Coverage Analysis Flow Chart

Transcription

1 US A1 (19) United States (12) Patent Application Publication (10) Pub. N0.: US 2004/ A1 Menendez (43) Pub. Date: Jul. 29, 2004 (54) (76) (21) (22) (60) METHOD OF EXPEDITING INSURANCE CLAIMS Inventor: Dale Menendez, Fox River Grove, IL (US) Correspondence Address: Welsh & Katz, Ltd. Jon P. Christensen 22nd Floor 120 South Riverside Plaza Chicago, IL (US) Appl. N0.: 10/740,066 Filed: Dec. 18, 2003 Related US. Application Data Provisional application No. 60/438,019,?led on Jan. 4, Publication Classi?cation (51) Int. Cl? G06F 17/60 (52) US. Cl /4 (57) ABSTRACT Coverage Analysis Flow Chart A method and apparatus are provided for processing an insurance claim. The method includes the steps of receiving a claim for a loss from an insured through an Internet connection and determining a policy type from the claim. The method further includes the steps of retrieving a set of keywords based upon the policy type, matching the retrieved set of keywords With Words contained Within the received claim, assigning an adjuster to the claim When any matched Words of the matching step meets a predetermined criteria and paying the claim Without assigning the claim to an adjuster When the matching does not meet the predetermined criteria and any auxiliary criteria. Claim Report Completed and Claim Number Assigned The data is analyzed to determine if the loss passes coverage or requires an adjuster to verify coverage. If building cover is all risk and content is named peril and both have damage claimed then the more narrow coverage, named peril, applies. The client s program will dictate the type of coverage. Detailed List of Property Not Covered Animal Vehicle All Risk Coverage Named Peril Coverage Detailed List Claim Report, Coverage and Detailed of Policy and Data Analyzed Against Key Listed of Insuring Words, Phrases, Dollar Limts, Covered Agreement Exclusions Time Periods, etc. + I Perils Property Not Covered m Matched Exclusions?o_t Matched Coverage Peril Matched Property Not Covered Matched Exclusion Matched Coverage Peril M Matched Claim Successfully Passes to Damage Veri?cation Process. Claim sent to the company with recommendation to Refer to Adjuster.

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19 Patent Application Publication Jul. 29, 2004 Sheet 18 of 22 US 2004/ A1 Damage Veri?cation Flow Chart The Claim Report questionnaire identi?es the three categories of damages that can be claimed. Building Damage, and/ or Content Damage, and/ or Expense Building Damage Expense Content Damage Itemized Damages Itemized Damages Itemized Damages Online Form Online Form Online Form Damages totaled to create a Sworn Statement In Proof Of Loss The insured must sign the sworn statement thereby agreeing to the facts reported and the dollar amount claimed recognizing that submitting false or incorrect information will have legal consequences and may result in disciplinary actions System Analysis of Claim Data, Dollar Limits, and Property Not Covered Against Damage Veri?cation Information and Data Provided. Claim and data success?illy complete coverage and damage analysis Recommend Payment of Claim to Company Claim and data do not pass coverage and damage analysis Recommend claim be Referred To Adjuster by the company I Claim Log Completed FXGJS

20 Patent Application Publication Jul. 29, 2004 Sheet 19 0f 22 Pay/ Referral Process Flow Chart US 2004/ A1 Claim Record and Log ' The Claim Report Log is a virtual claim record and log between the company and FastTrackClaimm. A record is created when a claim report is successfully completed and a claim number is assigned. At that point the claim is referred to an adjuster (RTA) if it does not pass the coverage analysis or it continues to the Damage Veri?cation process. If it does not successfully pass that process at any point in the damage submission process the claim is referred to adjuster (RTA). If the claim successfully passes Coverage Analysis and Damage Veri?cation it is on the log as a recommended payment to the company. The company may then choose to RTA or PAY the claim clearing the claim which will then be closed on the FastTrackClaim'm Record and system. Automatic Electronic Claim Payments The company/ client is asked to assign a claim administrator to review and process the online Claim Record for payment or referral to adjuster. IfFl C recommends payment it is the company's option to pay the claim. Once the program is in process and live claims are being processed the procedure can be manipulated and the system constraints adjusted for optimal results. Once claim payments become routine and it is clear the system is functioning properly the process may be automated to electronically pay claims without direction from the claim administrator. Using EDI or other electronic data interface systems the company system and FTC system can exchange data and information as necessary to electronically automate the payment process paying claims based upon system information. Claim Report Questionnaire V Claim Record Coverage Analysis + Refer To Adjuster Damage Veri?cation (RTA) Sworn Statement In Proof Of Loss l Claim Record Recommend To Pay (PAY) eta, \"t

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