Researchers Submit Patent Application, “Digital Life And/Or Health Claims Processing System Integrating Multiple Claim Channels, And Method Thereof”, for Approval (USPTO 20240185355): Swiss Reinsurance Company Ltd.

2024 JUN 25 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- From Washington, D.C., NewsRx journalists report that a patent application by the inventors GUJJULA, Lakshmi Narasimhulu (Zurich, CH); LYNCH, Benjamin (Zurich, CH); SHAH, Sourav (Zurich, CH), filed on February 12, 2024, was made available online on June 6, 2024.

The patent’s assignee is Swiss Reinsurance Company Ltd. (Zurich, Switzerland).

News editors obtained the following quote from the background information supplied by the inventors: “Over the last century the insurance business has grown into a diverse and widespread industry with numerous products, services, business models and capabilities for business entities, government units and individuals alike. Small insurance groups, large commercial insurers and reinsurers continuously modify and improve their products and risk coverage packages according to the needs of their customers and technological advancement. Besides mainstream risk protection covering for example life, health, disability, real estate, automobile, travel or legal costs, specialty insurances for unique objects and activities cover for example plants, special talents, body parts, or weddings. A large number of stakeholders is in involved in the insurance business. In addition to the customer ordering an insurance product and the insurance carrier providing payment in case of an insurance claim event, there are underwriting agents, independent insurance brokers, capital providers, risk advisors and others. Customers usually have a portfolio of various risk coverage policies for different subjects and activities concluded with several insurance service providers, which results in various claims channels for resolving an insurance claim in case of a claim event.

“Claim processing is the most important point at which insurers interact with their customers, but it has historically been an area of underinvestment and technological backlog. Automated electronic claim systems have often been introduced by the risk-transfer industry with little awareness of the needs of life and health risk cover or the specific considerations of a specific market, as e.g. the Australian market. Further, filling out forms to file insurance claims is notoriously time-consuming for both, policyholders, and insurance personnel. This is not surprising given that countless documents have to be processed to provide a broad range of detailed information about the claim event, the resulting damage and loss of value for each claim channel. At the same time, there are always new and changing regulations, improved insurance products outdating existing policies and changing life circumstances. Finally, customers have high expectations towards timeframes for settling insurance claims, transparency of the claim processing and convenience of their involvement. There are many players involved in the claims management: from the policyholder to the clerk at the insurance company to external service providers, appraisers, and legal experts. Claims processing is one of the most important touch points in the customer journey, which determines customer satisfaction and loyalty. On the other hand claims processing and the associated workflows are a large cost factor for insurance companies and demand a high degree of collaboration across various business units.

“New technologies open up new possibilities in the field of claims management. Insurance companies switched to claims processing software to digitally manage insurance data, handle policy and claims documents, interact with their customers and track the status of claims processing. Concluding new contracts and managing existing ones, comparing offers, submitting invoices, and reporting claims in a digital way became an important part of the communication between customers and insurance providers. For the insurance industry, digitization is therefore an essential tool for increasing efficiency, optimizing processes, and reducing costs. A key driver of this development is data related to insurance risks, damage specifications or customer circumstance. For the insurance industry, data has always been an essential part of any business activities, particularly for risk analysis, stocktaking, and pricing development. Modern data analytics harness the data to make informed decisions and better understand what products and services are successful.

“Various digital claim processing systems or risk assessment systems based on data analytics have already been developed. For example, EP2631858A1 shows a system for insurance claims processing, which extracts claim data from one or more data sources to obtain a consolidated claims record and removes noise from text data of the consolidated records to obtain a claim dataset. U.S. Ser. No. 11/170,450B1 shows a data processing system for insurance claims analysis and adjudication for obtaining policy coverage data for various insurance policies and insurance claim data associated with an insured user. The system analyses the insurance claim data using machine learning models to identify coverage of a claims event by a respective insurance policy. US2016/0055589A1 discloses a system to predict and identify claims that have a high likelihood of exceeding a predetermined limitation in a given excess workers’ compensation insurance policy and to automatically indicate possible intervention strategies to mitigate potential claims costs. The processing system is based on various statistical and machine learning algorithms and allows to electronically display and attach the results to a business process.

“A system for evaluating an insurance claim, as presented in US2022/0044328A1, comprises: (i) extracting data features for the insurance claim; (ii) processing the data features using a machine learning model to generate potential denial data objects for a propensity to deny data object; and (iii) processing potential denial data object using a mitigating model to identify at least one mitigating action configured to cure the potential issue associated with the at least one potential denial data object. Finally, WO2020/119119A1 shows a machine learning-based system for settling an insurance claim. When providing a claim settlement service for a customer, pre-processing diagnosis and treatment data are captured to obtain claim settlement audit information for settling a claim. Then, the claim settlement audit data are detected by means of a detection model obtained in advance by means of training so as to determine the authenticity thereof. Finally, the system performs corresponding processing according to the authenticity detection result.

“However, poor data quality and multiple handoffs due to non-synchronized communication channels and missing interfaces between all stakeholders involved results in unnecessary duplicate work processes, make it necessary to provide repeated information from the customer and open doors for irregularities and fraud. This not only causes workflow interruptions, but also longer processing times and incorrect claim settlements. Having multiple processing unit for the multiple claims channels of an insurance portfolio leads to high costs and technical debt, which is unsatisfying for the customer and the insurance providers.

“In summary, there is a need to simplify the claims handling process for the customer to be fast and transparent, facilitate communication and collaboration across the supply chain of risk coverage products and increase efficiency of claim processing across physical and virtual boundaries.”

As a supplement to the background information on this patent application, NewsRx correspondents also obtained the inventors’ summary information for this patent application: “It is one object of the present invention to provide a digital claims processing system and a method thereof for integrating multiple claims channels and processing one or more claims based on the multiple claims channels that is based on customer-centric principles for a satisfying customer journey and enables agile claims processing for transparent and flexible claims management. Further, the digital claims processing system and method should allow for improving digitization and automation in the claims handling process to align workflow process steps, provide efficient communication channels and facilitate decision making for claims settlement considerations. In particular, it is an object of the present invention to provide a digital claims processing system and a method thereof that improve data accessibility and data quality for data sets relevant for claims processing, avoid data duplication and data loss in the short- and long-term, and support data exchange across various claims channels.

“According to the present invention, these objects are achieved, particularly, with the features of the independent claims. In addition, further advantageous embodiments can be derived from the dependent claims and the related descriptions.

“According to the present invention, the above-mentioned objects are achieved by a digital claims processing system and a method thereof for automatically integrating multiple claims channels and processing one or more claims of a customer based on the multiple claims channels related to the customer. A claims channel includes a claims data set of claims characteristics related to a claim event, like a negative impact or a negative change of condition, a policy data set of policy characteristics related to a claim policy regarding the claim event, like risk coverage rules or limits, and/or a services data set of services characteristics related to claims services, for example provided by an insurance carrier or intermediate. Additionally, the claims channel can e.g. comprise a product data set of product characteristics of a risk-transfer structure as a product. A claims channels may include several claims data sets, policy data sets and/or services data sets. At least one of the claims data set, the policy data set and/or the services data set and/or the product data set can e.g. include measuring data for physical event or real-world object/individual characteristics parameter values quantifying the claims event and/or the physical impact of a loss event to said real-world object or individual or living thing, wherein the measuring data is captured by measuring devices or sensors e.g. associated wearables or telematics or laboratory devices capturing body related measuring parameter values or in the event of a natural event with appropriate measuring stations capturing e.g. weather related measuring values, temperature, wind speed etc. For example the physical characteristics values indicate a damage or injury/illness extent, event impact details like disease/illness/injury event parameters or natural catastrophe/natural event parameters, event circumstances like human interaction documentation or monitoring data, or health condition parameters, etc. As an embodiment variant, where the claims are e.g. related to death and terminal illness, measuring parameters may not be needed or only in the framework of a diagnosis or diagnostic notification. Such data can e.g. be accomplished by capturing data from birth, death and/or marriage registries to allow automatic confirmation of the occurrence of the death. In some cases, the system can e.g. also rely on capturing data from medical reports such as X-rays and doctor’s certificates to achieve an automated decision of the outcome. Captured medical reports may be filtered rule-based where the system automatically interprets data points from the reports to provide a better assessment decision.

“The digital claims processing system according to the invention comprises a cloud-based infrastructure platform accessible via a digital network and is hosting a storage module, a data modelling module, a claims processing module, and a communication module comprising a signal generator. Further, the digital claims processing system comprises at least one data transmission interface for exchanging data and/or information provided by at least one user device with the infrastructure platform via the digital network. Data and information may for example be provided by user devices of a customer. The customer for example initiates a claims process and provides data for the claims data set. Further, user devices of a service provider like an insurance broker, an appraiser or specialist, an underwriter or an insurance carrier, may for example provide data and information about the claim event, the risk coverage conditions, settlement requirements, etc. for the policy data set and/or the services data set. The at least one data transmission interface is realized as a shared boundary between the cloud-based infrastructure platform and links the user devices and with the cloud-based infrastructure platform via the digital network. Particularly, the data transmission interface can be realized as an application programming interface (API) for allowing applications and modules of the infrastructure platform to communication with applications of the user devices. The user devices may for example be a smartphone or laptop of a customer, a computer system of a services provider or a digital network device of an insurance carrier. The user devices may for example run a common type of digital claims processing application as mentioned earlier, which can be linked to the cloud-based infrastructure platform by the data transmission interface. The digital network may be provided by a secured internet environment and the user devices may be realized by web-enabled devices accessing the internet environment.

“The inventive system has, inter alia, the advantages to technically (1) enable the reuse existing capabilities (e.g. cloud tech and data modelling), (2) provide a single automated claim system for all policies and claim types irrespective of the policy source or risk structure, and (3) provide an API based approach for scalability and case of integrations. Technical key design principles for the claim processing capabilities, inter alia, include (1) providing ownership and visibility of the claims portfolio, (2) ensuring that all processed claims remain in focus with flexibility in the management of the portfolio depending on the needs of the claim and customer, (3) adaptable to meet the requirements of the Life Insurance Code of Practice with the allowance for future adaptability as the Code should change, (4) supporting flexible, agile and flexible working through in-built dashboards on claims durations and SLA management, (5) reporting suites to enable the tracking of claim conditions, occupations, portfolio sizes, product types, and claims trends, and (6) and ensuring case of access for individual product features to be incorporated into the claims assessment. By introducing a more flexible and agile technical approach to automated claim processing, this allows for human claims specialists to be able to manage their own portfolio, with targeted huddles each morning to talk through their work with the team. Further, the digital system allows for users to automate review and monitoring of their claims portfolio in size, product, and duration as well as focus on individual workflow items to target shorter durations in decision times. The system also allows for flexibility and technical adaptability to consider claim requirements based on the individual need of the claim or due to a focus on the specific needs of the customer. Monitoring and reporting features can easily be implemented in line with regulatory requirements as well as the needs of the claims specialists and claims manager. The standard reporting automatically can indicate claims acceptance rates, workflow trends, and SLA adherence by individual or portfolio. To ensure that the technical solution meet these technical requirements, rigorous user acceptance testing was conducted with the claims team to ensure that the inventive system is able to deliver against the concept requirements. In particular as a supporting platform to automated claim management, the inventive system allows for greater visibility over a complex claim portfolio and technically enables a more strategic approach to automated claim data processing and assessment. More particularly, the use of the inventive system allows by technical means (1) a significant reduction of the average open aged claims (typically up to 60%), (2) a significant reduction of the claims decision times (typically around to 58%), (3) SLA adherence rising to 99%, and (4) a significant reduction of the time required to produce regulatory reporting for claims (typically from weeks to days). Finally, the inventive system newly allows to provide an automated technical system for (1) online lodgment and tracking of claims, (2) technical integration with ID check provider systems, (3) easy technical integration with death notification service systems, (4) easy technical integration with medical service provider systems, (5) application of of AI/ML to provide the claims assessors to automatically detect and reduce frauds, validate product rules, enable OCR of documents to improve data quality and efficiency and validate product rules, and (5) easy technical integration with Eco system provider systems.”

There is additional summary information. Please visit full patent to read further.”

The claims supplied by the inventors are:

“1. A digital life and/or health claims processing system for electronically integrating multiple digital claims channels, where a claims channel includes a claims data set of claims characteristics related to a claim event, a policy data set of policy characteristics related to a claim policy regarding the claim event, a services data set of services characteristics related to claims services, and/or a risk-transfer product data set of product characteristics related to a product, and for processing one or more claims of a customer based on at least one digital claims channel related to the customer, the system comprising: a cloud-based infrastructure platform accessible via a digital network and configured to host a storage module, a data modelling module, a claims processing module, and a communication module including a signal generator; and at least one data transmission interface configured to exchange data and/or information provided by at least one user device with the infrastructure platform via the digital network, wherein at least the claims data set, the policy data set, and/or the services data set includes claimants doctors and/or medical cause data at least including measuring data for physical characteristics values quantifying the claim event and/or historic policy disclosure parameter values and/or product rule parameters and medical cause data and/or diagnostic measuring parameter values and/or laboratory measuring parameter values and/or measuring data for physical characteristics values quantifying a life or health claim event, wherein the data modelling module includes a data validation structure configured to validate data of characteristics values of the claims data sets, the policy data sets, and/or the services data sets received via the data transmission interface, wherein validated data sets of the multiple claims channels of the customer are stored as structured data sets in the storage module, wherein the claims processing module includes a processing and analyzing structure configured to analyze the structured data sets according to claims requirements defined in the digital claims channels, and to define a claim processing status, and wherein the communication module provides a digital communication signal representing the claim processing status via the signal generator to a user device within the digital network.

“2. The system according to claim 1, wherein at least the policy data set includes the historic policy disclosure parameter values, and/or the product rule parameters and the medical cause data and/or the diagnostic measuring parameter values, and/or the laboratory measuring parameter values.

“3. The system according to claim 1, wherein at least the policy data set includes the measuring data for physical characteristics values quantifying a life or health risk event exposure and/or a probability for an occurrence of a life or health risk event captured by diagnostic data, laboratory measuring data, and/or on-body sensor devices.

“4. The system according to claim 1, wherein a plurality of combined structured data sets of a plurality of customers is stored in the storage module.

“5. The system according to claim 1, wherein the multiple claim channels include policy data sets of policy characteristics and/or and service data sets of services characteristics related to historical, outdated, or retired claim policies.

“6. The system according to claim 1, wherein the data transmission interface is realized as an application programming interface providing digital applications access between the infrastructure platform and user devices.

“7. The system according to claim 1, wherein the data modelling module combines a structured claims data set, a structured policy data set, and/or a structured services data set referring to the claim event to an integrated claims processing data set, which includes structured measuring data for physical characteristics values quantifying a claim life or health event and/or structured measuring data quantifying a life or health event impact exposure and/or a probability for an occurrence of a life event or health event or critical illness event or terminal illness event impacting physically an individual and capturable by sensor or measuring laboratory or diagnostic devices.

“8. The system according to claim 1, wherein the data modelling module comprises a machine learning structure configured to analyze data sets of the claims channels, the machine learning structure is realized as a supervised or unsupervised machine learning algorithm configured to analyze input data sets and to provide validation for the data of the input data sets, and the data modelling module provides the validated data for the structured data sets.

“9. The system according to one of claim 1, wherein the data modelling module comprises a text mining structure configured to analyze textual data of the claims channel data sets, the text mining structure is realized as an information extraction module and/or interface configured to identify and to categorize claims, policy, and/or services characteristics in the textual data as validated data, and the data modelling module provides the validated data for the structured data sets.

“10. The system according to claim 7, wherein the data modelling module comprises a machine learning structure for dimensionality reduction of the integrated claims processing data set, and the machine learning structure is realized to select and/or extract data variables from the claims channel data sets and/or the structured data sets to simplify the integrated claims processing data set.

“11. The system according to claim 1, wherein the processing and analyzing structure of the claims processing module includes several workflow algorithms, and each of the workflow algorithms defines a processing step of a claims processing workflow.

“12. The system according to claim 11, wherein the processing and analyzing structure includes workflow algorithms at least for workflow processing steps of recording of a claims submission by a customer, analyzing of missing data information, analyzing of incorrect data information, analyzing of claim entitlement, and recording of a settlement decision.

“13. The system according to claim 1, wherein the claims processing module includes a prioritizing structure configured to identify and prioritize outstanding work tasks in a claims processing workflow.

“14. The system according to claim 7, wherein the cloud-based infrastructure platform hosts a tracking module configured to track the claim processing status and to create notification signals regarding the claim processing status, incorrect claim data/information, missing claim data/information, outstanding work tasks, and/or work task allocation.

“15. The system according to claim 14, wherein the claims processing module, the communication module, and/or the tracking module include a notification algorithm configured to create notification data for a notification signal for allocating work tasks and/or requesting missing claim data/information.

“16. The system according to claim 15, wherein the cloud-based infrastructure platform hosts a timeline module configured to indicate key data of the integrated claims processing data set on a timeline, and the key data at least indicates a policy activation date, a claim event date, a claim submission date, and a claim settlement date.

“17. The system according to claim 16, wherein the cloud-based infrastructure platform hosts a dashboard module, which is linked to the storage module, the claims processing module, the tracking module, and/or the timeline module, and the dashboard module is configured to create a visual display of at least the claim processing status and/or the communication signal.

“18. The system according to claim 6, wherein the user devices are network-compatible devices, and the cloud-based infrastructure platform hosts an authentication module configured to provide authentication credentials for a user and allowing access to the digital claims processing system.”

There are additional claims. Please visit full patent to read further.

For additional information on this patent application, see: GUJJULA, Lakshmi Narasimhulu; LYNCH, Benjamin; SHAH, Sourav. Digital Life And/Or Health Claims Processing System Integrating Multiple Claim Channels, And Method Thereof. U.S. Patent Application Number 20240185355, filed February 12, 2024 and posted June 6, 2024. Patent URL (for desktop use only): https://ppubs.uspto.gov/pubwebapp/external.html?q=(20240185355)&db=US-PGPUB&type=ids

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