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Insurance Abstract
A cosmetic dental insurance policy and a system and method for issuing
a cosmetic dental insurance policy providing cosmetic dental benefits
are provided. In one embodiment, the cosmetic dental insurance policy
is a rider to a base dental insurance policy. Cosmetic dental benefits
include, for example, veneers and bleaching. A system for processing
a claim received from a cosmetic dental insurance policyholder is
also provided.
Insurance Claims
1. A system for issuing a cosmetic dental insurance policy, said
system comprising: a processor; and a memory coupled to said processor
and storing an application that the processor executes to: receive
applicant data related to a prospective policy participant; apply
one or more business rules stored in said memory to said applicant
data to determine whether said prospective policy participant qualifies
for said cosmetic dental insurance policy; and transmit said cosmetic
dental insurance policy to a policy participant, wherein said policy
participant is comprised of said prospective policy participant
determined to qualify for said cosmetic dental insurance policy,
wherein said cosmetic dental insurance policy provides a cosmetic
dental benefit that provides a payment to a provider or the policy
participant of a portion or all of a covered cosmetic dental procedure.
2. The system of claim 1, wherein said cosmetic dental insurance
policy comprises a rider to a base dental insurance policy.
3. The system of claim 2, wherein said covered cosmetic dental
procedures comprise one or more of labial veneers, bleaching of
discolored teeth, occlusion adjustment, odontoplasty, or enamel
microbrasion.
4. The system of claim 1, wherein said cosmetic dental benefits
comprises payment of a pre-defined amount to be made to said policy
participant or to said provider.
5. The system of claim 4, wherein said provider comprises a dentist
or a dental hygienist.
6. A system for processing a cosmetic dental insurance policy claim,
said system comprising: a processor; and a memory connected to said
processor and storing a computer program executed by said processor
to: (a) receive a cosmetic dental insurance policy claim from a
policy participant, wherein said policy participant is a policyholder
of a cosmetic dental insurance policy; (b) determine whether said
policy participant incurred one or more expenses relating to covered
cosmetic dental procedures; and (c) authorize provision of a cosmetic
dental benefit based on the determination made in step (b), above.
7. The system of claim 6, wherein said covered cosmetic dental
procedures comprise one or more of labial veneers, bleaching of
discolored teeth, occlusion adjustment, odontoplasty, or enamel
microbrasion.
8. The system of claim 6, wherein said cosmetic dental benefit
comprises payment of a pre-defined amount to be made to said policy
participant or to a provider.
9. The system of claim 8, wherein said provider comprises a dentist
or a dental hygienist.
10. The system of claim 6, wherein said cosmetic dental insurance
policy comprises a rider to a base dental insurance policy.
11. A cosmetic dental insurance policy providing: a cosmetic dental
benefit that provides for one or more cosmetic dental benefit payments
to be made in response to a policy participant receiving covered
cosmetic dental procedures from a provider.
12. The cosmetic dental insurance policy of claim 11, wherein said
covered cosmetic dental procedures comprise one or more of labial
veneers, bleaching of discolored teeth, occlusion adjustment, odontoplasty,
or enamel microbrasion.
13. The cosmetic dental insurance policy of claim 11, wherein said
cosmetic dental benefit comprises payment of a pre-defined amount
to be made to said policy participant or to said provider.
14. The cosmetic dental insurance policy of claim 13, wherein said
provider comprises a dentist or a dental hygienist.
15. The cosmetic dental insurance policy of claim 11, wherein said
cosmetic dental insurance policy comprises a rider to a base dental
insurance policy.
16. A method of issuing a cosmetic dental insurance policy, said
method comprising the steps of: receiving applicant data related
to a prospective policy participant; determining, based at least
in part on said applicant data, whether said prospective policy
participant qualifies for said cosmetic dental insurance policy;
and issuing said cosmetic dental insurance policy to a policy participant,
wherein said policy participant is comprised of said prospective
policy participant determined to qualify for said cosmetic dental
insurance policy, wherein said cosmetic dental insurance policy
provides a cosmetic dental benefit that provides a payment to a
provider or the policy participant of a portion or all of a covered
cosmetic dental procedure.
17. The method of claim 16, wherein said covered cosmetic dental
procedure comprises one or more or labial veneers, bleaching of
discolored teeth, occlusion adjustment, odontoplasty, or enamel
microbrasion.
18. The method of claim 16, wherein said cosmetic dental benefit
comprises payment of a pre-defined amount to be made to said policy
participant or to said provider.
19. The method of claim 18, wherein said provider comprises a dentist
or a dental hygienist.
20. The method of claim 16, wherein said cosmetic dental insurance
policy comprises a rider to a base dental insurance policy.
21. A method of processing a cosmetic dental insurance policy claim,
said method comprising the steps of: (a) receiving a cosmetic dental
insurance policy claim from a policy participant; (b) determining
whether said policy participant incurred one or more expenses relating
to a covered cosmetic dental procedure; and (c) providing some cosmetic
dental benefit based on the determination made in step (b), above.
22. The method of claim 21, wherein said covered cosmetic dental
procedure comprises one or more of labial veneers, bleaching of
discolored teeth, occlusion adjustment, odontoplasty, or enamel
microbrasion.
23. The method of claim 21, wherein said cosmetic dental benefit
comprises payment of a pre-defined amount to said policy participant
or to a provider.
24. The method of claim 23, wherein said provider comprises a dentist
or a dental hygienist.
25. The method of claim 21, wherein said cosmetic dental insurance
policy comprises a rider to a base dental insurance policy.
26. A method of offering a cosmetic dental insurance policy, said
method comprising the step of: providing a cosmetic dental insurance
application to an applicant, wherein the cosmetic dental insurance
policy provides a cosmetic dental benefit comprised of a payment
to a policy participant or a provider for covered cosmetic dental
procedures; receiving applicant information from said applicant;
determining whether said applicant is qualified to become one of
the policy participants; and if said applicant is authorized to
become one of the policy participants; then issuing the cosmetic
dental insurance policy to the applicant, said applicant thus becoming
one of the policy participants.
27. The method of claim 26, wherein said covered cosmetic dental
procedures comprises one or more of labial veneers, bleaching of
discolored teeth, occlusion adjustment, odontoplasty, or enamel
microbrasion.
28. The method of claim 26, wherein said cosmetic dental benefit
comprises payment of a pre-defined amount to said policy participant
or to a provider.
29. The method of claim 28, wherein said provider comprises a dentist
or a dental hygienist.
30. The method of claim 26, wherein said cosmetic dental insurance
policy comprises a rider to a base dental insurance policy.
Insurance Description
BACKGROUND OF THE INVENTION
[0001] 1. Field of the Invention
[0002] The present invention generally relates to insurance policies,
and particularly relates to dental insurance policies, specifically
a cosmetic rider policy for a base dental insurance policy.
[0003] 2. Description of Related Art
[0004] Current base dental insurance policies typically provide
policyholders with basic preventative and restorative examinations
and treatments, such as annual check-ups and cleanings, x-rays and
fillings, at a reduced cost or in some cases without additional
cost to the policyholder. However, there is a need for improved
dental insurance policies that provide additional types of dental-related
coverage.
BRIEF SUMMARY OF THE INVENTION
[0005] Generally described, various embodiments of the present
invention provide an improvement over the known prior art by providing
a cosmetic dental insurance policy or a rider to a base dental insurance
policy and a method, system, computing device, and policy for issuing
the policy or rider. The rider provides policyholders with cosmetic-related
dental coverage that is in addition to base dental insurance coverage
for check-ups, cleanings and restorative products. A system for
processing a claim received from a cosmetic dental insurance policyholder
is also provided.
[0006] According to one aspect of the present invention, a system
for issuing a cosmetic dental insurance policy is provided. The
system is comprised of a processor and a memory coupled to the processor
that stores an application executable by the processor. The application
receives applicant data related to a prospective policy participant.
It then applies one or more business rules stored in the memory
to the applicant data to determine whether the prospective policy
participant qualifies for cosmetic dental insurance policy. The
application then transmits the cosmetic dental insurance policy
to a policy participant, where the policy participant is comprised
of the prospective policy participant determined to qualify for
then cosmetic dental insurance policy. The cosmetic dental insurance
policy provides a cosmetic dental benefit that provides a payment
to a provider or the policy participant of a portion or all of a
covered cosmetic dental procedure.
[0007] Another aspect of the invention is a system for processing
a cosmetic dental insurance policy claim. The system is comprised
of a processor and a memory connected to the processor that stores
a computer program executed by the processor. The computer program
receives a cosmetic dental insurance policy claim from a policy
participant, wherein the policy participant is a policyholder of
a cosmetic dental insurance policy. The computer program determines
whether the policy participant incurred one or more expenses related
to covered cosmetic dental procedures. If so, then the computer
program authorizes provision of some combination of a cosmetic dental
benefit.
[0008] Another aspect of the present invention is a cosmetic dental
insurance policy. The policy provides a cosmetic dental benefit
that provides for one or more cosmetic dental benefit payments to
be made in response to a policy participant receiving covered cosmetic
dental procedures from a provider.
[0009] Yet another aspect of the,present invention is a method
of issuing a cosmetic dental insurance policy. The method is comprised
of the steps of receiving applicant data related to a prospective
policy participant, and determining, based at least in part on the
applicant data, whether the prospective policy participant qualifies
for the cosmetic dental insurance policy. If the prospective policy
participant does qualify, then issuing the cosmetic dental insurance
policy to the policy participant. The cosmetic dental insurance
policy comprises a cosmetic dental benefit that provides a payment
to a provider or the policy participant of a portion or all of a
covered cosmetic dental procedure.
[0010] Another aspect of the present invention is a method of processing
a cosmetic dental insurance policy claim. The method is comprised
of the steps of receiving a cosmetic dental insurance policy claim
from a policy participant and determining whether the policy participant
incurred one or more expenses related to a covered cosmetic dental
procedure. If so, then providing a cosmetic dental benefit associated
with the covered cosmetic dental procedure.
[0011] Yet another aspect of the present invention is a method
of offering a cosmetic dental insurance policy. The method is comprised
of the steps of providing a cosmetic dental insurance application
to an applicant, wherein the cosmetic dental insurance policy provides
a cosmetic dental benefit comprised of a payment to a policy participant
or a provider for covered cosmetic dental procedures. Then, receiving
applicant information from the applicant and determining whether
the applicant is qualified to become one of the policy participants.
If the applicant is authorized to become one of the policy participants,
then issuing the cosmetic dental insurance policy to the applicant,
the applicant thus becomes a policy participant.
[0012] These and other aspects of the present invention are more
fully described herein.
BRIEF DESCRIPTION OF THE DRAWING(S)
[0013] Having thus described the invention in general terms, reference
will now be made to the accompanying drawings, which are not necessarily
drawn to scale, and wherein:
[0014] FIG. 1a is an illustration of one embodiment of a computer
that can be used to practice aspects of the present invention;
[0015] FIG. 1b is an embodiment of a processing system having a
distributed communication and processing architecture that may be
used to practice aspects of the present invention;
[0016] FIG. 2 is an illustration of an exemplary cosmetic dental
insurance rider that may be used to practice aspects of the invention;
[0017] FIG. 3 is a block diagram of a system for issuing a cosmetic
dental insurance policy according to one embodiment of the present
invention;
[0018] FIG. 4 is a block diagram of an Insurance Company computer
in accordance with one embodiment of the present invention;
[0019] FIG. 5 is a block diagram of a Computing Device in accordance
with one embodiment of the present invention;
[0020] FIG. 6A is a flow chart illustrating a method of issuing
a cosmetic dental insurance policy according to an embodiment of
the present invention;
[0021] FIG. 6B is a flow chart illustrating a method of issuing
a cosmetic dental insurance policy or according to another embodiment
of the present invention;
[0022] FIG. 7 is a block diagram of a system for processing a cosmetic
dental insurance policy claim according to one embodiment of the
present invention;
[0023] FIG. 8 is a block diagram of a Claim Processing Server in
accordance with embodiments of the present invention; and
[0024] FIG. 9 is a flow chart illustrating a method of processing
a cosmetic dental insurance policy claim according to an embodiment
of the present invention.
DETAILED DESCRIPTION OF THE INVENTION
[0025] The present invention now will be described more fully with
reference to the accompanying drawings, in which some, but not all
embodiments of the invention are shown. Indeed, this invention may
be embodied in many different forms and should not be construed
as limited to the embodiments set forth herein. Rather, these embodiments
are provided so that this disclosure will satisfy applicable legal
requirements. Like numbers refer to like elements throughout.
[0026] As will be appreciated by one skilled in the art, the present
invention may be embodied as a method, a data processing system,
or a computer program product. Accordingly, the present invention
may take the form of an entirely hardware embodiment, an entirely
software embodiment, or an embodiment combining software and hardware
aspects. Furthermore, the present invention may take the form of
a computer program product on a computer-readable storage medium
having computer-readable program instructions (e.g., computer software)
embodied in the storage medium. More particularly, the present invention
may take the form of web-implemented computer software. Any suitable
computer-readable storage medium may be utilized including hard
disks, CD-ROMs, optical storage devices, or magnetic storage devices.
[0027] The present invention is described below with reference
to block diagrams and flowchart illustrations of methods, apparatuses
(i.e., systems) and computer program products according to an embodiment
of the invention. It will be understood that each block of the block
diagrams and flowchart illustrations, and combinations of blocks
in the block diagrams and flowchart illustrations, respectively,
can be implemented by computer program instructions. These computer
program instructions may be loaded onto a general purpose computer,
special purpose computer, or other programmable data processing
apparatus to produce a machine, such that the instructions which
execute on the computer or other programmable data processing apparatus
create a means for implementing the functions specified in the flowchart
block or blocks.
[0028] These computer program instructions may also be stored in
a computer-readable memory that can direct a computer or other programmable
data processing apparatus to function in a particular manner, such
that the instructions stored in the computer-readable memory produce
an article of manufacture including computer-readable instructions
for implementing the function specified in the flowchart block or
blocks. The computer program instructions may also be loaded onto
a computer or other programmable data processing apparatus to cause
a series of operational steps to be performed on the computer or
other programmable apparatus to produce a computer-implemented process
such that the instructions that execute on the computer or other
programmable apparatus provide steps for implementing the functions
specified in the flowchart block or blocks.
[0029] Accordingly, blocks of the block diagrams and flowchart
illustrations support combinations of means for performing the specified
functions, combinations of steps for performing the specified functions
and program instruction means for performing the specified functions.
It will also be understood that each block of the block diagrams
and flowchart illustrations, and combinations of blocks in the block
diagrams and flowchart illustrations, can be implemented by special
purpose hardware-based computer systems that perform the specified
functions or steps, or combinations of special purpose hardware
and computer instructions.
[0030] In several of the embodiments of the invention referenced
herein, a "computer" is referenced. The computer may be,
for example, a mainframe, desktop, notebook or laptop, or a hand
held device such as a data acquisition and storage device, etc.
In some instances the computer may be a "dumb" terminal
used to access data or processors over a network. Turning to FIG.
1a, one embodiment of a computer is illustrated that can be used
to practice aspects of the present invention. In FIG. 1a, a processor
1, such as a microprocessor, is used to execute software instructions
for carrying out the defined steps. The processor receives power
from a power supply 17 that also provides power to the other components
as necessary. The processor 1 communicates using a data bus 5 that
is typically 16 or 32 bits wide (e.g., in parallel). The data bus
5 is used to convey data and program instructions, typically, between
the processor and memory. In the present embodiment, memory can
be considered primary memory 2 that is RAM or other forms which
retain the contents only during operation, or it may be non-volatile
3, such as ROM, EPROM, EEPROM, FLASH, or other types of memory that
retain the memory contents at all times. The memory could also be
secondary memory 4, such as disk storage, that stores large amount
of data. In some embodiments, the disk storage may communicate with
the processor using an I/O bus 6 instead or a dedicated bus (not
shown). The secondary memory may be a floppy disk, hard disk, compact
disk, DVD, or any other type of mass storage type known to those
skilled in the computer arts.
[0031] The processor 1 also communicates with various peripherals
or external devices using an I/O bus 6. In the present embodiment,
a peripheral I/O controller 7 is used to provide standard interfaces,
such as RS-232, RS422, DIN, USB, or other interfaces as appropriate
to interface various input/output devices. Typical input/output
devices include local printers 18, a monitor 8, a keyboard 9, and
a mouse 10 or other typical pointing devices (e.g., rollerball,
trackpad, joystick, etc.).
[0032] The processor 1 typically also communicates using a communications
I/O controller 11 with external communication networks, and may
use a variety of interfaces such as data communication oriented
protocols 12 such as X.25, ISDN, DSL, cable modems, etc. The communications
controller 11 may also incorporate a modem (not shown) for interfacing
and communicating with a standard telephone line 13. Finally, the
communications I/O controller may incorporate an Ethernet interface
14 for communicating over a LAN. Any of these interfaces may be
used to access the Internet, intranets, LANs, or other data communication
facilities.
[0033] Finally, the processor 1 may communicate with a wireless
interface 16 that is operatively connected to an antenna 15 for
communicating wirelessly with another device, using for example,
one of the IEEE 802.11 protocols, 802.15.4 protocol, or a standard
3G wireless telecommunications protocols, such as CDMA2000 1.times.EV-DO,
GPRS, W-CDMA, or other protocol.
[0034] An alternative embodiment of a processing system that may
be used is shown in FIG. 1b. In this embodiment, a distributed communication
and processing architecture is shown involving a server 20 communicating
with either a local client computer 26a or a remote client computer
26b. The server 20 typically comprises a processor 21 that communicates
with a database 22, which can be viewed as a form of secondary memory,
as well as primary memory 24. The processor also communicates with
external devices using an I/O controller 23 that typically interfaces
with a LAN 25. The LAN may provide local connectivity to a networked
printer 28 and the local client computer 26a. These may be located
in the same facility as the server, though not necessarily in the
same room. Communication with remote devices typically is accomplished
by routing data from the LAN 25 over a communications facility to
the Internet 27. A remote client computer 26b may execute a web
browser, so that the remote client 26b may interact with the server
as required by transmitted data through the Internet 27, over the
LAN 25, and to the server 20.
[0035] Those skilled in the art of data networking will realize
that many other alternatives and architectures are possible such
as, for example, the handheld devices contemplated herein and can
be used to practice the principles of the present invention. The
embodiments illustrated in FIGS. 1a and 1b can be modified in different
ways and be within the scope of the present invention as claimed.
Cosmetic Dental Insurance Policy
[0036] A cosmetic dental insurance policy (also referred to as
a "cosmetic policy" or a "cosmetic dental policy")
according to one embodiment of the invention comprises cosmetic
dental benefits that provide a payment to a provider or a policyholder
of a portion or all of a covered cosmetic dental procedure. In one
embodiment, the cosmetic dental insurance policy is provided as
a rider to a base dental insurance policy. Exemplary base dental
insurance benefits and cosmetic dental benefits are described more
fully below.
Base Dental Insurance Benefits
[0037] In various embodiments of the invention, base dental insurance
may provide benefits that include, for example, dental wellness
benefits, x-ray benefits, preventative benefits, diagnostic benefits,
fillings and other restorative benefits, crowns and other major
restorative benefits, root canals and other endodontic benefits,
gum treatments/periodontic benefits, dentures and other prosthetic
benefits, repairs and adjustments to prosthetic benefits, extractions
and other oral surgery benefits, and pain relief and adjunctive
services benefits. Benefits are generally described in a dental
insurance policy's "Policy Schedule." An exemplary Policy
Schedule's benefit categories are shown below in Table I, and the
Policy Schedule's optional benefits are shown in Table II. Benefits
may, or may not, be subject to a waiting period before they are
fully effective and the waiting periods shown in Tables I and II
are for exemplary purposes only. TABLE-US-00001 TABLE I Benefit
Categories Waiting Periods Dental Wellness Benefits [0, 0 months]
X-Ray Benefit [0, 0 months] Other Preventive Benefits [0, 6 months]
Other Diagnostic Benefits [0, 3 months] Fillings and Other Basic
Restorative Benefits [0, 3 months] Crowns and Other Major Restorative
Benefits [3, 12 months] Root Canals and Other Endodontic Benefits
[3, 12 months] Gum Treatments/Periodontic Benefits [3, 6 months]
Dentures and Other Prosthetic Benefits [6, 24 months] Repairs and
Adjustments to Prosthetic Benefits [3, 6 months] Extractions and
Other Oral Surgery Benefits [3, 6 months] Pain Relief and Adjunctive
Services Benefits [3, 3 months]
[0038] TABLE-US-00002 TABLE II Optional Benefits Waiting Periods
Orthodontic Benefit Rider 24 months Cosmetic Benefit Rider 24 months
[0039] Dental wellness benefits provide, for example, a predetermined
payment to be made when a charge is incurred for an oral evaluation,
prophylaxis, fluoride treatment, counseling, etc. for a person covered
by the base dental insurance policy (a "policy participant").
In various embodiments, this payment may be made directly to the
policy participant or to a service provider. In embodiments of the
invention, the base dental insurance policy may provide for policy
participants to receive one or more wellness benefits at no cost,
or substantially no cost, to the policy participant on an annual
basis.
[0040] X-ray benefits provide, for example, for a predetermined
x-ray payment to be made when a policy participant receives one
or more dental related x-rays such as, for example, interoral, extraoral,
bitewing, vertical bitewing, panoramic film, or cephalometric film
x-rays. The x-ray benefit payment may be made, for example, directly
to the policy participant or to a service provider. In embodiments
of the invention, the base dental policy may provide for policy
participants to receive the x-ray benefit at no cost, substantially
no cost or at a fixed or defined benefit amount, and such benefits
may be limited based on a time period (e.g., once per year, twice
per year, etc.)
[0041] Other preventive benefits include sealants, space maintainers,
and recementation of space maintainers. The benefit payments may
be made, for example, directly to the policy participant or to a
service provider. In embodiments of the invention, the base dental
policy may provide for policy participants to receive the other
preventative benefits at no cost, substantially no cost or at a
fixed or defined benefit amount, and such benefits may be limited
based on a time period (e.g., once per year, twice per year, etc.)
[0042] Other diagnostic benefits include oral evaluations, skull
and facial bone survey film, sialography, bacteriological studies,
pulp vitality tests, diagnostic casts and photographs, and histopathological
exams. The benefit payments may be made, for example, directly to
the policy participant or to a service provider. In embodiments
of the invention, the base dental policy may provide for policy
participants to receive the other diagnostic benefits at no cost,
substantially no cost or at a fixed or defined benefit amount, and
such benefits may be limited based on a time period (e.g., once
per year, twice per year, etc.)
[0043] Fillings and other basic restorative benefits include amalgams,
resin-based composites including resin-based composite crowns, and
gold foil. The benefit payments may be made, for example, directly
to the policy participant or to a service provider. In embodiments
of the invention, the base dental policy may provide for policy
participants to receive the fillings and other basic restorative
benefits at no cost, substantially no cost or at a fixed or defined
benefit amount, and such benefits may be limited based on a time
period (e.g., once per year, twice per year, etc.)
[0044] Crowns and other major restorative benefits include inlays,
onlays, crown repairs, sedative fillings, core buildup, pin retention,
cast or prefabricated post and core, post removal and temporary
crowns. The benefit payments may be made, for example, directly
to the policy participant or to a service provider. In embodiments
of the invention, the base dental policy may provide for policy
participants to receive the crowns and other major restorative benefits
at no cost, substantially no cost or at a fixed or defined benefit
amount, and such benefits may be limited based on a time period
(e.g., once per year, twice per year, etc.)
[0045] Root canals and other endodontic benefits include pulp caps,
pulpal therapy and therapeutic pulpotomy, root canals and treatment,
apexification/recalcification, apicoectomy/periradicular surgery,
retrograde fillings, root amputations, hemisections and canal preparation.
The benefit payments may be made, for example, directly to the policy
participant or to a service provider. In embodiments of the invention,
the base dental policy may provide for policy participants to receive
the root canals and other endodontic benefits at no cost, substantially
no cost or at a fixed or defined benefit amount, and such benefits
may be limited based on a time period (e.g., once per year, twice
per year, etc.)
[0046] Gum treatments/periodontic benefits include gingivectomies
or gingivoplasties, gingival flap procedures, clinical crown lengthening,
mucogingivla surgery, osseous surgery. Bone replacement grafts,
soft tissue grafts, provisional splintings, scaling and root planning,
and mouth debridement. The benefit payments may be made, for example,
directly to the policy participant or to a service provider. In
embodiments of the invention, the base dental policy may provide
for policy participants to receive the gum treatments/periodontic
benefits at no cost, substantially no cost or at a fixed or defined
benefit amount, and such benefits may be limited based on a time
period (e.g., once per year, twice per year, etc.)
[0047] Dentures and other prosthetic benefits include complete,
immediate and partial dentures, denture maintenance, surgical implants
and implant maintenance, pontics, retainers, denture inlays and
onlays, denture crowns, posts and cores. The benefit payments may
be made, for example, directly to the policy participant or to a
service provider. In embodiments of the invention, the base dental
policy may provide for policy participants to receive the dentures
and other prosthetic benefits at no cost, substantially no cost
or at a fixed or defined benefit amount, and such benefits may be
limited based on a time period (e.g., once per year, twice per year,
etc.)
[0048] Repairs and adjustments to prosthetic benefits include adjustments,
replacements, rebasing and relining complete, immediate and partial
dentures, tissue conditioning, and repair or removal of implants.
The benefit payments may be made, for example, directly to the policy
participant or to a service provider. In embodiments of the invention,
the base dental policy may provide for policy participants to receive
the repairs and adjustments to prosthetic benefits at no cost, substantially
no cost or at a fixed or defined benefit amount, and such benefits
may be limited based on a time period (e.g., once per year, twice
per year, etc.)
[0049] Extractions and other oral surgery benefits include coronal
remnants; extractions of an erupted tooth or exposed root; removal
of impacted teeth; surgical removal of teeth or roots; biopsies
of oral tissue; alveoloplasty; vestibuloplasty; excision of lesions,
cysts or tumors (benign or malignant); removal of lateral exostosis,
torus palatinus, torus mandibularis; surgical reduction of osseus
tuberosity; incision and drainage of abscesses; removal of foreign
bodies, tooth fragments, or nonvital bone; open or closed reductions
of the maxilla, mandible and/or zygomatic arch, malar, and alveolus;
frenulectomy; and excision of hyperplastic tissue or pericoronal
gingival. The benefit payments may be made, for example, directly
to the policy participant or to a service provider. In embodiments
of the invention, the base dental policy may provide for policy
participants to receive the extractions and other oral surgery benefits
at no cost, substantially no cost or at a fixed or defined benefit
amount, and such benefits may be limited based on a time period
(e.g., once per year, twice per year, etc.)
[0050] Pain relief and adjunctive services benefits include palliative
treatments; deep sedation/general anesthesia; analgesia, anxiolysis,
nitrous oxide; intravaneous sedation/analgesia; consultation; housed/extended
care facility/hospital call; office visit; and case presentation
and treatment planning. The benefit payments may be made, for example,
directly to the policy participant or to a service provider. In
embodiments of the invention, the base dental policy may provide
for policy participants to receive the pain relief and adjunctive
services benefits at no cost, substantially no cost or at a fixed
or defined benefit amount, and such benefits may be limited based
on a time period (e.g., once per year, twice per year, etc.)
Cosmetic Dental Insurance Benefits
[0051] While generally offered in addition to base benefits (i.e.,
a "rider"), cosmetic dental insurance benefits may also
be offered as a stand-alone policy or in conjunction with a base
or other types of dental insurance policies. Generally, "cosmetic"
as used herein describes services provided to improve the patient's
physical appearance, from which no significant improvement in physiologic
function can be expected, regardless of emotional or psychological
factors. A "rider" as used herein refers to an amendment
to an insurance policy that becomes a part of the insurance contract
and expands or limits the benefits payable. A rider may also be
referred to as an endorsement. Exemplary riders for a base dental
insurance policy include an orthodontic benefit rider and or a cosmetic
benefit rider. The cost or premium of the base dental insurance
policy is generally adjusted in accordance with the number or type
of riders that are provided in addition to the base policy.
[0052] An exemplary cosmetic benefits rider is shown in FIG. 2.
As shown, the cosmetic benefits rider 200 of FIG. 2 is comprised
of a preamble 210, an effective date section 220, a benefits section
230, a termination section 240, and a signature/authorization section
250.
[0053] The preamble 210 introduces the rider 200. The effective
date 220 informs the policyholder of when the policy goes into effect.
The benefits section 230 describes the benefits provided under the
rider 200 and some limitations on those benefits. The termination
section 240 informs the policyholder of when the rider 200 ends.
The signature/authorization section 250 indicates the insurer's
acceptance of the rider 200.
[0054] Below, the benefits section 230 of the exemplary cosmetic
benefit rider 200 of FIG. 2 is reproduced as Table III. It is to
be noted that the benefits shown in Table III, and FIG. 2, are exemplary
in nature and it is to be appreciated that the embodiments of this
invention include a cosmetic benefit rider that may have more, fewer,
and/or different benefits than those illustrated in Table III and
FIG. 2 TABLE-US-00003 TABLE III COSMETIC BENEFITS ADA Benefit Code
Description Level D2960 Labial Veneer (Laminate)--Chairside $200
D2961 Labial Veneer (Resin Laminate)--Laboratory 200 D2962 Labial
Veneer (Porcelain Laminate)Laboratory 200 D3960 Bleaching of discolored
tooth 100 D9951 Occlusion Adjustment--Limited 50 D9952 Occlusion
Adjustment--Complete 225 D9970 Enamel microbrasion 65 D9971 Odontoplasty
one-two teeth 125 D9972 External bleaching--per arch 250 D9973 External
bleaching--per tooth 25 D9974 Internal bleaching--per tooth 100
[0055] A typical cosmetic benefit provides for one or more benefit
payments to be made in response to a policy participant having a
covered treatment performed, as such covered treatments are defined
by the schedule of benefits (e.g., Table III), while coverage is
in force. In Table III (and FIG. 2), the benefits listed are per
covered person. Generally, the treatments must be performed by a
dentist or a dental hygienist. A "dentist" may be defined
for a base dental policy and the rider as a legally qualified person
who is licensed by the state to treat the type of condition for
which a claim is made. And, a "dental hygienist" may be
defined as a legally qualified person who is licensed by the state
to treat the type of condition for which a claim is made. In some
instances, members of a covered party's immediate family are excluded
from the definition of a dentist or a dental hygienist.
[0056] In Table III, and FIG. 2, each benefit is associated with
an American Dental Association (ADA) code to facilitate standardized
description of the treatment and billing. It is to be noted that
this invention can be practiced without the ADA code. Furthermore,
it is to be noted that each benefit is associated with a benefit
level, which is the payment made in response to a policy participant
having a covered treatment performed.
[0057] Benefits may be limited to a lifetime maximum and/or an
annual or "policy year" maximum. For instance, the benefits
section 230 of FIG. 2 indicates that for the exemplary benefits
shown, the lifetime maximum is $1,800 per policy and the maximum
amount payable under the rider 200 is $600 per policy year.
[0058] As shown in Table III, exemplary cosmetic dental insurance
benefits include (teeth) veneers, such as labial veneers, that are
comprised of laminates, resin laminates, porcelain laminates, or
combinations thereof. The benefit payments may be made, for example,
directly to the policy participant or to a service provider. In
embodiments of the invention, the cosmetic dental policy may provide
for policy participants to receive the veneer benefits at no cost,
substantially no cost or at a fixed or defined benefit amount, and
such benefits may be limited based on a time period (e.g., once
per year, twice per year, etc.) Other cosmetic benefits include
occlusion adjustments, enamel microbrasions, odontoplasty, and bleaching
of the teeth. As above, benefit payments may be made, for example,
directly to the policy participant or to a service provider. In
embodiments of the invention, the cosmetic dental policy may provide
for policy participants to receive the benefits at no cost, substantially
no cost or at a fixed or defined benefit amount, and such benefits
may be limited based on a time period (e.g., once per year, twice
per year, etc.)
Issuing Policy
System Architecture
[0059] FIG. 3 shows a block diagram of a system for issuing a cosmetic
dental policy 100 in accordance with various embodiments of the
present invention. As may be understood from this figure, the system
100 may include a prospective policy participant 20 in contact with
a salesperson 30 having a computing device 40, into which the salesperson
30 can enter Applicant data received from the prospective policy
participant 20. As can be appreciated by one of ordinary skill in
the art, the computing device 40 may be any type of computing device,
including, for example, a mobile telephone, personal data assistant
(PDA), laptop or mobile personal computer (PC), desktop unit, or
workstation.
[0060] The system further includes an office 50 in communication
with the handheld device 40, and an Insurance Company computer 60
in communication with the office 50. The office 50, which may be
operated directly by the Insurance Company or by some other entity
affiliated with the Insurance Company, includes at least an interface
55 to facilitate the communication of Applicant data between the
handheld device 40 and the Insurance Company computer 60. The interface
55 may be any known interface including, for example, a docking
station that is connected to an IT infrastructure, such as a Local
Area Network (LAN), Wide Area Network (WAN), or the Internet. Data
can, therefore, be communicated from the office 50 to the Insurance
Company computer 60 via any known means of communicating data including,
for example, via the Internet, via a cable connection, by fax, via
a telephone network, or even by a human operator located at the
office 50.
[0061] Alternatively, the computing device 40 can be configured
to communicate with the insurance company computer 60 directly without
the need for office 50 and the interface 55. The computing device
40 can communicate with the Insurance Company computer 60 via a
communications network such as the Internet, WAN, one or more LANs,
wireless network, cellular network, etc.
[0062] The Insurance Company computer 60 includes at least a cosmetic
dental insurance policy issuance module 62. The module 62 can be
configured to retrieve data from, and store data to, a database
64. As shown, policy data 65, Applicant data 66 and business rules
67 can each be stored in the database 64 and accessed by the cosmetic
dental insurance policy issuance module 62.
[0063] FIG. 4 shows an exemplary schematic diagram of the Insurance
Company computer 60 according to one embodiment of the invention.
The Insurance Company computer 60 includes a processor 210 that
communicates with other elements within the Insurance Company computer
60 via a system interface or bus 220. The processor 210 could be,
for example, a central processing unit, microprocessor, microcontroller,
programmable gate array, or some other device that processes data.
Also included in the Insurance Company computer 60 is a display
device/input device 230 for receiving and displaying data. The unit
230 may include, for example, an input device such as a keyboard,
mouse or pointing device, and a display device such as a monitor,
cathode ray tube (CRT), liquid crystal display (LCD), or other such
device. The Insurance Company computer 60 further includes a memory
240, which includes both random access memory (RAM) 245 and read
only memory (ROM) 247. The computer's ROM 247 is used to store a
basic input/output system 248 (BIOS), containing the basic routines
that help to transfer information between elements within the Insurance
Company computer 60. The computer's RAM 245 is used to store the
policy data 65, Applicant data 66 and business rules 67.
[0064] In addition, the Insurance Company computer 60 includes
at least one storage device 250, such as a hard disk drive, a floppy
disk drive, a CD-ROM drive, or optical disk drive, for storing information
on various computer-readable media, such as a hard disk, a removable
magnetic disk, or a CD-ROM disk. As will be appreciated by one of
ordinary skill in the art, each of these storage devices 250 is
connected to the system bus 220 by an appropriate interface. The
storage devices 250 and their associated computer-readable media
provide nonvolatile storage for a personal computer. It is important
to note that the computer-readable media described above could be
replaced by any other type of computer-readable media known in the
art. Such media include, for example, magnetic cassettes, flash
memory cards, digital video disks, and Bernoulli cartridges.
[0065] A number of program modules may be stored by the various
storage devices 250 and within RAM 245. Such program modules include
an operating system 260, and the cosmetic dental insurance policy
issuance module 270. The cosmetic dental insurance issuance module
270 controls certain aspects of the operation of the Insurance Company
computer 60, as is described in more detail below, with the assistance
of the processor 210 and the operating system 260.
[0066] Also located within the Insurance Company computer 60 is
a network interface 280, for interfacing and communicating with
other elements of a computer network. It will be appreciated by
one of ordinary skill in the art that one or more of the Insurance
Company computer 60 components may be located geographically remotely
from other Insurance Company computer 60 components. Furthermore,
one or more of the components may be combined, and additional components
performing functions described herein may be included in the Insurance
Company computer 60.
[0067] FIG. 5 shows an exemplary schematic diagram of the Computing
Device 40 according to one embodiment of the invention. The Computing
Device 40 is used by the prospective policy participant 20 or the
salesperson 30, or both, to receive Applicant data 66 and to transfer
the same to the Insurance Company computer 60. The elements of the
Computing Device 40 shown in FIG. 5 are the same or similar to corresponding
elements of the Insurance Company computer 60 shown in FIG. 4, with
a few exceptions. In particular, the Computing Device 40 includes
a processor 310 that communicates with other elements within the
Computing Device 40 via a system interface or bus 320, a display
device/input device 330 for receiving and displaying data, a memory
340, which includes both random access memory (RAM) 345 and read
only memory (ROM) 347, wherein the ROM 347 is used to store a basic
input/output system 348 (BIOS) and the RAM 345 is used to at least
temporarily store policy data 65 and applicant data 66, at least
one storage device 350, and a network interface 380, for interfacing
and communicating with other elements of a computer network.
[0068] Like the Insurance Company computer 60, a number of program
modules may be stored by the various storage devices 350 and within
RAM 345. Such program modules include an operating system 360, and
an applicant data processing module 370. The applicant data processing
module 370 controls certain aspects of the operation of the Computing
Device 40, as is described in more detail below, with the assistance
of the processor 310 and the operating system 360.
Method of Issuing Cosmetic Dental Insurance Policy
[0069] FIG. 6A illustrates the steps taken when issuing the above
described cosmetic dental insurance policy according to one embodiment
of the present invention. As shown, in one embodiment the process
of issuing a cosmetic dental insurance policy begins at Step 602
in which a salesperson collects Applicant data 66 from a prospective
policy participant and enters it into his or her computing device
40. In Step 604, the salesperson transmits the Applicant data 66
from the computing device 40 to the Insurance Company computer 60
using the application data processing module 370 on the computing
device 40. The Applicant data collected may include, for example,
the prospective policy participant's name, address or medical history,
and/or other types of insurance coverage owned by the prospective
policy participant.
[0070] In other embodiments, the process could likewise begin with
a prospective policy participant entering his or her own Applicant
data directly into an application form provided by the Insurance
Company, and sending the application form to the Insurance Company.
The application form could be in hard copy, requiring, for example,
that the prospective policy participant enter the Applicant data
by hand, and then mail or fax the form to the Insurance Company.
The Applicant data could then be entered into the Insurance Company
computer 60 by, for example, an Insurance Company employee. Alternatively,
the application form could be provided over the Internet on a website
operated by the Insurance Company, or by some other company affiliated
with the Insurance Company. In this case the prospective policy
participant could merely enter the data into the online version
of the application form and then send the data electronically to
the Insurance Company computer 60. In yet another embodiment, the
prospective policy participant may contact an Insurance Company
operator directly, by telephone or by other means, and communicate
the Applicant data to the operator, the data is then into the Insurance
Company computer 60 by the operator or another associated individual.
[0071] Once the Insurance Company computer 60 has received the
Applicant data 66, in Step 606, the Insurance Company computer 60
stores the Applicant data 66 in a database 64 on the Insurance Company
computer 60. The cosmetic dental insurance policy issuance module
62 then applies business rules 67, which are also stored in the
database 64 on the Insurance Company computer 60, to the Applicant
data 66 to determine whether the prospective policy participant
qualifies for the cosmetic dental insurance policy (Step 608). This
may include, for example, checking the applicant's name and address
to determine whether they are valid, authenticating the applicant
to ensure that the applicant is who he/she claims to be, determining
whether the applicant is financially responsible based on a credit
or payment history check, for example, determining whether the applicant's
medical/dental history and status are within risk parameters of
the policy, determining whether the applicant has pre-existing conditions
that should be excluded from policy coverage, determining whether
the applicant is of legal age to enter a binding contract in the
State in which a policy is sought, etc. Furthermore, if the cosmetic
dental insurance policy is a rider to a base dental insurance policy,
business rules may be invoked to determine whether the applicant's
base policy is in effect and whether there are any outstanding premiums
or other issues that may affect coverage.
[0072] If the Insurance Company computer 60 determines that the
applicant is not qualified for the policy based on the applicant
data 66 and business rules 67, then the Insurance Company computer
60 rejects the application. Conversely, upon a determination by
the Insurance Company computer 60 that the prospective policy participant
qualifies for the cosmetic dental insurance policy, in Step 610
the Insurance Company issues the cosmetic dental insurance policy
to the policy participant by, for example, generating policy data
65 that is specific to the prospective policy participant, storing
the policy data 65 in the database 64, and transmitting the policy
data 65 to the policy participant. The policy data 65 may be sent,
for example, electronically, by mail, by fax or delivered by hand,
to the policy participant directly, or via the salesperson.
[0073] FIG. 6B illustrates the steps taken when issuing a cosmetic
dental insurance policy or a cosmetic dental rider to a base dental
insurance policy according to one embodiment of the present invention.
As shown, in the embodiment of FIG. 6B, the process of issuing a
cosmetic dental insurance policy begins at Step 612 in which a salesperson
collects Applicant data 66 from a prospective policy participant
and enters it into his or her computing device 40. In Step 614,
the salesperson transmits the Applicant data 66 from the computing
device 40 to the Insurance Company computer 60 using the application
data processing module 370 on the computing device 40. The Applicant
data collected may include, for example, the prospective policy
participant's name, address or medical history, and/or other types
of insurance coverage owned by the prospective policy participant.
[0074] In other embodiments, the process likewise begins with a
prospective policy participant entering his or her own Applicant
data directly into an application form provided by the Insurance
Company, and sending the application form to the Insurance Company.
The application form could be in hard copy, requiring, for example,
that the prospective policy participant enter the Applicant data
by hand, and then mail or fax the form to the Insurance Company.
The Applicant data could then be entered into the Insurance Company
computer 60 by, for example, an Insurance Company employee. Alternatively,
the application form could be provided over the Internet on a website
operated by the Insurance Company, or by some other company affiliated
with the Insurance Company. In this case the prospective policy
participant could merely enter the data into the online version
of the application form and then send the data electronically to
the Insurance Company computer 60. In yet another embodiment, the
prospective policy participant may contact an Insurance Company
operator directly, by telephone or by other means, and communicate
the Applicant data to the operator, the data is then entered into
the Insurance Company computer 60 by the operator or another associated
individual.
[0075] Once the Insurance Company computer 60 has received the
Applicant data 66, in Step 616, the Insurance Company computer 60
stores the Applicant data 66 in a database 64 on the Insurance Company
computer 60. At Step 618, from the Applicant data 66, the cosmetic
dental insurance policy issuance module determines whether the applicant
has a qualified base dental insurance policy. "Qualified,"
in this sense, means a base dental insurance policy for which the
issuer is willing to issue a cosmetic dental insurance rider policy
(see FIG. 2). If the applicant does have a qualified base dental
insurance policy, then the process goes to Step 620. The cosmetic
dental insurance policy issuance module 62 then applies business
rules 67, which are also stored in the database 64 on the Insurance
Company computer 60, to the Applicant data 66 to determine whether
the prospective policy participant qualifies for the cosmetic dental
insurance rider policy (Step 620). This may include, for example,
checking the applicant's name and address to determine whether they
are valid, authenticating the applicant to ensure that the applicant
is who he/she claims to be, determining whether the applicant is
financially responsible based on a credit or payment history check,
for example, determining whether the applicant's medical/dental
history and status are within risk parameters of the policy, determining
whether the applicant has pre-existing conditions that should be
excluded from policy coverage, determining whether the applicant
is of legal age to enter a binding contract in the State in which
a policy is sought, etc. Business rules may be invoked to determine
whether the applicant's base policy is in effect and whether there
are any outstanding premiums or other issues that may affect coverage.
[0076] If the Insurance Company computer 60 determines that the
applicant is not qualified for the rider policy based on the applicant
data 66 and business rules 67, then the Insurance Company computer
60 rejects the application. Conversely, upon a determination by
the Insurance Company computer 60 that the prospective policy participant
qualifies for the cosmetic dental insurance rider policy, in Step
622 the Insurance Company issues the cosmetic dental insurance rider
policy to the policy participant by, for example, generating policy
data 65 that is specific to the prospective policy participant,
storing the policy data 65 in the database 64, and transmitting
the policy data 65 to the policy participant. The policy data 65
may be sent, for example, electronically, by mail, by fax or delivered
by hand, to the policy participant directly, or via the salesperson.
The process then ends at Step 624.
[0077] If, at Step 618, the applicant does not have a qualified
base dental insurance policy, then the process goes to Step 626.
At Step 626 it is determined whether the applicant wants to apply
for a qualifying base dental insurance policy. If so, then the process
goes to Step 628. At Step 628, the cosmetic dental insurance policy
issuance module 62 applies business rules 67, which are also stored
in the database 64 on the Insurance Company computer 60, to the
Applicant data 66 to determine whether the prospective policy participant
qualifies for a qualified base dental insurance policy. This may
include, for example, checking the applicant's name and address
to determine whether they are valid, authenticating the applicant
to ensure that the applicant is who he/she claims to be, determining
whether the applicant is financially responsible based on a credit
or payment history check, for example, determining whether the applicant's
medical/dental history and status are within risk parameters of
the policy, determining whether the applicant has pre-existing conditions
that should be excluded from policy coverage, determining whether
the applicant is of legal age to enter a binding contract in the
State in which a policy is sought, etc.
[0078] If the Insurance Company computer 60 determines that the
applicant is not qualified for the base policy based on the applicant
data 66 and business rules 67, then the Insurance Company computer
60 rejects the application. Conversely, upon a determination by
the Insurance Company computer 60 that the prospective policy participant
qualifies for the base dental insurance policy, in Step 630 the
Insurance Company issues the base dental insurance policy to the
policy participant by, for example, generating policy data 65 that
is specific to the prospective policy participant, storing the policy
data 65 in the database 64, and transmitting the policy data 65
to the policy participant. The policy data 65 may be sent, for example,
electronically, by mail, by fax or delivered by hand, to the policy
participant directly, or via the salesperson. The process then goes
to Steps 620 and 630, where the applicant is issued a cosmetic dental
insurance rider policy, as described above. The process then ends
at Step 624.
[0079] If, at Step 626, it is determined that the applicant does
not want to apply for a qualifying base dental insurance policy
then, in one embodiment of the invention, the applicant may be issued
a stand-alone cosmetic dental insurance policy beginning at Step
632. At Step 632, the cosmetic dental insurance policy issuance
module 62 applies business rules 67, which are also stored in the
database 64 on the Insurance Company computer 60, to the Applicant
data 66 to determine whether the prospective policy participant
qualifies for a cosmetic dental insurance policy. This may include,
for example, checking the applicant's name and address to determine
whether they are valid, authenticating the applicant to ensure that
the applicant is who he/she claims to be, determining whether the
applicant is financially responsible based on a credit or payment
history check, for example, determining whether the applicant's
medical/dental history and status are within risk parameters of
the policy, determining whether the applicant has pre-existing conditions
that should be excluded from policy coverage, determining whether
the applicant is of legal age to enter a binding contract in the
State in which a policy is sought, etc.
[0080] If the Insurance Company computer 60 determines that the
applicant is not qualified for the stand-alone policy based on the
applicant data 66 and business rules 67, then the Insurance Company
computer 60 rejects the application. Conversely, upon a determination
by the Insurance Company computer 60 that the prospective policy
participant qualifies for the cosmetic dental insurance policy,
in Step 634 the Insurance Company issues the cosmetic dental insurance
policy to the policy participant by, for example, generating policy
data 65 that is specific to the prospective policy participant,
storing the policy data 65 in the database 64, and transmitting
the policy data 65 to the policy participant. The policy data 65
may be sent, for example, electronically, by mail, by fax or delivered
by hand, to the policy participant directly, or via the salesperson.
The process then goes to Steps 620 and 630, where the applicant
is issued a cosmetic dental insurance rider policy, as described
above. The process then ends at Step 624.
Claim Processing
System Architecture
[0081] FIG. 7 shows a block diagram of a system 700 for processing
a cosmetic dental insurance policy claim in accordance with various
embodiments of the present invention. As may be understood from
this figure, the system 700 may include one or more policy participant
computers 710, 720 that are connected, via a network 730 (e.g.,
a Local Area Network (LAN), wide area network (WAN), Internet, etc.),
to a Claim Processing Server 750. In one embodiment, the Claim Processing
Server 750 is configured to retrieve data from, and store data to,
a database 740 that may be stored on (or, alternatively, stored
remotely from) the Claim Processing Server 750.
[0082] FIG. 8 shows a schematic diagram of the Claim Processing
Server 750 according to one embodiment of the invention. The elements
of the Claim Processing Server 750 shown in FIG. 8 are the same
or similar to corresponding elements of the Insurance Company computer
60 shown in FIG. 4 and of the Computing Device 40 shown in FIG.
5, with a few exceptions. In particular, the Claim Processing Server
750 includes a processor 810 that communicates with other elements
within the Claim Processing Server 750 via a system interface or
bus 820, a display device/input device 830 for receiving and displaying
data, a memory 840, which includes both random access memory (RAM)
845 and read only memory (ROM) 847, wherein the ROM 847 is used
to store a basic input/output system 848 (BIOS), at least one storage
device 850, and a network interface 880, for interfacing and communicating
with other elements of a computer network.
[0083] Like the Insurance Company computer 60 and the Computing
Device 40, a number of program modules may be stored by the various
storage devices 850 and within RAM 845. Such program modules include
an operating system 860, and a claim processing module 870. The
claim processing module 870 controls certain aspects of the operation
of the Claim Processing Server 750, as is described in more detail
below, with the assistance of the processor 810 and the operating
system 860.
Method of Processing Cosmetic Dental Insurance Policy Claim
[0084] FIG. 9 depicts a process of the Claim Processing Module
870 according to one embodiment of the invention. In general, this
figure illustrates the steps taken when processing a claim received
from a cosmetic dental insurance policy participant according to
various embodiments of the present invention. As may be understood
from this figure, the process begins at Step 902 in which the Claim
Processing Module 870 on the Claim Processing Server 750 receives
a dental insurance policy claim. As will be understood by those
of skill in the art, the claim may have been communicated by the
policy participant, for example, by telephone, mail, fax, or network
(e.g., the Internet) by electronic, optical, or wireless media,
for example. Once received, the Claim Processing Module 870, in
one embodiment, first determines, based on the claim received, whether
the claim is received from a Policy Participant at Step 904. If
it is determined at Step 904 that the claim is from a Policy Participant,
then at Step 906 it is determined whether the Policy Participant
has incurred an expense for a routine dental procedure, which may
include, for example, expenses associated with procedures described
in Tables I and II, above. The Policy Participant may prove that
it has incurred the expense by submitting, along with the claim
for reimbursement, an invoice or statement of services rendered
by the dentist, dental hygienist, or other qualified dentistry service
provider. In other embodiments, the Insurance Company can receive
and store in a database accessible to the Claim Processing Module
870 data that reflects expenses incurred by policy participants
directly from cosmetic dental care service providers. By using the
claim information, the Claim Processing Module 870 can check the
database to determine whether the expense for the service was incurred
by the Policy Participant. If, at Step 904 it is determined that
the claim is not received from a policy participant, then the process
goes to Step 916 where it ends.
[0085] If, at Step 906, it is found that the Policy Participant
has in fact incurred one of the routine dental procedure expenses
(e.g., Tables I and II, above) covered by the base dental insurance
policy, the Claim Processing Module 870, in one embodiment, determines
that the Insurance Company is to provide, in Step 908, at least
partial reimbursement to the policy participant for the expenses
incurred. The amount of reimbursement and the extent that these
expenses are covered varies for different embodiments of the present
invention. For example, in one embodiment, if the policy participant
has only a base dental insurance policy, then the policy participant
is not reimbursed for any expenses incurred when undergoing a cosmetic
procedure; while in other embodiments, if the policy participant
has a cosmetic dental rider or a cosmetic dental insurance policy,
the participant may receive partial or full reimbursement for such
expenses, as further described herein. If, at Step 906, it is determined
that the policy participant incurred expenses for other than covered
routine dental care, then the process goes to Step 912, further
described below.
[0086] After payment (or partial payment) of the expenses at Step
908, the process goes to Step 910. At Step 910, the Claim Processing
Module 870 determines whether there are any other expenses associated
with the claim that were not for routine dental care. If, at Step
910, there are no additional expenses associated with the claim,
then the process of the Claims Processing Module 870 goes to Step
916, at which the process ends. If, at Step 910, there are additional
expenses with the claim, then the process goes to Step 912 where
it is determined whether the policy participant participates in
a cosmetic dental insurance policy or a cosmetic dental rider.
[0087] If, at Step 912, the policy participant does participate
in a cosmetic dental insurance policy, then the process goes to
Step 914. If, at Step 912, it is determined that the policy participant
does not participate in a cosmetic dental insurance policy, then
the process goes to Step 916, at which it ends.
[0088] At Step 914 it is determined whether the policy participant
has received a procedure for which coverage is provided by the cosmetic
dental insurance policy. Exemplary procedures that are covered by
the cosmetic dental insurance policy may include, for example, those
procedures listed in Table III. If the policy participant has received
one or more of the covered procedures, the Claim Processing Module
870 determines that the Insurance Company is to make, in Step 908,
one or more cosmetic dental insurance benefit payments to the policy
participant. In one embodiment, the one or more cosmetic dental
insurance benefit payments include a payment of a pre-defined amount
(e.g., $1000).
[0089] If it is determined that the policy participant has not
incurred expenses for routine dental care or cosmetic dental care,
the claim received is not valid and a denial letter is generated,
after which the process ends (shown in Step 916).
[0090] As will be understood by those of ordinary skill in the
art, the steps of process described above need not be performed
in the order in which they are described above. For instance, it
is not necessary that the Claim Processing Module 870 determine
whether the policy participant has received routine dental care
before determining whether the policy participant has received cosmetic
dental procedures, as long as the necessary determinations are made
to assess what benefits the policy participant should receive.
Modifications and Alternative Embodiments
[0091] Many modifications and other embodiments of the invention
will come to mind to one skilled in the art to which this invention
pertains having the benefit of the teachings presented in the foregoing
descriptions. Accordingly, it should be understood that the invention
is not to be limited to the specific embodiments disclosed and that
modifications and other embodiments are intended to be included
within the scope of the appended exemplary inventive concepts. Although
specific terms are employed herein, they are used in a generic and
descriptive sense only and not for purposes of limitation.
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