System for claim data segmentation

• US 9,984,421 B2
• Filed: 10/31/2014
• Issued: 05/29/2018
• Est. Priority Date: 09/05/2014
• Status: Active Grant

• Current Assignee: Hartford Fire Insurance Company (The Hartford Financial Services Group, Inc.)
• Original Assignee: Hartford Fire Insurance Company (The Hartford Financial Services Group, Inc.)
• Inventors: Blakeman, Cory R., Edwards, Paul J., Shemesh, Keren
• Primary Examiner(s): Poinvil, Frantzy
• Application Number:
  US14/530,141
• Publication Number:
  US 20160071218A1
• Time in Patent Office: 1,306 Days
• Field of Search: 705 3- 44
• CPC Class Codes: G06Q 10/063116 Schedule adjustment for a person or group
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

According to some embodiments, data is received indicative of a plurality of insurance claims. It may then be automatically determined that a first insurance claim is associated with a first type of insurance and that a second insurance claim is associated with a second type of insurance. The received data associated with the first insurance claim may be analyzed in accordance with first segmentation logic to determine a first segment classification appropriate for the first insurance claim. Similarly, the received data associated with the second insurance claim may be automatically analyzed in accordance with second segmentation logic to determine a second segment classification appropriate for the second insurance claim. Indications of the first and second segment classifications may then be transmitted (e.g., to a load balancing and assignment engine that automatically selects claim handlers for insurance claims).

Claims

1. A system, comprising:

a communication device to receive data indicative of a plurality of claims submitted in connection with policies providing at least a first type of coverage and a second type of coverage;

a computer storage unit for receiving, storing, and providing the data indicative of the plurality of claims;

a claim intake computer system configured for receiving claim data corresponding to a plurality of claims of the first type of coverage and the second type of coverage; and

a claims processing computer system coupled to the computer storage unit and the claim intake computer system, the claims processing computer system including;

a configurable segment ranking table for configuring first segmentation logic and second segmentation logic;

a segmentation platform processor in communication with the storage unit, wherein the segmentation platform processor is configured for;

automatically determining, for each claim of the plurality of claims, whether the claim is associated with the first type of coverage or whether the claim is associated with the second type of coverage different from the first type of coverage,

analyzing, for each of the claims associated with the first type of coverage, the received data associated with the claim, in accordance with first segmentation logic, to determine a first segment classification appropriate for the claim,

analyzing, for each of the claims associated with the second type of coverage, the received data associated with the claim, in accordance with second segmentation logic different from the first segmentation logic, to determine a second segment classification appropriate for the claim, and

transmitting a segment classification indication for each of the plurality of claims including one of a first segment classification indication or a second segment classification indication;

a load balancing and assignment engine configured for;

receiving the segment classification indication for each of the plurality of claims from the segmentation platform processor;

automatically selecting, for each of the plurality of claims based on the segment classification indication, assignment of each claim to one of a claim handler and a case manager; and

transmitting an electronic file for each of the plurality of claims to the assigned one of the claim handler and the case manager.

2. The system of claim 1, wherein at least one of the first and second types of coverage are associated with at least one of:

(i) workers'"'"' compensation insurance, (ii) automobile insurance, (iii) homeowners insurance, (iv) property insurance, (v) general liability insurance, (vi) commercial insurance, and (vii) personal insurance.

3. The system of claim 1, wherein at least one of the first and second segmentation logic is associated with at least one of:

(i) a potential claim liability, (ii) an injury classification, (iii) an injury severity, (iv) a hospitalization, and (v) an admission to intensive care.

4. The system of claim 1, wherein at least one of the first and second segmentation logic is associated with at least one of:

(i) a claimant age, (ii) co-morbidity information, (iii) an amount of work absence, (iv) jurisdiction information, and (v) an indication of potential litigation.

5. The system of claim 1, wherein said analyzing the received data associated with the claim, in accordance with first segmentation logic, comprises:

determining an injury driven foundation segment;

applying non-injury driven rules to determine a non-injury driven segment; and

selecting one of the injury driven foundation segment and non-injury driven segment based on the configurable segment ranking table.

6. The system of claim 1, wherein at least some of the received data indicative of a plurality of claims are associated with at least one of:

(i) a newly received first notice of loss, or (ii) information determined after a first notice of loss was received.

7. The system of claim 1, wherein the received data indicative of a plurality of claims include at least five of:

(i) a date and time, (ii) a claim number, (iii) a claim type, (iv) a loss date, (v) a benefit state, (vi) a claimant name, (vii) a claimant date of birth, (viii) a cause of injury, (ix) a claim description, (x) a body part, (xi) an injury, (xii) a return to work date, (xiii) an indication of whether the claimant was injured doing normal job duties, (xiv) an employment status, (xv) an indication of whether an injury resulted in death, (xvi) an indication of whether the injury requires surgery, (xvii) an indication of whether claim involves equipment or machinery, (xviii) an indication of whether safety equipment was provided, (xix) an indication of whether the claim is questionable, (xx) an indication of whether and injured worker is represented by an attorney, (xxi) a claim description, (xxii) a type of loss, (xxiii) a body part, (xxiv) an injury, (xxv) a geographic location, and (xxvi) forms and policy endorsements.

8. The system of claim 1, wherein the processor is further configured for:

automatically transmitting indications of the first and second segment classifications to at least one of;

(i) an email server, (ii) a workflow application, (iii) a report generator, (iv) a calendar application, and (v) a load balancing and assignment engine.

9. The system of claim 1, wherein the data indicative of the plurality of claims is received via at least one of:

(i) submitted paper claims, (ii) telephone call center operators, and (iii) an online claim submission web site.

10. The system of claim 1, wherein each claim handler is further selected based on numbers of other claims currently assigned to the claim handlers.

11. The system of claim 10, wherein each claim handler is further selected based on load factors associated with claim handlers.

12. The system of claim 11, wherein each claim handler is further selected based on paid time off information associated with claim handlers.

13. The system of claim 12, wherein each claim handler is further selected based on requests to receive more claims received from claim handlers.

14. The system of claim 1, wherein at least one of the segmentation platform processor and load balancing and assignment engine are associated with a predictive model trained with historical claim information.

15. The system of claim 14, wherein the predictive model is associated with at least one of:

(i) a neural network, (ii) a Bayesian network, (iii) a Hidden Markov model, (iv) an expert system, (v) a decision tree, (vii) a collection of decision trees, (viii) a support vector machine, and (ix) weighted factors.

16. A computer-implemented method comprising:

receiving, by a claim intake computer system, claim data corresponding to a plurality of claims of a first type of coverage and a second type of coverage;

receiving, by a communication device of a claim intake computer system, data indicative of a plurality of claims submitted in connection with policies providing at least the first type of coverage and the second type of coverage;

storing, by a computer storage unit, the data indicative of the plurality of claims;

automatically determining, by a segmentation platform processor of a claims processing computer system for each claim of the plurality of claims, whether the claim is associated with the first type of coverage or whether the claim is associated with the second type of coverage different from the first type of coverage,

analyzing, for each of the claims associated with the first type of coverage, the received data associated with the claim, by the segmentation platform processor in accordance with first segmentation logic configured by a configurable segment ranking table, to determine a first segment classification appropriate for the claim;

analyzing, for each of the claims associated with the second type of coverage, the received data associated with the claim, by the segmentation platform processor in accordance with second segmentation logic configured by the configurable segment ranking table different from the first segmentation logic, to determine a second segment classification appropriate for the claim; and

transmitting a segment classification indication for each of the plurality of claims including one of a first segment classification indication or a second segment classifications indication from the segmentation platform processor to a load balancing and assignment engine;

receiving, by the load balancing and assignment engine, the segment classification indication for each of the plurality of claims from the segmentation platform processor;

automatically selecting, by the load balancing and assignment engine for each of the plurality of claims based on the segment classification indication, assignment of each claim to one of a claim handler and a case manager; and

transmitting, by the load balancing and assignment engine, an electronic file for each of the plurality of claims to the assigned one of the claim handler and the case manager.

17. The method of claim 16, wherein at least one of the first and second types of coverage are associated with at least one of:

(i) workers'"'"' compensation insurance, (ii) automobile insurance, (iii) homeowners insurance, (iv) property insurance, (v) general liability insurance, (vi) commercial insurance, and (vii) personal insurance.

18. The method of claim 16, wherein at least one of the first and second segmentation logic is associated with at least one of:

(i) a potential claim liability, (ii) an injury classification, (iii) an injury severity, (iv) a hospitalization, and (v) an admission to intensive care.

19. The method of claim 16, wherein at least one of the first and second segmentation logic is associated with at least one of:

(i) a claimant age, (ii) co-morbidity information, (iii) an amount of work absence, (iv) jurisdiction information, and (v) an indication of potential litigation.

20. A system comprising:

a communication device to receive data indicative of a plurality of claims submitted in connection with coverage policies, including policies providing at least a first type of coverage and a second type of coverage, wherein the first type of coverage is associated with workers'"'"' compensation coverage and the second type of coverage is associated with automobile coverage;

a computer storage unit for receiving, storing, and providing the data indicative of the plurality of claims; and

a claim intake computer system configured for receiving claim data corresponding to a plurality of claims of the first type of coverage and the second type of coverage; and

a claims processing computer system coupled to the computer storage unit and the claim intake computer system, the claims processing computer system including;

a configurable segment ranking table for configuring first segmentation logic and second segmentation logic;

a segmentation platform processor in communication with the storage unit, wherein the segmentation platform processor is configured for;

automatically determining, for each claim of the plurality of claims, whether the claim is associated with the workers'"'"' compensation coverage or whether the claim is associated with the automobile coverage,

analyzing, for each of the claims associated with the workers'"'"' compensation coverage, the received data associated with the claim, in accordance with workers'"'"' compensation segmentation logic, to determine a first segment classification appropriate for the claim,

analyzing, for each of the claims associated with the automobile coverage, the received data associated with the claim, in accordance with automobile segmentation logic to determine a second segment classification appropriate for the claim, and

transmitting a segment classification indication for each of the plurality of claims including one of a first segment classification indication or a second segment classification indication;

a load balancing and assignment engine configured for;

receiving the segment classification indication for each of the plurality of claims from the segmentation platform processor;

automatically selecting, for each of the plurality of claims based on the segment classification indication, assignment of each claim to one of a claim handler and a case manager; and

transmitting an electronic file for each of the plurality of claims to the assigned one of the claim handler and the case manager.

21. The system of claim 20, wherein at least one of the workers'"'"' compensation and automobile segmentation logic is associated with at least one of:

(i) a potential claim liability, (ii) an injury classification, (iii) an injury severity, (iv) a hospitalization, and (v) an admission to intensive care.

22. The system of claim 20, wherein at least one of the workers'"'"' compensation and automobile segmentation logic is associated with at least one of:

(i) a claimant age, (ii) co-morbidity information, (iii) an amount of work absence, (iv) jurisdiction information, and (v) an indication of potential litigation.

23. The system of claim 20, wherein at least some of the received data indicative of a plurality of claims are associated with at least one of:

(i) a newly received first notice of loss, or (ii) information determined after a first notice of loss was received.