Claims processing of information requirements

• US 8,010,390 B2
• Filed: 06/29/2007
• Issued: 08/30/2011
• Est. Priority Date: 06/04/2007
• Status: Active Grant

• Current Assignee: Computer Sciences Corporation (DXC Technology Company)
• Original Assignee: Computer Sciences Corporation (DXC Technology Company)
• Inventors: Wait, Julian F., Knifton, Jess V.
• Primary Examiner(s): Abdi; Kambiz
• Assistant Examiner(s): Ziegle; Stephanie
• Application Number:
  US11/824,544
• Publication Number:
  US 20090006139A1
• Time in Patent Office: 1,523 Days
• Field of Search: 705 2- 4, 705 35- 45
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Methods and systems are provided for processing claims. A claim management case is created for an insured in response to a notice of a claim. One or more insurance policies covering the insured are associated with the claim management case. At least one process is performed at a claim management case level to fulfill an information requirement that applies to at least two of the insurance policies associated with the claim management case. Claims are adjudicated under the one or more of the insurance policies covering the insured.

Claims

1. A method of processing claims relating to a policy, comprising:

a computer system receiving at least one notice of an event or a condition that gives rise to a claim for payment under a first policy;

the computer system creating a claim management case in response to the at least one notice of the event or condition that gives rise to the claim for payment under the first policy, wherein creating the claim management case comprises associating one or more policies with the claim management case and associating one or more coverages with one of the policies;

the computer system creating a node hierarchy for processing claims, wherein creating the node hierarchy comprises;

the computer system creating, at a claim management case level, a claim management case node;

the computer system creating, at a policy level separate from and below the claim management case level, one or more policy nodes, wherein each of at least one of the policy nodes is associated with one of the policies,

the computer system creating, at a coverage level separate from and below the policy level, one or more coverage nodes, wherein each of at least one of the coverage nodes is associated with a base coverage or a rider under at least one of the policies associated with one of the policy nodes,

the computer system creating, at a designee level, one or more designee nodes, wherein at least one of the designee nodes is associated with a designee on at least one of the policies or on at least one of the base coverages or riders; and

the computer system attaching at least one of the designee nodes of the designee level to at least one of the policy nodes of the policy level or at least one of the coverage nodes of the coverage level, wherein the level of the node to which the at least one designee node is attached by the computer system depends on whether the designee node corresponds to one of the policies as a whole or pertains to a particular base coverage or a particular rider under a policy, wherein the at least one designee node is attached to a policy node of the policy level if the at least one designee node pertains to one of the policies as a whole, wherein the at least one designee node is attached to a coverage node of the coverage level if the designee node pertains to a particular one of the base coverages or to a particular one of the riders;

the computer system performing, at the claim management case level, using the claim management case node, at least one process to fulfill an information requirement for adjudicating the policies;

the computer system performing, at the policy level, using at least one of the policy nodes, one or more processes to fulfill an information requirement for adjudicating an policy associated with the claim management case, wherein the at least one of the one or more processes performed at the policy level applies to only one of the policies associated with the claim management case;

the computer system performing, at the coverage level, using at least one of the coverage nodes, one or more processes to fulfill an information requirement for a coverage associated with the claim management case, wherein the at least one of the one or more processes performed at the coverage level applies to only one of the coverages associated with one of the policies;

the computer system determining whether predetermined information requirements for the claim management case have been met at the case management level, the policy level, and the coverage level;

the computer system inhibiting adjudication of any the policies in the claim management case or adjudication of any of the coverages in the claim management case until the predetermined information requirements for the claim management case are satisfied at the case management level, the policy level, and the coverage level;

the computer system performing at least one rendezvous, wherein at least one rendezvous comprises;

a queued item waiting for a response from a policy administration system;

the queued item receiving response data from the policy administration system;

the computer system comparing the response data from the policy administration system to expected data; and

the computer system determining that a rendezvous is effective based on a match of the response data and the expected data; and

adjudicating at least one claim under one or more of the policies.

2. The method of claim 1, wherein at least one of the policies is a life insurance policy, wherein the information requirement comprises receipt of a death certificate of an insured under the at least one life insurance policy.

3. The method of claim 1, wherein all of the policies covering an insured carried by a particular carrier are associated with the claim management case.

4. The method of claim 1, further comprising performing at least one process relating to a second policy in response to receiving the notice relating to the first policy, wherein the event or condition comprises the death of an insured under at least one of the policies, wherein the at least one process relating to the second policy comprises suspending a premium on the second policy.

5. The method of claim 1, further comprising performing a first process relating to the first policy in response to receiving the notice and performing a second process relating to a second policy in response to receiving the notice, wherein the first process is different from the second process.

6. The method of claim 1, further comprising terminating the first policy in response to receiving the notice and suspending payments a second policy in response to receiving the at least one notice.

7. The method of claim 1, further comprising proceeding with processing of one or more of the policies and suspending processing of one or more other policies in response to receiving the at least one notice.

8. The method of claim 1, further comprising suspending activity for the claim management case at the policy level until one or more predetermined conditions are satisfied at the claim management case level.

9. The method of claim 1, further comprising suspending activity for the claim management case at the claim management case level until one or more predetermined conditions are satisfied at the policy level.

10. The method of claim 1, further comprising suspending activity for the claim management case at the claim management case level until one or more predetermined conditions are satisfied at the policy level and the coverage level.

13. The method of claim 1, further comprising the computer system performing, at the designee level, one or more processes to fulfill an information requirement for a designee associated with the claim management case, wherein the at least one of the one or more processes performed at the designee level applies to only one of the designees associated with one of the policies or one of the coverages.

14. The method of claim 1, further comprising:

the computer system performing, at the designee level, one or more processes to fulfill an information requirement for a designee associated with the claim management case, wherein the at least one of the one or more processes performed at the designee level applies to only one of the designees associated with one of the policies or one of the coverages; and

the computer system inhibiting adjudication of any the policies in the claim management case or adjudication of any of the coverages in the claim management case until the predetermined information requirements for the claim management case are satisfied at the case management level, the policy level, the coverage level, and the designee level.

15. The method of claim 1, wherein the node hierarchy comprises two or more procedures and two or more data structures in a service-oriented architecture.

16. The method of claim 1, wherein creating the claim management case comprises:

performing a search for policies against one or more policy administrative host systems;

associating at least two policies found in the search with the claim management case; and

displaying, in a claim policy portfolio table, at least two policies found in the search against the one or more policy administrative host systems.

17. The method of claim 1, wherein associating at least one policy with the claim management case comprises adding the policy to a claim policy portfolio table.

11. A system, comprising:

a processor;

a memory coupled to the processor and configured to store program instructions executable by the processor to;

receiving at least one notice of an event or a condition that gives rise to a claim for payment under a first policy;

creating a claim management case in response to the at least one notice of the event or condition that gives rise to the claim for payment under the first policy, wherein creating the claim management case comprises associating one or more policies with the claim management case and associating one or more coverages with one of the policies;

creating a node hierarchy for processing claims, wherein creating the node hierarchy comprises;

creating, at a claim management case level, a claim management case node;

creating, at a policy level separate from and below the claim management case level, one or more policy nodes, wherein each of at least one of the policy nodes is associated with one of the policies,

creating, at a coverage level separate from and below the policy level, one or more coverage nodes, wherein each of at least one of the coverage nodes is associated with a base coverage or rider under at least one of the policies associated with one of the policy nodes,

creating, at a designee level, one or more designee nodes, wherein at least one of the designee nodes is associated with a designee on at least one of the policies or on at least one of the base coverages or riders; and

attaching at least one of the designee nodes of the designee level to at least one of the policy nodes of the policy level or at least one of the coverage nodes of the coverage level, wherein the level of the node to which the at least one designee node is attached depends on whether the designee node corresponds to one of the policies as a whole or pertains to a particular base coverage or a particular rider under a policy, wherein the at least one designee node is attached to a policy node of the policy level if the at least one designee node pertains to one of the policies as a whole, wherein the at least one designee node is attached to a coverage node of the coverage level if the designee node pertains to a particular one of the base coverages or to a particular one of the riders;

performing, at the claim management case level, using the claim management case node, at least one process to fulfill an information requirement for adjudicating the policies;

performing, at the policy level, using at least one of the policy nodes, one or more processes to fulfill an information requirement for adjudicating a policy associated with the claim management case, wherein the at least one of the one or more processes performed at the policy level applies to only one of the policies associated with the claim management case;

performing, at the coverage level, using at least one of the coverage nodes, one or more processes to fulfill an information requirement for a coverage associated with the claim management case, wherein the at least one of the one or more processes performed at the coverage level applies to only one of the coverages associated with one of the policies;

determining whether predetermined information requirements for the claim management case have been met at the case management level, the policy level, and the coverage level;

inhibiting adjudication of any the policies in the claim management case or adjudication of any of the coverages in the claim management case until the predetermined information requirements for the claim management case are satisfied at the case management level, the policy level, and the coverage level;

the computer system performing at least one rendezvous, wherein at least one rendezvous comprises;

a queued item waiting for a response from a policy administration system;

the queued item receiving response data from the policy administration system;

the computer system comparing the response data from the policy administration system to expected data; and

the computer system determining that a rendezvous is effective based on a match of the response data and the expected data; and

adjudicating at least one claim under one or more of the policies.

12. A tangible, computer readable physical storage medium comprising program instructions stored thereon, wherein the program instructions are computer-executable to:

receiving at least one notice of an event or a condition that gives rise to a claim for payment under a first policy;

creating a claim management case for the insured in response to the at least one notice of the event or condition that gives rise to the claim for payment under the first policy, wherein creating the claim management case comprises associating one or more policies with the claim management case and associating one or more coverages with one of the policies;

creating a node hierarchy for processing claims, wherein creating the node hierarchy comprises;

creating, at a claim management case level, a claim management case node;

creating, at a policy level separate from and below the policy level, one or more policy nodes, wherein each of at least one of the policy nodes is associated with one of the policies,

creating, at a coverage level separate from and below the policy level, one or more coverage nodes, wherein each of at least one of the coverage nodes is associated with a base coverage or rider under at least one of the policies associated with one of the policy nodes,

creating, at a designee level, one or more designee nodes, wherein at least one of the designee nodes is associated with a designee on at least one of the policies or on at least one of the base coverages or riders; and

attaching at least one of the designee nodes of the designee level to at least one of the policy nodes of the policy level or at least one of the coverage nodes of the coverage level, wherein the level of the node to which the at least one designee node is attached depends on whether the designee node corresponds to one of the policies as a whole or pertains to a particular base coverage or a particular rider under a policy, wherein the at least one designee node is attached to a policy node of the policy level if the at least one designee pertains to one of the policies as a whole, wherein the at least one designee is attached to a coverage node of the coverage level if the designee node pertains to a particular one of the base coverages or to a particular one of the riders;

performing, at the claim management case level, using the claim management case node, at least one process to fulfill an information requirement for adjudicating the policies, wherein the information requirement applies to at least one of the policies associated with the claim management case;

performing, at the policy level, using at least one of the policy nodes, one or more processes to fulfill an information requirement for adjudicating an policy associated with the claim management case, wherein the at least one of the one or more processes performed at the policy level applies to only one of the policies associated with the claim management case;

performing, at the coverage level, using at least one of the coverage nodes, one or more processes to fulfill an information requirement for a coverage associated with the claim management case, wherein the at least one of the one or more processes performed at the coverage level applies to only one of the coverages associated with one of the insurance policies;

determining whether predetermined information requirements for the claim management case have been met at the case management level, the policy level, and the coverage level;

inhibiting adjudication of any the policies in the claim management case or adjudication of any of the coverages in the claim management case until the predetermined information requirements for the claim management case are satisfied at the case management level, the policy level, and the coverage level;

the computer system performing at least one rendezvous, wherein at least one rendezvous comprises;

a queued item waiting for a response from a policy administration system;

the queued item receiving response data from the policy administration system;

the computer system comparing the response data from the policy administration system to expected data; and

the computer system determining that a rendezvous is effective based on a match of the response data and the expected data; and

adjudicating at least one claim under one or more of the policies.