Insurance Coverage Validation

• US 20110313794A1
• Filed: 06/22/2010
• Published: 12/22/2011
• Est. Priority Date: 06/22/2010
• Status: Abandoned Application

• Current Assignee: Rosa M. Feeney
• Original Assignee: Rosa M. Feeney
• Inventors: Feeney, Rosa M.
• Application Number:
  US12/820,332
• Publication Number:
  US 20110313794A1
• 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

A method of evaluating insurance coverage under a policy of insurance, including receiving first insurance claim information associated with an insurance claim, outputting a representative portion of the insurance policy, receiving second insurance claim information in response to the output representative portion of the insurance policy and generating an insurance coverage record based on the second insurance claim information and the insurance policy. The first insurance claim information includes a claimant identifier and a policy identifier. The policy identifier corresponds to a portion of an insurance policy. The representative portion of the insurance policy being selected by a computer processing device in response to the receipt of the first insurance claim information. The second insurance claim information being associated with the insurance claim. The insurance coverage record identifies whether there exists an issue needed to be resolved for the validation of insurance coverage and identifies if any issues exist.

Claims

1. A method of evaluating insurance coverage under a policy of insurance, the method comprising:

receiving first insurance claim information associated with an insurance claim, the first insurance claim information including a claimant identifier and a policy identifier, the policy identifier corresponding to at least one portion of an insurance policy;

outputting a representative portion of the insurance policy, the representative portion of the insurance policy selected by a computer processing device in response to the receipt of the first insurance claim information;

receiving second insurance claim information in response to the output representative portion of the insurance policy, the second insurance claim information associated with the insurance claim; and

generating an insurance coverage record based on the second insurance claim information and the insurance policy, wherein the insurance coverage record identifies whether there exists an issue needed to be resolved for the validation of insurance coverage and identifies if any issues exist.

2. The method of claim 1, wherein the first insurance claim information includes an indication of a type of claim to which the insurance claim applies.

3. The method of claim 1, wherein the representative portion of the insurance policy is rephrased and presented in the form of a question.

4. The method of claim 1, wherein the representative portion of the insurance policy includes at least one Exclusion, Term, Condition, Provision, Policy Endorsement or Definition, as reflected in the insurance policy.

5. The method of claim 1, wherein the representative portion of the insurance policy includes or incorporates at least one judicial decision, regulatory or statutory authority or guidelines pertaining to the insurance claim.

6. The method of claim 1, wherein the second insurance claim information is at least partially responsive to the rephrased output representative portion of the insurance policy.

7. The method of claim 1, wherein the generated insurance coverage record includes a warning or basis for denial of the insurance claim.

8. The method of claim 1, wherein the generated insurance coverage record indicates no valid basis for denial of the insurance claim.

9. The method of claim 1, wherein the generated insurance coverage record includes a list or summary of compiled details regarding the insurance claim.

10. The method of claim 9, wherein the list or summary identifies a form, document, or written communication needed for the validation of insurance coverage.

11. The method of claim 1, wherein the record includes actual copies of the needed form, document or written communication.

12. The method of claim 1, wherein the identified issue includes at least one factual issue or at least one legal issue for further inquiry or investigation.

13. The method of claim 1, wherein the identified issue includes a basis for consulting legal counsel.

14. The method of claim 1, wherein the insurance coverage record includes an assessment of the responses received from the queries.

15. The method of claim 14, wherein the assessment includes an indication of how the queries were answered.

16. The method of claim 1, wherein the insurance coverage record is used for auditing or monitoring the insurance claims representatives performance and evaluation of coverage under the insurance policy for a particular insurance claim.

17. The method of claim 1, wherein the insurance coverage record is used for training an insurance claims representative.

18. The method of claim 1, wherein the insurance coverage record is used for a different insurance claim.

19. The method of claim 1, wherein the insurance coverage record includes information based on a determination of at least one of legal precedent and guidelines altering the interpretation, at least in part, of a portion of the insurance policy.

20. A system to evaluate insurance coverage under a policy of insurance, the system comprising:

a computer processing device that

receives first insurance claim information associated with an insurance claim, the first insurance claim information including a claimant identifier and a policy identifier, the policy identifier corresponding to at least one portion of an insurance policy;

outputs a representative portion of the insurance policy, the representative portion of the insurance policy selected by the computer processing device in response to the receipt of the first insurance claim information;

receives second insurance claim information in response to the output representative portion of the insurance policy, the second insurance claim information associated with the insurance claim; and

generates an insurance coverage record based on the second insurance claim information and the insurance policy, wherein the insurance coverage record identifies whether there exists an issue needed to be resolved for the validation of insurance coverage and identifies if any issues exist.

21. The system of claim 20, wherein the first insurance claim information includes an indication of a type of claim to which the insurance claim applies.

22. The system of claim 20, wherein the representative portion of the insurance policy is rephrased and presented in the form of a question.

23. The system of claim 20, wherein the second insurance claim information is at least partially responsive to the rephrased output representative portion of the insurance policy.

24. The system of claim 20, wherein the generated insurance coverage record includes a warning or basis for denial of the insurance claim.

25. The system of claim 20, wherein the generated insurance coverage record includes a list or summary of compiled details regarding the insurance claim, wherein the list or summary identifies a form, document, or written communication needed for the validation of insurance coverage.

26. The system of claim 20, wherein the identified issue includes at least one factual issue or at least one legal issue for further inquiry or investigation.

27. The system of claim 20, wherein the insurance coverage record includes an assessment of the responses received from the queries.

28. The system of claim 20, wherein the insurance coverage record includes information based on a determination of at least one of legal precedent and guidelines altering the interpretation, at least in part, of a portion of the insurance policy.