the selected one of the client computing devices if the diagnosis is flagged for manual review, the eighth user interface presenting information indicating the need for a manual claim review.

14. A computer readable medium and computer executable instructions for:

providing a first user interface with one or more controls for enabling a user to specify one or more health conditions in an enrollment application for pet health insurance;

receiving data representing one or more health conditions specified through the first user interface;

electronically processing the data representing the one or more health conditions and electronically flagging each as a condition that is acceptable, precluded, or manual review; and

where all conditions are and flagged as acceptable or determined to be acceptable following a manual review, calculating, a dollar limit of coverage for each of a plurality of diagnoses in lieu of one or more exclusions, the plurality of diagnoses including one or more diagnoses related to one or more of the health conditions and packaging an active policy to include coverage for each of the plurality of diagnoses up to each diagnosis'"'"' corresponding dollar limit of coverage.

15. The medium of claim 14, having further instructions for:

returning a second user interface presenting information indicating declined enrollment if at least one of the conditions is flagged as precluded;

returning a third user interface presenting information indicating approved enrollment, if all of the conditions are flagged as acceptable; and

returning a fourth user interface presenting information indicating the need for a manual review if none of the conditions is flagged as precluded and at least one of the conditions is flagged manual review.

16. The medium of claim 15, having further instructions for, following a return of the third user interface, establishing an electronic record associated with an active policy for pet health insurance, the electronic record containing the data representing one or more health conditions specified through the first user interface and data representing an effective date for the policy.

17. The medium of claim 14, having further instructions for calculating a geographic insurance rating, and wherein calculating a dollar limit of coverage includes calculating a dollar limit of coverage for each of the plurality of diagnosis based at least in part on the geographic insurance rating.

18. The medium of claim 17, wherein the instructions for calculating a geographic insurance rating include instructions for:

identifying a location associated with the pet;

identifying a geographic risk zone;

comparing the location to the geographic risk zone to determine if the location is at least partially within the risk zone; and

calculating an insurance rating according to the comparison.

19. The medium of claim 14, having further instructions for:

providing a fifth user interface having controls for enabling a user to submit a claim with respect to the active policy, the controls enabling the user to specify a diagnosis for which coverage is requested;

receiving data representing the diagnosis;

electronically processing the data representing the diagnosis with the electronic record associated with the active policy comparing the data representing the diagnosis with the data representing one or more health conditions specified through the first user interface and comparing a date of the claim with the data representing the effective date of the active policy.

20. The medium of claim 19, wherein the instructions for electronically processing include instructions for:

flagging the diagnosis as limited where the comparison of the data representing the diagnosis with the data representing one or more health conditions reveals that the diagnosis is for a condition identified by the data representing one or more health conditions; and

otherwise determining if the diagnosis is for a suspect condition or a non-suspect condition and;

flagging the diagnosis as covered if the diagnosis is for a non-suspect condition;

flagging the diagnosis for manual review if the diagnosis is for a suspect condition.

21. The medium of claim 20, wherein the instructions for determining include instructions for:

determining the diagnosis to be for a non-suspect condition if a difference between the date of the claim and the effective date of the active policy exceeds a predetermined duration;

otherwise determining the diagnosis to be for a non-suspect condition.

22. The medium of claim 21, having further instructions for selecting the predetermined duration according to the diagnosis.

23. The medium of claim 20, having further instructions for:

returning a sixth user interface presenting information indicating claim approval if the diagnosis is flagged approved;

returning a seventh user interface presenting information indicating claim limitation, if the diagnosis is flagged as limited; and

returning an eighth user interface presenting information indicating the need for a manual claim review if the diagnosis is flagged for manual review.

24. An insurance enrollment and underwriting system, comprising:

an enrollment engine operable to provide a first user interface with one or more controls for enabling a user to specify one or more health conditions in an enrollment application for pet health insurance;

an underwriting engine operable to;

receive and electronically process data representing one or more health conditions specified through the first user interface and to electronically flag each as a condition that is acceptable, precluded, or manual review; and

where all conditions are flagged as acceptable or determined to be acceptable following a manual review, calculate, a dollar limit of coverage for each of a plurality of diagnoses in lieu of one or more exclusions, the plurality of diagnoses including one or more diagnoses related to one or more of the health conditions and package an active policy to include coverage for each of the plurality of diagnoses up to each diagnosis'"'"' corresponding dollar limit of coverage.

25. The system of claim 24, wherein the enrollment engine is operable to:

return a second user interface presenting information indicating declined enrollment if at least one of the conditions is flagged as precluded;

return a third user interface presenting information indicating approved enrollment, if all of the conditions are flagged as acceptable; and

return a fourth user interface presenting information indicating the need for a manual review if none of the conditions is flagged as precluded and at least one of the conditions is flagged manual review.

26. The system of claim 25, wherein, following a return of the third user interface, the underwriting engine is operable to establish an electronic record associated with an active policy for pet health insurance, the electronic record containing the data representing one or more health conditions specified through the first user interface and data representing an effective date for the policy.

27. The system of claim 24, wherein the underwriting engine is further operable to calculating a geographic insurance rating, and to calculate a dollar limit of coverage by calculating a dollar limit of coverage for each of the plurality of diagnosis based at least in part on the geographic insurance rating.

28. The system of claim 27, wherein the underwriting engine is operable to calculate a geographic insurance rating by:

identifying a location associated with the pet;

identifying a geographic risk zone;

comparing the location to the geographic risk zone to determine if the location is at least partially within the risk zone; and

calculating an insurance rating according to the comparison.

29. The system of claim 24, further comprising:

a claim submission engine operable to provide a fifth user interface having controls for enabling a user to submit a claim with respect to the active policy, the controls enabling the user to specify a diagnosis for which coverage is requested; and

a claim adjusting engine operable to receive data representing the diagnosis and to electronically process the data representing the diagnosis with the electronic record associated with the active policy comparing the data representing the diagnosis with the data representing one or more health conditions specified through the first user interface and to compare a date of the claim with the data representing the effective date of the active policy.

30. The system of claim 29, wherein the claim adjusting engine is operable to:

flag the diagnosis as limited where the comparison of the data representing the diagnosis with the data representing one or more health conditions reveals that the diagnosis is for a condition identified by the data representing one or more health conditions; and

otherwise to determine if the diagnosis is for a suspect condition or a non-suspect condition and;

flag the diagnosis as covered if the diagnosis is for a non-suspect condition, or

flag the diagnosis for manual review if the diagnosis is for a suspect condition.

31. The system of claim 30, wherein the claim adjusting engine is operable to determine if the diagnosis is for a suspect condition or a non-suspect condition by:

determining the diagnosis to be for a non-suspect condition if a difference between the date of the claim and the effective date of the active policy exceeds a predetermined duration;

otherwise determining the diagnosis to be for a suspect condition.

32. The system of claim 31, wherein the claim adjusting engine is operable to select the predetermined duration according to the diagnosis.

33. The system of claim 30, wherein the claim submission engine is operable to:

return a sixth user interface presenting information indicating claim approval if the diagnosis is flagged approved;

return a seventh user interface presenting information indicating claim limitation, if the diagnosis is flagged as limited; and

return an eighth user interface presenting information indicating the need for a manual claim review if the diagnosis is flagged for manual review.

34. An insurance enrollment and underwriting system, comprising:

client computing devices each positioned in a pet related location, each client computing device operable to display user interfaces and to receive and transmit user input;

an enrollment engine operable to provide a first selected one of the client computing devices with a first user interface with one or more controls for enabling a user to specify one or more health conditions in an enrollment application for pet health insurance;

an underwriting engine operable to;

receive data representing one or more health conditions specified through user input received at the first selected one of the client computing devices in response to a display of the first user interface;

electronically process the data representing the one or more health conditions and electronically flagging each as a condition that is acceptable, precluded, or manual review; and

where all conditions are flagged as acceptable or determined to be acceptable following a manual review, calculate, a dollar limit of coverage for each of a plurality of diagnoses in lieu of one or more exclusions, the plurality of diagnoses including one or more diagnoses related to one or more of the health conditions and package an active policy to include coverage for each of the plurality of diagnoses up to each diagnosis'"'"' corresponding dollar limit of coverage;

wherein the enrollment engine is further operable to;

return a second user interface to the first selected one of the client computing devices if at least one of the conditions is flagged as precluded, the second user interface presenting information indicating declined enrollment;

return a third user interface to the first selected one of the client computing devices if all of the conditions are flagged as acceptable, the third user interface presenting information indicating approved enrollment; and

return a fourth user interface to the first selected one of the client computing devices if none of the conditions is flagged as precluded and at least one of the conditions is flagged manual review, the fourth user interface presenting information indicating the need for a manual review.

35. The system of claim 34, wherein, following a return of the third user interface, the underwriting engine is operable to establish an electronic record associated with an active policy for pet health insurance, the electronic record containing the data representing one or more health conditions specified through the first user interface and data representing an effective date for the policy.

36. The system of claim 35, further comprising:

a claim submission engine operable to provide a fifth user interface to a second selected one of the client computing devices, the fifth user interface having controls for enabling a user to submit a claim with respect to the active policy, the controls enabling the user to specify a diagnosis for which coverage is requested;

a claim adjusting engine operable to;

receiving data representing the diagnosis specified through user input received at the selected one of the client computing devices in response to a display of the fifth user interface;

electronically process the data representing the diagnosis with the electronic record associated with the active policy comparing the data representing the diagnosis with the data representing one or more health conditions specified through the first user interface and comparing a date of the claim with the data representing the effective date of the active policy;

select a predetermined duration according to the diagnosis;

determine the diagnosis to be for a pre-existing condition where the comparison of the data representing the diagnosis with the data representing one or more health conditions reveals that the diagnosis is for a condition identified by the data representing one or more health conditions;

determine the diagnosis to be for a non-suspect condition if a difference between the date of the claim and the effective date of the active policy exceeds the predetermined duration;

determine the diagnosis to be for a suspect condition if a difference between the date of the claim and the effective date of the active policy does not exceed the predetermined duration;

flag the diagnosis as limited if the diagnosis is determined to be for a pre-existing condition;

flag the diagnosis as covered if the diagnosis is determined not to be for a pre-existing condition and is also determined to be non-suspect;

flag the diagnosis for manual review if the diagnosis is determined not to be for a pre-existing condition and is also determined to be suspect;

wherein the claim submission engine is further operable to;

return a sixth user interface to the second selected one of the client computing devices if the diagnosis is flagged approved, the sixth user interface presenting information indicating claim approval;

return a seventh user interface to the second selected one of the client computing devices if the diagnosis is flagged as limited, the seventh user interface presenting information indicating claim limitation; and

return an eighth user interface to the second selected one of the client computing devices if the diagnosis is flagged for manual review, the eighth user interface presenting information indicating the need for a manual claim review.

37. An insurance enrollment and underwriting system, comprising:

client computing devices each positioned in a pet related location, each client computing device operable to display user interfaces and to receive and transmit user input;

means for providing a first selected one of the client computing devices with a first user interface with one or more controls for enabling a user to specify one or more health conditions in an enrollment application for pet health insurance;

means for receiving data representing one or more health conditions specified through user input received at the first selected one of the client computing devices in response to a display of the first user interface;

means for electronically processing the data representing the one or more health conditions and electronically flagging each as a condition that is acceptable, precluded, or manual review;

means for returning a second user interface to the first selected one of the client computing devices if at least one of the conditions is flagged as precluded, the second user interface presenting information indicating declined enrollment;

means for returning a third user interface to the first selected one of the client computing devices if all of the conditions are flagged as acceptable, the third user interface presenting information indicating approved enrollment;

means for returning a fourth user interface to the first selected one of the client computing devices if none of the conditions is flagged as precluded and at least one of the conditions is flagged manual review, the fourth user interface presenting information indicating the need for a manual review; and

means for calculating, a dollar limit of coverage for each of a plurality of diagnoses in lieu of one or more exclusions, the plurality of diagnoses including one or more diagnoses related to one or more of the health conditions;

means for packaging an active policy to include coverage for each of the plurality of diagnoses up to each diagnosis'"'"' corresponding dollar limit of coverage where all conditions are and flagged as acceptable or determined to be acceptable following a manual review.

38. The system of claim 37, further comprising means for establishing an electronic record associated with an active policy for pet health insurance, the electronic record containing the data representing one or more health conditions specified through the first user interface and data representing an effective date for the policy.

39. The system of claim 38, further comprising:

means for providing a fifth user interface to a second selected one of the client computing devices, the fifth user interface having controls for enabling a user to submit a claim with respect to the active policy, the controls enabling the user to specify a diagnosis for which coverage is requested;

means for receiving data representing the diagnosis specified through user input received at the second selected one of the client computing devices in response to a display of the fifth user interface;

means for electronically processing the data representing the diagnosis with the electronic record associated with the active policy comparing the data representing the diagnosis with the data representing one or more health conditions specified through the first user interface and comparing a date of the claim with the data representing the effective date of the active policy;

means for selecting a predetermined duration according to the diagnosis;

means for determining the diagnosis to be for a pre-existing condition where the comparison of the data representing the diagnosis with the data representing one or more health conditions reveals that the diagnosis is for a condition identified by the data representing one or more health conditions;

means for determining the diagnosis to be for a non-suspect condition if a difference between the date of the claim and the effective date of the active policy exceeds the predetermined duration;

means for determining the diagnosis to be for a suspect condition if a difference between the date of the claim and the effective date of the active policy does not exceed the predetermined duration;

means for flagging the diagnosis as limited if the diagnosis is determined to be for a pre-existing condition;

means for flagging the diagnosis as covered if the diagnosis is determined not to be for a pre-existing condition and is also determined to be non-suspect;

means for flagging the diagnosis for manual review if the diagnosis is determined not to be for a pre-existing condition and is also determined to be suspect;

means for returning a sixth user interface to the selected one of the client computing devices if the diagnosis is flagged approved, the sixth user interface presenting information indicating claim approval;

means for returning a seventh user interface to the selected one of the client computing devices if the diagnosis is flagged as limited, the seventh user interface presenting information indicating claim limitation; and

means for returning an eighth user interface to the selected one of the client computing devices if the diagnosis is flagged for manual review, the eighth user interface presenting information indicating the need for a manual claim review.