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Insurance Abstract
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.
Insurance Claims
1. A method of processing an insurance claim such method comprising
the steps of: storing in memory plural sets of keywords, wherein
each set of keywords is associated with at least one of a plurality
of policy types and wherein the keywords in said plural set of keywords
are descriptive of damages covered by the plurality of policy types;
receiving a claim from an insured through an Internet connection
wherein the received claim contains a description of loss for determining
a who, what and why about how the loss occurred; determining a policy
type of the plurality of policy types from said received claim;
identifying an insurance criteria based on said determined policy
type for evaluating the loss, wherein the insurance criteria is
based upon insuring agreements, exclusions, coverage limits and
terms and conditions selected from the group consisting of all risk
of loss, named perils, accident to object, supplemental coverage,
consequential loss, coverage extensions, exclusions, limitations
and property not covered or limited; retrieving from said memory
a predetermined set of that are associated with said determined
policy type and with said identified insurance criteria; matching
said retrieved set of keywords with words contained within the description
of loss of said received and assigning the claim to an adjuster
when any matched words of said matching step meets a predetermined
criteria; and paying the claim without assigning the claim to an
adjuster when said matching step does not meet the predetermined
criteria and any auxiliary criteria.
2. The method of processing said claim as in claim 1 further comprising
defining the predetermined criteria as a match between any word
of the retrieved set of keywords and any word within said received
claim.
3. The method of processing said claim as in claim 2 wherein the
matching step further comprises selecting a description of how a
loss occurred and matching said retrieved set of keywords with a
text of said description.
4. The method of processing said claim as in claim 2 wherein the
matching step further comprises retrieving and matching a set of
keywords of covered property and property not covered.
5. The method of processing said claim as in claim 1 further comprising
defining the predetermined criteria as an absence of a match between
any keyword of covered property, property not covered and/or exclusions
and any word within the received claim.
6. The method of processing said claim as in claim 5 wherein the
matching step further comprises selecting a description of how a
loss occurred and matching the retrieved set of keywords with a
text of that description.
7. The method of processing said claim as in claim 5 wherein the
matching step further comprises selecting a description of building
damage and matching the retrieved set of keywords with a text of
the description.
8. The method of processing said claim as in claim 1 further comprising
assigning the claim to an adjuster and/or investigator and/or other
vendor/entity when the claim indicates that a third or other party
may be responsible.
9. The method of processing said claim as in claim 1 further comprising
assigning the claim to an adjuster and/or other vendors/resources
when the claim indicates that emergency services are required.
10. The method of processing said claim as in claim 1 further comprising
assigning the claim to an adjuster and/or investigator and/or other
vendor/entity when the claim indicates potential employee dishonesty.
11. The method of processing said claim as in claim 1 further comprising
assigning the claim to an adjuster when the policy type and/or keyword
matching/mismatching indicates a claim for damages with no coverage
and/or a different deductible than claimed.
12. The method of processing said claim as in claim 1 further comprising
assigning the claim to an adjuster when the claim indicates that
a time period greater than a predetermined threshold has passed
since the loss occurred/date of loss.
13. The method of processing said claim as in claim 1 further comprising
assigning the claim to an adjuster when the claim indicates that
it exceeds a predetermined set of criteria for the number of claims
previously submitted for a predetermined time period.
14. The method of processing said claim as in claim 1 further comprising
assigning the claim to an adjuster or investigator when the claim
meets a predetermined criteria used to identify potential fraudulent
claims.
15. The method of processing said claim as in claim 1 further comprising
assigning the claim to an adjuster when a total dollar value of
the claim and/or subtotals exceed predetermined threshold limit
values for building, personal property and/or expense.
16. The method of processing said claim as in claim 1 further comprising
assigning the claim to an adjuster when the a time period between
the loss and completion of a damages and/or proof of loss section
of the claim exceeds a predetermined time threshold value.
17. The method of processing said claim as in claim 1 further comprising
providing an online record, log and report allowing review of the
claim and processing of payment or assigning an adjuster and further
allowing servers/computers to exchange and query data to automate
the payment and assignment process.
18. An apparatus for processing an insurance claim related to property
damage on a property and casualty insurance policy, except personal
automobile and commercial automobile, as defined by the NAIC Uniform
Property and Casualty Product Coding Matrix, such apparatus comprising:
plural sets of keywords stored in memory, wherein each set of keywords
is associated with at least one policy type and wherein the keywords
in said plural set of keywords are descriptive damages covered by
the at least one policy type; means for receiving a claim from an
insured for a loss to property, but not automobile property and
not a health care claim, through an Internet connection wherein
the received claim contains a description of loss for determining
a who, what and why about how the loss occurred; means for determining
a policy type from said received claim; means for identifying an
insurance criteria based upon said determined policy type for evaluating
the loss, wherein the insurance criteria is based upon insuring
agreements, exclusions, coverage limits and terms and conditions
selected from the group consisting of all risk of loss, named perils,
accident to object, supplemental coverage, consequential loss, coverage
extensions, exclusions, limitations and property not covered or
limited; means for retrieving from said memory a predetermined set
of keywords that are associated with said determined policy type
and with said identified insurance criteria; means for matching
said retrieved set of keywords with words contained within the description
of loss of said received claim; means for assigning the claim to
an adjuster when the words matched by said means for matching meet
a predetermined criteria; and means for paying the claim without
assigning the claim to an adjuster when the matched words do not
meet the predetermined criteria.
19. The apparatus for processing said claim as in claim 18 wherein
the predetermined criteria further comprises a match between any
word of the retrieved set of keywords and any word within said received
claim.
20. The apparatus for processing said claim as in claim 19 wherein
means for matching further comprises means for selecting a description
of how a loss occurred and matching said retrieved set of keywords
with a text of that description of how the loss occurred.
21. The apparatus for processing said claim as in claim 19 wherein
the means for matching further comprises means for selecting a set
of keywords of covered property, property not covered and/or exclusions.
22. The apparatus for processing said claim as in claim 18 further
comprising defining the predetermined criteria as the absence of
a match between any word of the retrieved set of keywords for property
not covered covered proper, exclusions and any word within the received
claim.
23. The apparatus for processing said claim as in claim 22 wherein
the means for matching further comprises means for selecting a description
of how a loss occurred and matching the retrieved set of keywords
with a text of that description.
24. The apparatus for processing said claim as in claim 22 wherein
the means for matching further comprises means for selecting a description
of building damage and matching the retrieved sets of keywords with
a text of that description.
25. The apparatus for processing said claim as in claim 18 further
comprising means for assigning the claim to an adjuster and/or investigator
and/or other vendor/entity when the claim indicates that a third
or other party may be responsible.
26. The apparatus for processing said claim as in claim 18 further
comprising means for assigning the claim to an adjuster and/or other
vendors/resources when the claim indicates that emergency services
are required.
27. The apparatus for processing said claim as in claim 18 further
comprising means for assigning the claim to an adjuster and/or investigator
and/or other vendor/entity when the claim indicates potential employee
dishonesty.
28. The apparatus for processing said claim as in claim 18 further
comprising means for assigning the claim to an adjuster when the
policy type indicates a claim for damages with no coverage and/or
a different deductible than claimed.
29. The apparatus for processing said claim as in claim 18 further
comprising means for assigning the claim to an adjuster when the
claim indicates that a time period greater than a predetermined
threshold has passed since the loss occurred.
30. The apparatus for processing said claim as in claim 18 further
comprising means for assigning the claim to an adjuster when the
claim indicates that it exceeds a predetermined set of criteria
for the number of claims submitted for a predetermined time period.
31. The apparatus for processing said claim as in claim 18 further
comprising means for assigning the claim to an adjuster when the
claim meets a predetermined criteria used to identify potential
fraudulent claims.
32. The apparatus for processing said claim as in claim 18 further
comprising means for assigning the claim to an adjuster when a total
dollar value of the claim and/or subtotals exceed predetermined
threshold limit values for building, personal property and/or expense.
33. The apparatus for processing said claim as in claim 18 further
comprising means for assigning the claim to an adjuster when the
a time period between the loss and completion of a damages and/or
proof of loss section of the claim exceeds a predetermined time
threshold value.
34. The apparatus for processing said claim as in claim 18 further
comprising means for providing an online record, log and report
allowing review of the claim and processing of payment or assigning
an adjuster and further allowing servers/computers to exchange and
query data to automate said claim payment and assignment process.
35. An apparatus for processing an insurance claim related to property
damage on a property and casualty insurance policy, except personal
automobile and commercial automobile, as defined by the NAIC Uniform
Property and Casualty Product Coding Matrix, such apparatus comprising:
plural sets of keywords stored in memory, wherein each set of keywords
is associated with at least one policy type and wherein the keywords
in said plural set of keywords are descriptive damages covered by
the at least one policy type; a website adapted to receive a claim
from an insured for a loss to property, but not automobile property
and not a health care claim, through an Internet connection wherein
the received claim contains a description of loss for determining
a who, what and why about how the loss occurred; a policy processor
adapted to determine a policy type from said received claim; said
policy processor being further adapted to identify an insurance
criteria based upon the determined policy type for evaluating the
loss, wherein the insurance criteria is based upon insuring agreements,
exclusions, coverage limits and terms and conditions selected from
the group consisting of all risk of loss, named perils, accident
to object, supplemental coverage, consequential loss, coverage extensions,
exclusions, limitations and property not covered or limited; a predetermined
set of keywords retrieved from said memory that are associated with
said determined policy type and with said identified insurance criteria;
a matching processor adapted to match said retrieved set of keywords
with words contained within the description of loss of said received
claim a criteria processor adapted to assign said received claim
to an adjuster when the words matched by the matching processor
meet a predetermined criteria; and a payment processor adapted to
authorize payment of the claim without assigning the claim to an
adjuster when the matched words does not meet the predetermined
criteria and any auxiliary criteria.
36. The apparatus for processing said claim as in claim 35 wherein
the predetermined criteria further comprises a match between any
word of the retrieved set of keywords and a word within said received
claim.
37. The apparatus for processing said claim as in claim 35 wherein
the words contained within the received claim matched by the matching
processor further comprises a description of how a loss occurred.
38. The apparatus for processing said claim as in claim 35 wherein
the set of keywords further comprises a set of keywords that describe
covered property, property not covered, exclusions and any word
within said received claim.
39. The apparatus for processing said claim as in claim 35 wherein
the predetermined criteria used by the criteria processor further
comprises the absence of a match between any word of the retrieved
set of keywords and any word within the received claim.
40. The apparatus for processing said claim as in claim 39 wherein
the words contained within the received claim matched by the matching
processor further comprises a description of how a loss occurred.
41. The apparatus for processing said claim as in claim 35 wherein
the words contained within the received claim matched by the matching
processor further comprises description of building damage and matching
the retrieved set of keywords with a text of the description.
42. The method of processing said claim as in claim 1 further comprising
an insured and claimants, including their agents, brokers and others
submitting claims under a number of different formats including
but not limited to, commercial lines, personal lines insurance,
self insurance which includes self insured retentions, and deductibles.
43. The method of processing said claim as in claim 1 further utilizing
an "Emergency" icon that allows the insured or claimant
to request emergency services across many disciplines including
but not limited to disaster restoration services for fire, water,
smoke, a salver or salvage team, an investigation expert, building
repair contractor, etc. Upon completion of the electronic claim
form an email, text or other electronic message is sent for each
service requested immediately notifying that service vendor to respond
as an emergency.
44. The method of processing said claim as in claim 1 further comprising
utilizing claim forms for various classes of damages including at
least one from the group consisting of: (1) building and tenant
improvement type damages, (2) Contents, merchandise, furniture,
fixtures and equipment, and (3) extra expense, additional living
expense, and in-house labor (4) Sworn Statement in Proof of Loss
and wherein if the claim is accepted and is to be paid or is not
assigned to an adjuster after initially being reported, the adjusting
rules and claim criteria for coverage and damages continue an approval/recommendation
for payment process by pending the claim within a specified time
allowed until the insured or claimant enters all dollar damages
and information/documentation for the various classes of damages
claimed e.g. building, contents, extra expense per the forms online
in the claim submission process.
45. The method of processing said claim as in claim 44 further
comprising the system continuing to use key word matching and mismatching
from the plural sets of keywords stored in memory from the policy
type initially identified once the insured or claimant enters the
damages, which may include entering specific, itemized and detailed
costs for the damages claimed to complete further analysis on the
claim for covered damages, covered property and/or property not
covered.
46. The method of processing said claim as in claim 45 further
comprising the insured entering and completing the claim including
entering classes of damages and when substantially all damages have
been documented with information and dollar damages and estimates
of dollar damages to repair or replace said property, including
any extra expense and loss of net business earning and the total
value of each class of damage along with the date and time of loss,
a detailed description of how the loss occurred is recovered from
the claim data previously entered to create a "Sworn Statement
in Proof of Loss" document which requires the insured or claimant's
electronic signature to subscribe and affirm that all statements
and damages are true and correct to the best of their knowledge
and belief and acknowledge their understanding that making a false
claim may result in serious consequences including denial of the
claim.
47. The apparatus as in claim 18 further comprising an insured
and claimants, including their agents, brokers and others submitting
claims under a number of different formats including but not limited
to, commercial lines, personal lines insurance, self insurance which
includes self insured retentions, and deductibles.
48. The apparatus as in claim 18 further utilizing an "Emergency"
icon that allows the insured or claimant to request emergency services
across many disciplines including but not limited to disaster restoration
services for fire, water, smoke, a salver or salvage team, an investigation
expert, building repair contractor, etc. Upon completion of the
electronic claim form an email, text or other electronic message
is sent for each service requested immediately notifying that service
vendor to respond as an emergency.
49. The apparatus as in claim 18 further comprising utilizing claim
forms for various classes of damages including at least one from
the group consisting of: (1) building and tenant improvement type
damages, (2) Contents, merchandise, furniture, fixtures and equipment,
and (3) extra expense, additional living expense, and in-house labor
(4) Sworn Statement in Proof of Loss and wherein if the claim is
accepted and is to be paid or is not assigned to an adjuster after
initially being reported, the adjusting rules and claim criteria
for coverage and damages continue an approval/recommendation for
payment process by pending the claim within a specified time allowed
until the insured or claimant enters all dollar damages and information/documentation
for the various classes of damages claimed e.g. building, contents,
extra expense per the forms online in the claim submission process.
50. The apparatus as in claim 49 further comprising the system
continuing to use key word matching and mismatching from the plural
sets of keywords stored in memory from the policy type initially
identified once the insured or claimant enters the damages, which
may include entering specific, itemized and detailed costs for the
damages claimed to complete further analysis on the claim for covered
damages, covered property and/or property not covered.
51. The apparatus as in claim 50 further comprising the insured
entering and completing the claim including entering classes of
damages and when substantially all damages have been documented
with information and dollar damages and estimates of dollar damages
to repair or replace said property, including any extra expense
and loss of net business earning and the total value of each class
of damage along with the date and time of loss, a detailed description
of how the loss occurred is recovered from the claim data previously
entered to create a "Sworn Statement in Proof of Loss"
document which requires the insured or claimant's electronic signature
to subscribe and affirm that all statements and damages are true
and correct to the best of their knowledge and belief and acknowledge
their understanding that making a false claim may result in serious
consequences including denial of the claim.
52. The apparatus as in claim 35 further comprising an insured
and claimants, including their agents, brokers and others submitting
claims under a number of different formats including but not limited
to, commercial lines, personal lines insurance, self insurance which
includes self insured retentions, and deductibles.
53. The apparatus as in claim 35 further utilizing an "Emergency"
icon that allows the insured or claimant to request emergency services
across many disciplines including but not limited to disaster restoration
services for fire, water, smoke, a salver or salvage team, an investigation
expert, building repair contractor, etc. Upon completion of the
electronic claim form an email, text or other electronic message
is sent for each service requested immediately notifying that service
vendor to respond as an emergency.
54. The apparatus as in claim 35 further comprising utilizing claim
forms for various classes of damages including at least one from
the group consisting of: (1) building and tenant improvement type
damages, (2) Contents, merchandise, furniture, fixtures and equipment,
and (3) extra expense, additional living expense, and in-house labor
(4) Sworn Statement in Proof of Loss and wherein if the claim is
accepted and is to be paid or is not assigned to an adjuster after
initially being reported, the adjusting rules and claim criteria
for coverage and damages continue an approval/recommendation for
payment process by pending the claim within a specified time allowed
until the insured or claimant enters all dollar damages and information/documentation
for the various classes of damages claimed e.g. building, contents,
extra expense per the forms online in the claim submission process.
55. The apparatus as in claim 54 further comprising the system
continuing to use key word matching and mismatching from the plural
sets of keywords stored in memory from the policy type initially
identified once the insured or claimant enters the damages, which
may include entering specific, itemized and detailed costs for the
damages claimed to complete further analysis on the claim for covered
damages, covered property and/or property not covered.
56. The apparatus as in claim 55 further comprising the insured
entering and completing the claim including entering classes of
damages and when substantially all damages have been documented
with information and dollar damages and estimates of dollar damages
to repair or replace said property, including any extra expense
and loss of net business earning and the total value of each class
of damage along with the date and time of loss, a detailed description
of how the loss occurred is recovered from the claim data previously
entered to create a "Sworn Statement in Proof of Loss"
document which requires the insured or claimant's electronic signature
to subscribe and affirm that all statements and damages are true
and correct to the best of their knowledge and belief and acknowledge
their understanding that making a false claim may result in serious
consequences including denial of the claim.
Insurance Description
FIELD OF THE INVENTION
[0001] The field of the invention relates to the insurance industry
and more particularly to the payment of claims on insurable losses.
BACKGROUND OF THE INVENTION
[0002] The insurance industry exists for the purpose of protecting
clients from unexpected losses. Typically, an insurance actuary
calculates (or estimates) the probability and frequency of a loss,
adds a safety margin and then charges a premium based upon the calculated
probabilities.
[0003] On the average, insurance companies are profitable based
upon their ability to accurately calculate the probability and frequency
of losses and upon their ability to efficiently process claims.
To efficiently process claims, an insurance company must be able
to detect and recognize fraudulent claims without interfering with
the processing of valid claims.
[0004] It has been generally recognized that fraudulent claims
form a very small portion of the total claims filed in any given
time period. In addition, when a small amount of money is involved,
insurance companies frequently find that it is more cost effective
to pay claims rather than to investigate such claims.
[0005] In general, the greatest number of property claims consists
of small claims. It has been recognized by experts in property claims
that approximately 75% of all property claims submitted to the insurance
and risk management industry are under $25,000. Of this, approximately
50% are under $15,000 and 25% are under $10,000. There are hundreds
of millions of property claims reported and settled each year totaling
billions of dollars.
[0006] Typically a claim is reported to the agent or insurance
company over the phone or faxed into the company. The claim is matched
to the coverage and assigned to an adjuster. That adjuster will
investigate the claim, document the cause of loss, confirm that
the loss is covered, adjust and pay the claim, if covered. The expense
associated with this process is referred to in the industry as the
loss adjustment expense.
[0007] An insurance company's combined ratio is the dollar value
of the loss (called severity) plus the loss adjustment expense.
The industry strives for a combined ratio under $1.00, that is,
for every $1.00 collected in premiums, the losses should be less
than $1.00. Historically they will run $1.05 to $1.20 or higher
for individual claimants. This means that for every dollar of premium
collected, the insurance company is paying out $1.05 to $1.20 or
higher in covered damages plus loss adjusting expense. To survive,
the insurance company must control costs and provide quality claim
service. Accordingly, a need exists for a better method of processing
and paying claims.
BRIEF DESCRIPTION OF THE DRAWINGS
[0008] FIG. 1 is a block diagram of a system for processing insurance
claims under an illustrated embodiment of the invention;
[0009] FIG. 2 is a statement of purpose webpage that may be used
by the system of FIG. 1;
[0010] FIG. 3 is an introductory webpage that may be used by the
system of FIG. 1;
[0011] FIG. 4 is a sign-on webpage that may be used by the system
of FIG. 1;
[0012] FIG. 5 is a claim instructions webpage that may be used
by the system of FIG. 1;
[0013] FIGS. 6-7 is a claim report webpage that may be used by
the system of FIG. 1;
[0014] FIG. 8 is an emergency resources webpage that may be used
by the system of FIG. 1;
[0015] FIGS. 9-10 is a building damages webpage that may be used
by the system of FIG. 1;
[0016] FIGS. 11-12 is a merchandise damages webpage that may be
used by the system of FIG. 1;
[0017] FIGS. 13-15 is a payroll, property damage and extra expense
webpage that may be used by the system of FIG. 1;
[0018] FIGS. 16-17 is a sworn statement in proof of loss webpage
that may be used by the system of FIG. 1;
[0019] FIG. 18 is a damage verification flow chart that describes
steps that may be used by the system of FIG.
[0020] FIG. 19 is a pay/referral process flow chart that describes
steps that may be used by the system of FIG. 1;
[0021] FIG. 20 is a claim reporting flow chart that describes steps
that may be used by the system of FIG. 1;
[0022] FIG. 21 is a claim process flow chart that describes steps
that may be used by the system of FIG. 1; and
[0023] FIG. 22 is a coverage analysis process flow chart that describes
steps that may be used by the system of FIG. 1.
SUMMARY
[0024] 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.
Detailed Description of an Illustrated Embodiment
[0025] FIG. 1 is a block diagram of the system for expediting insurance
claims 10, shown generally in accordance with an illustrated embodiment
of the invention.
[0026] One of the advantages of the system 10 is that when a claim
meets certain criteria, the claim may be paid automatically, without
the involvement of an adjuster. The automatic payment of a claim
is referred to herein as an "expedited claim" or as a
"fast track claim". The automatic payment of claims has
been found to significantly reduce insurance costs when the details
of the claim can be matched to the appropriate criteria.
[0027] Under illustrated embodiments, the system 10 may be used
under any of a number of different insurance formats (e.g., self-insurance,
commercial line insurance, personal lines insurance, etc.) to service
claims filed by claimants. It should also be understood in this
regard, that while the system 10 may be used by a single client
to service its claimants, the system 10 may be simultaneously used
by many different clients to serve their respective claimants.
[0028] Because of the variety of clients that may use the system
10, the term "insured" will often be used interchangeably
with the claimant. It should be understood that these terms and
naming conventions will be used even in the case of a self-insured
organization where the "insured" or "claimant"
may simply be an employee of the client and payment of the claim
simply results in movement of money or resources from one account
to another within the same organization.
[0029] In order to service claims, a claim form made up of a number
of webpages (FIGS. 2-17) may be downloaded to a claimant 12, 14.
The webpages of the claim form allow the claimant 12, 14 to file
a claim by entering claim information through the Internet 16. In
the case where many different clients are involved, one of the identifiers
needed is the identifier of the client, either by name or policy
number.
[0030] Once the claimant 12, 14 has entered basic information (e.g.,
name, address, policy number, type of loss, etc.), the system 10
may assign a claim number. The assignment of a claim number allows
the claimant 12, 14 to tender a claim proximate the time of the
loss yet still access the same claim file at a later time to enter
additional information (e.g., repair estimates from contractors,
salvage value estimates from experts, etc.).
[0031] Once the claim has been completed, a number of processing
applications within the host 20 function to evaluate the claim under
a number of different criteria to either assign a claims adjuster
to the claim or to pay the claim directly, without the involvement
of a claims adjuster. The criteria used to evaluate the claim may
be based upon the type of policy upon which the claim is based and
also upon the type and magnitude of loss incurred.
[0032] Under a first criteria, key word searching of selected fields
of a claim may be used as a basis for assigning (or not assigning)
a claims adjuster. Under other, auxiliary criteria, claim form discrepancies
or past claims from the same claimant may be used as a basis for
assigning a claims adjuster to the claim.
[0033] Turning now to the use of the website 10, an explanation
will be provided of the steps that may be used for accessing and
using the website 10. As a first step, it may be assumed that each
claimant 12, 14 is provided with a website address upon being accepted
into the insurance program. The website address (Universal Resource
Locator (URL)) may be provided as part of a written description
of the insurance program.
[0034] Considering a self insured client first, the use of the
webpages 1-10 shown in FIGS. 2-17 in this context will be considered
first. The description will also assume that the self insured client
is a national retail/department store organization.
[0035] It should be noted with regard to FIGS. 2-17 that the circled
page numbers in the upper right corners are webpage numbers. The
smaller circled numbers shown in FIGS. 2-17 are reference numbers
that refer to the adjacent software keys (softkeys), interactive
boxes or the content of those boxes as appropriate to the circumstances
and as discussed in more detail below.
[0036] Upon entering the URL of the website 24, a first webpage
(FIG. 2) of the form may be downloaded to the claimant 12, 14. The
first page (FIG. 2) may be used to provide the claimant 12, 14 with
a preliminary description and purpose of the website 24. Webpage
2 (FIG. 3) may server a similar purpose. Webpage 3 (FIG. 4) may
provide instructions to a store manager (claimant) 12, 14.
[0037] In order to identify a criteria to apply to processing claims,
the system 10 requires the store manager to enter a policy identifier
(policy number) into an interactive box 5. The policy number for
a self-insured client may be a store number.
[0038] Webpage 4 (FIG. 5) may provide detailed instructions. Webpage
5 (FIGS. 6-7) may be a claim report questionnaire. Webpage 6 (FIG.
8) may allow the client to request emergency response services from
the client. Webpage 7 (FIGS. 9-10) allow for the entry of building
damages. Webpage 8 (FIGS. 11-12) allow for entry of merchandise
damages. Webpage 9 (FIGS. 13-15) allows for entry of extra expenses,
such as payroll and property damage. Webpage 10 (FIGS. 16-17) is
the sworn statement of proof of loss.
[0039] The processing of the claim form results in entries to three
databases 26, 28, 30. The first database 26 is claim specific and
may include data gathered from the online pages (FIGS. 2-17) and
stored in a claim record that has been assigned a specific claim
number. In this regard, each claim is assigned a unique number.
For some companies (referred to as clients) the claim number may
be the store number or some other number of significance.
[0040] The second database is the logging database 28. Certain
data obtained from the record 26 will be maintained within the log.
The client may view the log at any time to see the status of various
claims collected at various times. The log 28 allows the client
to search for a claim on the log by store unit number, state, date
of loss, etc. Each log is client specific. The log may be for a
calendar or fiscal year or for all open and closed claims for a
specified period.
[0041] The third database is a report database 30. The report database
30 is associated with an interactive report generating program that
allows the client to manipulate claim data and summarize this data
for any specific time frame chosen. For example, a client may request
a summary of data for all losses for a 36 month period by cause
of loss, total dollars, subrogation, salvage, state and type of
store. The report uses data from all records for the given client
to extract the parameter and type of claims in the query.
[0042] Processing of claims may be performed by a criteria processor
34 under a set of general rules that also provide a basis for an
auxiliary criteria that limits automatic disposition of the claim.
The first general rule includes a claim frequency check. In a claim
frequency check, the records of a store or unit number, loss location,
manager's name and date of loss is searched. If the same store,
unit number or loss location has more than three occurrences/losses
in a 12 month period, then the claim cannot be adjusted electronically
(i.e., cannot be paid without the approval of an adjuster) and must
be assigned to an adjuster for investigation/resolution. The number
of occurrences are client specific.
[0043] When the claim report (page 5) is completed, a claim number
is assigned by a claim number processor 36. The claim number is
assigned by a claim number generator under any of a number of different
criteria. For example, a random number may be generated and used
or a store identifier may be used for self-insured retail chains.
The claim may be stored under this assigned claim number.
[0044] Page 4 provides, in printable format, directions for the
claim report and damage pages. The client's customer is instructed
how to complete the form and assess damages and what they need to
provide to complete the remaining screens including entry of building
damage repair costs, inventory of merchandise, payroll and extra
expense. The instruction page (page 4) and damage documentation
screens (pages 7, 8 and 9) can be printed off so the client's customer
can have hard-copy documentation to aid in obtaining the information
from outside sources that they will need to complete the claim.
[0045] Based upon the client's specified time-limitation the customer
can have 30, 60, 90 days or longer to gather the information and
complete the claim. During this time period, the client's customer
can sign onto the system 10 and enter the previously assigned claim
number to recall their claim record. They can then proceed to enter
the additional necessary information on each page (page 7, 8 or
9) for the damage.
[0046] Once the damage pages are completed as required, the final
page, page 10, Sworn Proof of Loss must be completed. Most of the
blanks on this page can be automatically or manually pulled from
the claim report and damage pages to completed the document.
[0047] The client's customer must review the sworn statement of
proof of loss form on page 10, the data and information being submitted
and submit this data as a completed claim (see box entitled "Automatic
Electronic Claim Payments" in FIG. 19). If it meets the criteria
for an online adjusted claim, then a payment processing application
42 within the host may compose and forward a final e-mail with a
summary of the claim data and damages that is, in turn, sent to
the client's accounting department for a credit to be applied to
the store's account with a debit from the risk management reserve.
[0048] If the claim has been referred to an adjuster, then the
adjuster must authorize the client customer's claim. It is the adjuster's
responsibility to approve the final claim and authorize payment/credit
to the stores account. Once approved by the adjuster, an e-mail
may be used to send the finished proof of loss and damages to the
client's accounting center (see box entitled "Automatic Electronic
Claim Payments" in FIG. 19). Without the adjuster's authorization
the email is not sent and the claim is not paid/credited.
[0049] The client may choose the dollar threshold within which
claims can be approved in the online adjusting process. In the system
10, $50,000 may be used as the default threshold. The total dollar
damages estimated (item 31 on page 5) is checked against this threshold.
If the loss exceeds $50,000 the adjuster is immediately notified
of the claim by email, and the client's customer is notified an
adjuster has been assigned.
[0050] Even when the claim damage pages are completed within the
30, 60 or 90 days as chosen by the client, if the total damages
(item 295) exceed the $50,000 threshold as described above, the
loss is assigned to an adjuster. This is the case even if the initial
estimate (item 31) was below the threshold.
[0051] Other situations may also result in assignment to an adjuster.
For example, if the loss occurs off premises (item 22) the claim
is immediately assigned to an adjuster when the claim report is
completed. In each case, the criteria processor 34 evaluates and
determines disposition of the claim.
[0052] In general, the criteria processor 34 functions to identify
situations where the context of the claim suggests the possibility
of an unjustified claim or fraud. The criteria processor 34 may
do this based upon a set of heuristic rules and based-upon word
searching. The flowcharts of FIGS. 18-22 depict the overall process
of claim disposition. However, even where word searching is used,
word searching by itself would be of limited value because of the
variety of policies and covered risks. In order to accommodate the
vagaries of claims processing, a policy processing application 40
functions to identify a policy number associated with each claim.
Once a policy number is identified, the policy processing application
40 may determine a type of policy involved in the claim and retrieve
a set of keywords 46 from memory 44 that are associated with that
type of policy.
[0053] A word comparator program 32 within the host 20 may compare
each word in the "description of loss" (item 37) against
a list of key words for matches. The key words may be identified
based upon the policy number entered through interactive box 5.
The key word can include a broad range of words to allow the program
to tightly screen each claim or the set of key words can include
fewer words, allowing claims to pass and be electronically adjusted
without an adjuster assigned. If a key word matches any word in
the description, then a matching processor 38 detects the match,
transfers notification to the criteria processor 34 and the claim
is immediately assigned to an adjuster. Each phrase in the key words
must match exactly. For example, if the key word is "power
surge", the word "power" itself will not be sufficient
to cause an adjuster to be assigned. An exemplary set of key words
that may be used for self-insured retail may be as follows: surge,
electrical surge, power surge, utility interruption, customer property,
property in transit, shipment, missing property, lost property,
customer return, product defect, defective, credit, credit card,
fraud, checks, money order, war, terrorism, municipality, code,
penalty, insect, animal, cracking, settling, shrinkage, deterioration,
nuclear, atomic, invasion, governmental, pollutant, contaminant,
shortage, mysterious, disappear, indirect and, loss of market.
[0054] The lists of damaged items (items 68-87) and description
column (items 105-175) may also be compared with a list of key words
for property not covered. Key words for property not covered are
client specific depending upon the policy type and may be as follows:
returns, customer returns, customer property, property of others,
automobile, vehicle, land, leased, growing crops, property sold,
property in transit, customer property, oil rig, satellites, dam
and dike.
[0055] If item 35 is checked yes or chosen from a drop down indicating
a third party may be responsible, then the claim is automatically
assigned by the criteria processor 34 to an adjuster once the client
completes the claim report. If emergency services are required as
indicated by selection of any of items 39-43, then an adjuster is
assigned to investigate. The criteria in this case may be client
controlled to allow the client to determine at what level the adjuster
is involved.
[0056] The type of loss drop down (item 20) may include the following
list of losses: fire, smoke, wind, hail, vandalism, theft, burglary,
robbery, employee dishonesty and other.
[0057] If employee dishonesty is chosen, then an adjuster is immediately
assigned by the criteria processor 34 once the claim report is completed.
[0058] Each client may choose the dollar deductible applicable
by type of loss. Deductibles can vary by the client's customer and
may require client system verification. When employee dishonesty
is chosen, then the deductible (item 296) is $25,000. For all other
losses, the deductible is $10,000 unless changed by the client.
[0059] If the claim report exceeds the threshold time allowed by
the client to complete the damage pages, then it is assigned by
the criteria processor 34 to an adjuster. For example, if the time
to submit damages exceeds 60 days, then an assignment of the claim
is made to an adjuster.
[0060] A set of page/item rules may be considered next. Page 1
(FIG. 2) is a sign-on screen. Item 1 takes you to the self-insured
sign-on screen.
[0061] Page 2 (FIG. 3) contains a client specific introduction.
The icon from the fast track claim welcome screen takes you to the
client's introduction page. It is proprietary to the client in style
based upon that client's wants and needs for a self-insured retail
or department store.
[0062] Page 3 (FIG. 4) is a secure client sign-on screen. The sign-on
screen of page 3 describes and explains the self-insured program.
It requires the claimant 12, 14 (client's customer) who is signing-on
to check a box (item 2) agreeing to the terms and conditions of
the program. They may be required to enter an access code or some
other means of identification.
[0063] Item 3 is an interactive box that requests the full name
of the person entering the information. This will be retained in
the claim record as the person reporting the clam.
[0064] Item 4 requests the title of the person who reported the
claim. This will also be retained in the claim record.
[0065] Item 5 requests the store or unit number specific to the
location of loss. This is retained in the claim record and on the
log.
[0066] Item 6 requests the date the loss is reported. This is retained
in the claim record and on the log. Item 7 is an icon that takes
the claimant 12, 14 to Page 4.
[0067] Page 4 includes claim instructions. If items in Page 3 are
completed, a continue icon will take the customer to the next set
of pages, which are the claim instructions.
[0068] Item 7 is an emergency icon. Selection of this icon immediately
takes the client to the claim report screen, page 5. Alternatively
the claimant 12, 14 can click on the emergency icon after the claim
report is complete and the system 20 will notify the adjuster and
others, as designated, that an emergency claim has been reported.
[0069] Item 8 is the continue icon. This allows the customer to
continue to the next page, which is page 5, the claim report screen.
It will not take the customer through the emergency screen.
[0070] Page 5 is the claim report. The box labeled "Unit Number"
is the store number and will be saved in the log.
[0071] Item 10 requests entry of the type of store/unit. Any entered
information will be included within the log. This can be a drop
down menu.
[0072] Items 11 & 12 may indicate soft keys that may activate
drop down menus. The drop down menus may be used to determine if
the premises are owned or leased.
[0073] Item 13 requests the street address of the store/unit. Item
14 requests the city, state and zip. The city and state are may
be included within the log.
[0074] Item 15 requests the e-mail address of the claimant 12,
14 reporting the clam. Item 16 requests the phone number and item
17 requests the cell phone number of the claimant.
[0075] Item 18 requests the date of loss. This is entered on the
log and record. Item 19 requests a time of loss.
[0076] Item 20 may be a drop down menu. Included within the drop
down menu may be a line for customer to choose various types of
losses. The selection of a type of loss will go into the log. Examples
include: fire, lightning, burglary, theft, robbery, water, wind,
flood, vehicle, employee Dishonesty and possibly more.
[0077] Item 21 requests a location of the loss. The entered location
will be compared to item numbers 13 and 14 found earlier in the
claim report and if the location of loss is different then the location
described in 13 and 14, the claim would be declined by the criteria
processor 34 and assigned to an adjuster for investigation.
[0078] Item 22 and 23 requests information as to whether this loss
occurred on or off premises. Items 22 and 23 can be a drop down
menus that suggest possible scenarios for the loss. If the loss
was off premises, then the claim is declined by the criteria processor
34 and assigned to an adjuster for investigation.
[0079] Items 24 thru 29 allows the claimant 12, 14 to choose whether
there is building damage, merchandise damage, loss of money and
securities or jewelry, additional expense, equipment and supplies
or other damage. A claimant 12, 14 can chose more than one entry.
Items 24-29 can be provided as drop down menus or can be more then
one selection box, whatever is more efficient. Item 30 allows a
narrative section where the claimant may enter other types of damages
that are not already included in the boxes checked for building,
merchandise, etc.
[0080] Item 31 allows the claimant 12, 14 to estimate the total
dollar amount of all damages. Entry of damages may be provided as
a drop down menu that allows someone to choose some dollar range
(e.g., $10,000.00 to $19,999.99; $20,000.00 to $49,999.00; $50,000.00
to $99,999.00; greater then 100,000.00, etc.).
[0081] Item 32 allows entry of an emergency number. This emergency
number is sent via page or e-mail to the adjuster when the emergency
screen is completed and immediate contact is required.
[0082] Items 33 and 34 requests information regarding salvage.
This can be a yes or no selection or drop down menus.
[0083] Items 35 and 36 requests information as to third party legal
responsibility. Activation of one of these softkeys may allow for
a yes or no answer or may provide a drop down menu for additional
selections.
[0084] Item 37 requests a detailed description of loss. This should
allow the claimant to enter information regarding the specifics
of who, what and why about how the loss occurred.
[0085] Item 38 is a softkey that allows a transition to the next
webpage. Upon activating the softkey 38, the claim is saved and
assigned a claim number, once this and the previous pages have been
accurately completed. It takes the claimant 12, 14 to the next screen.
[0086] If the Emergency Box was checked on page 4 of the claim
instructions, then the claimant 12, 14 is transferred to page 6,
which is the emergency resource request page. Otherwise, the claimant
12, 14 is transferred to page 7, if building damages were indicated.
Alternatively, the claimant 12, 14 is transferred to page 8 if merchandise
damage was indicated or page 9 if payroll, extra expense or other
property damage were indicated. If more than one category was entered
on items 24 thru 29 the claimant is transferred thru these damage
screens sequentially.
[0087] Once the claim report is complete and emergency contact
is sent, some claims are declined for online adjusting and must
be handled by an adjuster. The client may request all claims be
completed online as opposed to just those being adjusted electronically.
[0088] Those claims assigned to the adjuster will require an adjuster
authorization/approval once the client's customer submits the online
information for damages. All claims reported may remain in a pending
or open status for a specified time, 30, 60, and 90 days, or longer.
A previously assigned claim number can be referred to later by the
claimant 12, 14 to allow the claimant to come back online and complete
various damage screens to conclude and submit the claim online for
settlement.
[0089] Page 6 is for emergency responses. Item 39 is an adjuster
box softkey that may be selected for serious or large losses. The
Adjuster Box 39 may be checked and the claim is reported by pager
to the adjuster with the emergency cell phone number of the claimant
12, 14.
[0090] Item 40 identifies a softkey that alerts the system 10 in
the case where a claimant needs emergency services for water, fire
or smoke restoration. Activation of box number 40 causes the emergency
cell phone number of the claimant to be sent to an adjuster by pager.
[0091] Item 41 identifies a softkey that alerts the system 10 that
salvage teams are needed to remove damaged merchandise. The cell
phone number of the claimant is sent by pager to the adjuster.
[0092] Item 42 identifies a softkey that alerts the system 10 that
an investigation and expert are needed (especially if others may
be legally responsible for property damage). Again, the cell phone
number of the claimant is sent by pager to the adjuster.
[0093] Item 43 is a softkey that alerts the system 10 that a building
contractor or construction team is needed. The adjuster is notified
by pager.
[0094] Item 44 is a SUBMIT softkey that initiates any needed emergency
activity. If the SUBMIT icon is activated, then support services
targets of all the boxes, 39-43, which were previously checked will
receive an e-mail or page advising them of the emergency number
that was collected from the claim report Item No. 32. It may also
send an e-mail to the claimant 12, 14 at the e-mail address that
they provided in the claim report advising them that the emergency
claim report of damage was received and they will be contacted shortly.
If the claimant does not hear from somebody shortly, then they may
be given an alternative phone number that they can call in an emergency.
[0095] If from the claim report, the claimant clicks NEXT and in
the claim instruction page, the claimant did not identify the claim
as an emergency, then the system 10 would take the claimant to the
damage pages. The progression from the damage pages depends upon
what was identified as being damaged in the claim report, items
24 thru 30. For example if the building (item 24) was damaged it
would start with page 7.
[0096] If the Merchandise Box (item 25) were checked on the claim
report, then the system 10 would progress to the merchandise damage
screen, which is page 8. If extra expense, payroll or property damage
are involved such as indicated by activation of Box 28 or 29, the
system 10 would proceed to page 9 for entry of extra expense, payroll
and property damage. Otherwise, page 9 would not be presented to
the claimant. This follows for each class of damage with a specific
page necessitated by entry of additional information.
[0097] Page 7 is for building damage. Items 46-53 are softkeys
that allow entry of descriptive information regarding what is damaged
on the building.
[0098] Item 54 is an interactive box that allows entry the store
number and/or the claim number specific to the client. Item 55 is
a interactive box that allows entry of the job number assigned for
building repairs by the client.
[0099] Item 56 is a interactive box that allows entry of the total
estimated building damages. This is not the amount claimed.
[0100] Item 57-59 may be drop down menus to determine if customer
has an estimate. If the claimant enters yes or, later, when the
claims has collected estimates, pending items 60-66 are prompted.
If no, the customer receives information to contact a contractor.
[0101] Items 60-66 are contingent on the answer to the item 57
softkey. If the softkey 57 is not activated, interactive boxes 60-66
are not presented.
[0102] Item 67 is a drop down menu that requests information about
ownership of the building. If there are building damages and the
building is leased, then the claim is assigned out to an adjuster
to determine responsibility under the written lease. If owned, the
customer continues. This is a required field. The drop down menu
may also have an "unknown" where the customer does not
know if it is leased or owned. If unknown is chosen, then it is
treated as being leased and assigned out for an adjuster.
[0103] Items 68-87 are interactive boxes that request loss information.
The boxes 68-87 are used by the customer to list damage and cost
to repair.
[0104] Item 88 requests information regarding total building damages,
as itemized in items 68-87. This estimate is entered into the log.
[0105] Item 89, 91 & 92 are interactive boxes that requires
information regarding consultants. In these boxes the claimant must
identify any project consultant including their name, phone number
and email.
[0106] Item 90 requires the customer to agree to repair the damages.
This is a required item that must be checked to continue.
[0107] Item 93 is the NEXT button that causes presentation of the
claim form to proceed to the Merchandise Damage (page 8), if merchandise
has been identified on the claim report (page 5, item 25). If not,
then the page presentation goes to Payroll (page 9), if payroll
was identified on page 5 item 28. Otherwise, it proceeds to the
Sworn Statement, page 10.
[0108] Page 8 is for merchandise damage. Items 94-98 are softkeys
that are used to list the type of merchandise damaged. Item 97 is
an interactive box that lists the store and/or claim number. Each
page will always have the claim number for the claim being established.
[0109] Items 99-104 are softkey boxes that allow entry of salvage
information through a series of questions and rules. Alternatively,
items 99-104 may be drop down boxes with rules. If item 99 is yes,
then item 101 must be yes and Item 41 on the Emergency Response
page must have been indicated and submitted. If item 100 is no,
then item 102 must also be no. If item 103 is yes then the column
the labeled "markdown" will apply in items 105 through
174. If item 104 is entered as no and the customer attempts to enter
a percentage in the markdown column, then they will receive an error
massage stating no merchandise was sold with a markdown. If they
enter 103 as yes and they attempt to leave the markdown column blank,
then they will be prompted with an error message that states a markdown
percentage must be entered for all damaged merchandise retained
and sold with a markdown.
[0110] Items 105-175 are interactive boxes that may be used by
the customer to enter information about damaged merchandise. It
requests the division, description, quantity, sell price, markdown,
cost and amount claimed. The information from these columns are
used together to determine the amount claimed. The sell price is
multiplied by the mark down to determine the cost. Depending on
the client's instructions, merchandise can be claimed at cost or
selling price. Under one mode of operation, the system 10 values
the claim for merchandise at cost. Clients may chose sell price
or cost.
[0111] Item 176 is a softkey that allows the claimant to agree
that the valued allowed is the lower of cost or the markdown. If
cost is claimed, then the damaged merchandise must be given to an
approved salver. Another column may be provided asking if merchandise
was damaged and given as salver. In this case, the cost of the merchandise
is allowed. If damaged and sold "as is" with a markdown,
then only the value of the markdown is allowed.
[0112] Activation of Item 177, the "NEXT" softkey, continues
the page presentation and causes the page presented to proceed to
Payroll, Property and Extra-Expense (page 9), if these types of
damages are applicable to this claim. If not, page progression goes
to the Sworn Statement in Proof of Loss (page 10).
[0113] Page 9 is for payroll, property damage and extra expenses.
Item 178 is the claim number, again this is on every page.
[0114] Items 179-229 allows the claimant to provide information
about Payroll. The information from the columns for Rate and Hour
should are multiplied and should equal the sum in the total column.
The information from the total column is added and placed in the
total box as item 229.
[0115] Interactive boxes 230-255 allow the claimant to provide
information about Property damage. The cost column should add up
to equal the total in box 255.
[0116] Interactive boxes 256-281 allow the claimant to provide
information about extra expenses. The column for cost adds and totals
in box 281.
[0117] The totals for each category of damage in webpage 9 is carried
forward in the summary of expenses. Payroll total 229 is reiterated
in item 282, property damage total in item 255 is reiterated in
item 283 and extra expense total 281 is reiterated in item 284.
Then items 282, 283 and 284 are added and totaled in item 285.
[0118] Box 286 requires that the claimant 12, 14 indicate and agree
that all costs have been incurred and paid. If it is not checked,
then the claim cannot continue with the "NEXT" icon.
[0119] Item 287 is the "NEXT" icon and this will take
the claimant 12, 14 to the final document for the claim. Page 10
is the sworn statement of proof of loss. In item 288, the store
number carries over and is also used as the claim number. Item 289
is the same as item 20 from the claim report found on page 5.
[0120] Item 290 is the same as item items 18 and 19 from the claim
report found on page 5. It shows the date and time of the loss.
[0121] Item 291 is the same as item 37 on the claim report found
on page 5. This provides a detailed description of the loss. The
word "is" as the end of this item can be deleted.
[0122] Item 292 is the same as total building damages found in
item 88 on page 7. It carries forward.
[0123] Item 293 is the same as the total content damages item 175
found on page 8. It carries forward.
[0124] Item 294 is the same as total payroll, property damage and
extra expense item 285 found on page 9. It carries forward.
[0125] Item 295 lists the total of all damages. This item contains
the totals found in items 292, 293 and 294.
[0126] Item 296 is taken from the General Rule 16 for deductibles.
If the claim is for an employee dishonesty type loss as indicated
on item 20 of the claim report found on page 5, then the deductible
is $25,000. If the claim is any other loss, then the deductible
is $10,000. The clients choose the deductible based on their own
program.
[0127] Item 297 identifies the net claim and is determined by subtracting
the deductible, item 296 from the total damages, item 295. The result
is entered in item 297.
[0128] Item 298 requires the claimant 12, 14 to certify to the
validity of the claim. A check mark in this box 298 has the same
force and effect of a signature. An interactive box may also be
provided where the person is required to type in their name and
e-mail address.
[0129] The final icon is SUBMIT. The claim report with the damage
pages and proof of loss are e-mailed to the client's accounting
department and others as identified on the distribution list (see
box entitled "Automatic Electronic Claim Payments" in
FIG. 19). Additionally, the person that agreed to the terms, item
298, and entered their name and e-mail address may also be on the
distribution list.
[0130] The use of the system 10 by a client offering commercial
lines insurance will be considered next. For ease of explanation,
only the differences in operation of the system 10 in handling claims
between self-insured clients and commercial line clients will be
discussed.
[0131] In this regard, webpages 1-10 may be used for commercial
line insurance in a manner similar to the self-insured context.
In addition, databases 26, 28, 30 may be used in a similar manner.
[0132] With regard to general rules, when the claim report (page
5) is completed, a claim number is assigned. The claimant 12, 14
is allowed to continue at this point to enter damages on the applicable
pages or may come back within a specified time allowed by the client
to complete the damage pages. As above, page 4 provides, in printable
format, directions for the claim report and damage pages. The client's
customer is instructed how to complete the form and assess damages
and what they need to provide to complete the remaining screens
including building damage repair costs, inventory of business personal
property, business earnings and extra expense.
[0133] Based upon the client's specified time limitation the insured/client's
customer have 30, 60, 90 days or longer to gather the information
and complete the claim. They may complete the damage pages while
currently online or come back and complete the pages within the
time allowed by the client. During this time period, the client's
customer can sign onto the system 10 and enter the claim number
to recall their claim record. They can then proceed to enter the
necessary information on each page (page 7, 8 or 9) for the damage.
[0134] If the claim has been referred to an adjuster, then the
claim is closed and the record is marked as referred to an adjuster.
The claim, once referred to an adjuster, cannot be referred back
to the system 10 for adjustment. The claim is closed on the system
10.
[0135] Although there may be some clients that would like to retain
the claim online on the system 10 for the adjuster to complete,
it is not considered essential to the system 10. As such, the system
10 allows paperless claims and virtual information on the status
of the claim to be retained and processed.
[0136] The client must choose the dollar threshold within which
a claim can be approved in the online adjusting process. In this
case, the system 10 may use $10,000 as this threshold. The total
dollar damages estimated (item 31 on page 5) is checked against
this threshold. If the loss exceeds $10,000 the adjuster/client
is immediately notified of the claim and the client's customer is
notified an adjuster has been assigned.
[0137] When the claim damage pages are completed within the 30,
60 or 90 days as chosen by the client, if the total damages (item
295) exceed the $10,000 threshold as described above, then the loss
is assigned to an adjuster. This is the case even if the initial
estimate (item 31) was below the threshold.
[0138] With regard to key word searching, commercial lines insurance
proceeds somewhat differently. In the commercial line situation,
if only building damages are claimed, then the list of key words
is different than if business personal property (BPP) damages are
also claimed and included (building and BPP). This may also vary
by policy prefix. By this it is meant that some policies (identified
by a prefix e g. CBX) will only use List A with regard to the building
and business personal property (BPP) damages. Other policy prefix
types may require a different list of key words. In this case, a
List B may be used.
[0139] "Building damage keywords are List A. Business Personal
Property (BPP) damage is List B. For List A (Building) if a key
word for the list matches any word in the Description of Loss (item
37) the claim is immediately assigned to an adjuster. For List B
(Business Personal Property Damage Only or Building and BPP Damages)
if a key word is not present in the Description of Loss (item 37),
then the loss is assigned to an adjuster. How the lists apply will
depend of the policy number prefix and clients policies sold to
its customers. Essentially it is the application of all risk coverage
or named peril.
[0140] The system 10 may get a claim for a policy prefix that is
identified not to use List A, but only have building damages. As
such, List A would still be used because building damages are subject
to all risk coverage. If business personal property damage were
added to the claim, then List B would then have to apply (requiring
words to match) to avoid assignment to an adjuster. Business Personal
Property is subject to named peril coverage.
[0141] For example a claim is submitted with a policy prefix not
recognized to only use List A. However, only building damages (Bldg.)
are claimed, (no business personal property). As such, List A would
be used.
[0142] In another example, a claim has both Building and BPP damages
claimed and the policy prefix is not listed indicating to only use
List A, therefore List B will apply. List B requires one of the
keywords in List B to be in the description of loss (item 37). If
not, and there is no match, then the loss is assigned to an adjuster
after recording the information on the claim. If a word in the description
of loss (item 37) matches the List B keyword, then the claim continues
to be adjusted electronically.
[0143] As an example, List A may include a set of key words as
follows: surge, electrical surge, power surge, power failure, utility
interruption, ordinance, law, earthquake, quake, flood, surface
water, waves, pump, sump pump, property in transit, shipment, missing
property, lost property, lost, missing, neglect, intentional, defective,
maintenance, credit card, fraud, checks, money order, war, terrorism,
municipality, code, penalty, insect, cracking, settling, cracking,
bulging, expansion, shrinkage, wear, tear, wear and tear, vacant,
mechanical, mechanical breakdown, smog, animals, birds, under construction,
rust, corrosion, deterioration, nuclear, atomic, invasion, governmental,
pollutant, contaminant, shortage, mysterious, disappear, indirect,
sewer backup, sewer, sewage, drain backup, backup of sewer, backup
of drain, mold, fungus, wet rot, dry rot, rot, rotten, converted,
volcanic, bacteria, mud, mudslide, nesting, infestation, rodents,
electrical, temperature, change in temperature, boiler, steam, turbine,
improper construction, faulty and seepage. In contrast, List B (words
must match or claim is referred to an adjuster) may be as follows:
fire, lightning, wind, windstorm, hail, storm, explosion, riot,
civil, civil commotion, aircraft, plane, vehicle, car, smoke, vandalism,
mischief, malicious mischief, theft, falling, weight of ice, weight
of snow, water or freezing.
[0144] The type of loss drop down (item 20) may include the following
list of losses: fire, smoke, wind, hail, vandalism, theft, burglary,
robbery, employee dishonesty and other.
[0145] Employee dishonesty is applicable to a commercial lines
claim. Once the claim report is completed the claim is assigned
to an adjuster to investigate due to legal issues (denial, etc.)
and the fact that the employee may be responsible for reimbursement.
[0146] The client's customer enters the deductible amount. On commercial
lines type policies this can be $100 to $10,000 or higher and can
vary incrementally. If a zero deductible is chosen, then the loss
should be assigned to an adjuster. Each client will provide parameters
for the deductible to be entered by their customer.
[0147] Turning now to webpages 1-10 (FIGS. 2-17), an explanation
will be provided as to the differences in appearance and function
between self-insured and commercial lines insurance. For example,
a commercial lines insured may enter a URL of the website 24 for
commercial lines insurance and be presented with page 1 (FIG. 2)
that displays an identifier of the client.
[0148] For commercial lines insurance, page 2 (FIG. 3) may be used
as an introduction screen. Page 2 may state the following unless
changed by a client. [0149] "Our customers, insureds and agents,
may now report a claim online to be immediately adjusted, paid and
closed, if possible. Some claims may require additional information
or adjustment before they can be concluded. If so, you will be contacted
by an adjuster. Please enter your policy number and name as it appears
on your policy."
[0150] Page 3 (FIG. 4) may contain a client specific introduction.
The icon from the introductory screen (FIG. 3) takes the insured
to the client's sign-on screen. It may be proprietary to the client
in style based upon that client's wants and needs for a Commercial
Lines insurance company. It may provide specific information to
file the claim, as follows.
Commercial Lines Insurance Company
[0151] Please report your claim by completing the online claim
report questionnaire. Once completed a claim number will be assigned
and provided to you to complete your claim. You may continue on
and complete the damage section now. However, you have 30 days to
gather information about your damages and complete the online claim.
[0152] For building damages you should obtain and estimate the cost
to repair or replace the damaged property. You may know some of
the material if you intend to do repairs yourself, allowing a reasonable
charge for your own labor. If you need a contractor you may search
on the list of approved contractors in your area, or obtain one
of your own choosing. For the estimate you will need to provide
the breakdown of cost online. [0153] For business personal property,
also referred to as contents, you will need to list each item, its
description; age by month and year, original cost and cost to replace
today. To obtain replacement cost at this time, before replacing,
you must agree to comply with the policy conditions that require
you to replace the property. As such, you must agree online that
the property will be replaced. [0154] If you have incurred loss
of business earnings and/or extra expense. That is expense to continue
normal operations had no loss occurred or expediting expense to
get back into business more quickly you must itemize the cost/expense
you have incur. These expenses must be over and above your normal
everyday operating expenses. If you will require and extended time
indicate this so an adjuster can contact you as soon as possible.
[0155] Business earnings losses typically require an adjuster to
work with you to determine the amount claimed and recoverable under
your policy of insurance. If you were closed only a few hours or
one or two days and the loss is not extensive you may claim that
amount without an adjuster. Or if your policy has a set limit for
each days your business is closed you may claim that amount. [0156]
Should you have questions please use the toll free number or contact
us by email. Once the claim report and damages are reported and
acknowledged your claim may be adjusted and concluded-online or
an adjuster will be assigned. You will be notified immediate if
an adjuster is assigned.
[0157] In general, the client's secure page (FIG. 4) describes
and explains the client's Commercial Lines program. It requires
the claimant (client's customer who is signing on) to check a box
(item 2) agreeing to the terms and conditions of the program. This
will be required in addition to the name and relation to the named
insured to continue.
[0158] Item 3 allows the claimant to enter their full name as the
person entering the site and completing the claim form. This will
be in the claim record as the person reporting the claim.
[0159] Item 4 requires the person reporting the claim to enter
the relationship to the named insured. A drop down box may be provided
for selecting the relationship (e.g., as the named insured, the
owner, manager, partner, insurance agent, etc.). This will also
be in the claim record.
[0160] Item 5 allows the claimant to signify whether this is a
new claim or follow-up on an existing claim. If new, it takes the
customer to the claim instruction page. This is retained in the
claim record and on the log.
[0161] Item 6 allows the claimant to enter the date the loss is
reported. This is retained in the claim record and on the log. Following
the completion of page 3, the claimant activates the NEXT icon (item
7) and proceeds to page 4.
[0162] Page 4 operates substantially the same as in the self-insured
context. Page 5 differs in the format of the enter information.
[0163] For example, Item 9 allows for the entry of a policy number.
In this regard, most policy numbers have two parts, a prefix and
a number. e g. PRO 00223547. This is client specific and is used
by the client to identify their insured.
[0164] Item 10 allows entry of the effective date of the policy.
This date must be after the date of loss, item 18, or the claimant
will be asked to confirm that the date is correct. If the claimant
indicates that the entered date is correct and is before the date
of the policy, then the loss will be assigned to an adjuster.
[0165] Items 11-20 are used substantially the same as the self-insured
lines. Item 20 may be a drop down menu that allows the customer
to choose various types of loss. This type of loss will go into
the log. The types of loss may include fire, lightning, burglary,
theft, robbery, water, wind, flood, vehicle, vandalism, smoke, employee
dishonesty and other.
[0166] Item 21-23 are used substantially the same as the self-insured
model. Items 24-29 are used somewhat differently.
[0167] Item 25 would be changed to read "Business Personal
Property". It allows the claimant to choose whether there is
building damage, business personal property, money/securities, business
earnings and extra expense, or other damage. It can be a drop down
menu. More then one box may be checked. Item 27 is changed to read
Business Earnings, item 28 is changed to read Extra Expense, and
item 29 is changed to read Other which, in turn, can be described
in box 30.
[0168] Item 30 provides a narrative section where the person filling
out the form can enter other types of property damages that are
not already included in the boxes checked for personal property,
jewelry, etc.
[0169] Item 31 allows the claimant to estimate the total dollar
amount of all damages. This is important and may be provided as
a drop down that allows the claimant to choose a dollar range (e.g.,
1 to 1000; 1001 to 2,500; 2501 to 3,500; 3,501 to 5,000; 5001 to
7,500; 7,501 to 10,000).
[0170] Items 32-37 are used in a similar manner to that of the
self-insured model. Item 38 is used somewhat differently.
[0171] When item 38 is activated, the claim is saved and assigned
a claim number assuming that this page has been accurately completed.
It takes the claimant to the next screen. If the Emergency Box was
checked in the initial page from the claim instructions, then the
next page that it takes the claimant to is page 6, which is the
emergency research page. Otherwise it takes the claimant to page
7, if building damages were indicated, page 8 if business personal
property was indicated or page 9 if business income and extra expense
were indicated. If more than one category was entered on items 24
thru 29, then it takes the claimant thru these damage screens sequentially.
[0172] Once the claim report is complete and emergency contact
is sent, some claims are declined for online adjusting and must
be handled by an adjuster. The client may request all claims be
completed online as opposed to just those being adjusted electronically.
For commercial lines, this will require a substantial database.
Once the claim is assigned to an adjuster, the data and future claim
information goes with the client and the claim on system 10 is closed
and marked assigned to adjuster.
[0173] Those claims assigned to the adjuster and retained on the
system 10 will require an adjuster authorization/approval once the
client's customer submits the online information for damages. All
claims reported may remain in a pending or open status for a specified
time, 30, 60, and 90 days, or longer. A claim number is assigned
at this point and can be referred to later by the claimant to come
back online and complete various damage screens to conclude and
submit the claim online for settlement.
[0174] Page 6, items 39-44 are used substantially as described
for the self-insurance model. However, if Business Personal Property
(item 25, 26, 27, 29 and 30) were selected on the claim report,
then the claimant would get the business personal property damage
screen, which is page 8. If business earnings and extra expense
is involved (e.g., Box 28 is selected), page 9 must also be completed.
This follows for each class of damage with a specific page.
[0175] Page 7 is used substantially as described for the self-insured
model. However, item 93 is the NEXT button and, when selected, causes
the claimant to go to the Business Personal Property Damage (page
8) if business personal property has been identified on the claim
report (page 5, item 25). If not, then the claimant it taken to
Business earnings and Extra expense (page 9) if has been identified
on page 5 item 28. Otherwise, it proceeds to the Sworn Statement,
page 10.
[0176] Page 8 is used somewhat differently. For example, items
94-98 may be relabeled as follows; item 94 is labeled Merchandise,
item 95 is Equipment, item 96 is Office Furniture and Equipment,
and item 98 is Other.
[0177] Item 97 lists the claim number. Each page will always include
the assigned claim number for the claim. One claim number will be
used for each occurrence/claim reported and each claim may include
damages such as building, business personal property and business
earnings and extra expense.
[0178] Items 99-104 identifies salvage through a series of questions
and rules. In business personal lines, the claimant is asked if
there is salvage. If yes, a salver needs to be notified and the
claim is assigned to an adjuster if the client doesn't wish to use
salvers direct.
[0179] Items 105-175 are used by the customer to enter information
about damaged business personal property. The columns and column
headings for all merchandise from the self-insured program are deleted.
In its place is the Property Damage section from Self-Insured Items
230 thru 255. Business Personal Property is now the property damage
section exactly as it was under the self-insured model. In this
area, the claimant can enter all business personal property including
tenant improvements in a leased facility. The item number 175 Total
Business Personal Property is carried forward to the Sworn Statement
in proof of Loss, page 10.
[0180] Item 176 requires the client to agree to replace the business
personal property in accordance with the policy terms and conditions
that require replacement in order to collect replacement cost coverage.
Verification of replacement is difficult. Therefore the client's
customer must enter his acceptance via item 176, replacement of
property. The wording for the agreement is changed to require acceptance
of this condition.
[0181] Item 177 "NEXT" continues and takes the claimant
to Business Earnings and Extra Expense (page 9), if these types
of damages are applicable to this claim as previously selected on
the claim report. If not, the claimant is taken to the Sworn Statement
in Proof of Loss (page 10).
[0182] Page 9 is used somewhat differently. Item 178 is the claim
number. Again, this is on every page.
[0183] Items 179-229 falls under the Extra Expense heading found
in items 256 thru 280. In the Commercial Program, Payroll is part
of extra expense category of damages and should read Extra Expense-Payroll.
If Business Earnings is claimed, then payroll would not be allowed,
as it is a continuing expense and part of the business earnings
calculation.
[0184] Items 230-255 the wording of the previously used Property
Damage is changed for commercial lines to read Business Earnings.
The columns and heading titles also change. The first column will
recite the question "How long has the business been totally
or partially interrupted?" An entry box next to the question
will provide a drop down menu for business hours and business days
and then an interactive box for the claimant to enter the amount
of time. For example, 3 business days. The next question will be
"How much of the estimate was lost in net income?" A box
to enter a dollar amount is provided. Business Earnings is a very
difficult area of damage and some clients may require any claim
of business earnings loss to be assigned to an adjuster. Others
may allow small claims, under $1,000 for lost business earnings.
In the system 10, $2,500 may be allowed for business earnings before
the loss is assigned out to an adjuster.
[0185] Other clients may have programs that allow a Valued Daily
Limit (VDL) for business income. For example, the policy has a VDL
of $1,000 per day. This means the client will pay $1,000 per day
for up to 30 days loss of business income when the business is closed
due to damage or destruction of the building or business personal
property by a covered cause of loss. As such, a client may claim
the business was shut down for three days at $1,000 per day for
a $3,000 total business earnings loss. Some clients may have a Valued
Daily Limit. If so, a per-day allowance may be allowed without the
assignment of an adjuster. The system 10 multiplies the per-day
allowance by the number of days down and calculates a total value.
Alternatively, the system 10 takes the hours of a day (say 4 hours
were lost or half a day) and allows a proportion of a day, in this
case 50%. If a valued daily limit is not used, then a net income
per day times the number of days lost may be used to get the business
earnings loss.
[0186] Items 256-281 provide information about Extra Expense. The
heading "Acct. No." can be changed to "Incurred"
or "Estimated", the claimant must choose one of the two
categories. The client may require all claims with estimated extra
expense over a certain dollar parameter be reported to the company
for an adjuster to be assigned. The system 10 may allow up to $2,500
estimated or incurred extra expense before the claim is assigned
to an adjuster.
[0187] The total for Business Earning, Extra Expense and Payroll
Extra Expense is calculated and transferred to the Summary of Business
Earnings and Extra Expense and totaled. That total in item 285 is
carried forward to the Sworn Statement In proof of Loss on page
10. Page 10 is used substantially as described for the self-insured
model.
[0188] The use of the system 10 by a client offering personal lines
insurance will be considered next. For ease of explanation, only
the differences in operation of the system 10 in handling claims
between self-insured clients and personal line clients will be discussed.
[0189] In this regard, webpages 1-10 may be used for personal line
insurance in a manner similar to the self-insured context. In addition,
databases 26, 28, 30 may be used in a similar manner.
[0190] With regard to general rules, the claim frequency check
may be somewhat different. In this regard, the system 10 may search
the insured's name, loss location, other names and date of loss.
If the same insured or loss address/location has more than three
occurrences/losses in a 12 month period, then the claim cannot be
adjusted electronically and must be assigned to an adjuster for
investigation/resolution. The number of occurrences are client specific.
All claims will be referred to an outside service/database for a
fraud check. If the claim is immediately assigned (does not meet
fast track parameters) to an adjuster, then the fraud check will
still be completed and the results reported to the client.
[0191] When the claim report (page 5) is completed, a claim number
is assigned. This is recorded in the claim record. Page 4 provides,
in printable format, directions for the claim report and damage
pages. The client's customer is instructed how to complete the form
and assess damages and what they need to provide for completion
of the remaining screens. Damages may include building damage repair
costs, inventory of contents/personal property and additional living
expense. The instruction page (page 4) and damage documentation
screens (pages 7, 8 and 9) can be printed in hard copy so the client's
customer (the insured) can have documentation to help obtain the
information they will need to complete the claim.
[0192] Based upon the client's specified time limitation the insured/client's
customer have 30, 60, 90 days or longer to gather the information
and complete the claim. During this time period the client's customer
can sign onto the system 10 and enter the claim number to recall
their claim record. They can then proceed to enter the necessary
information on each page (page 7, 8 or 9) for the damage.
[0193] Once the damage pages are completed as required, the final
page, page 10, Sworn Proof of Loss must be completed. Most of the
blanks on this page can be retrieved automatically or manually from
the claim report and damage pages to complete the claim document.
[0194] The client's customer (the insured) must review the sworn
statement in proof of loss on page 10, the data and information
being submitted and submit this data as a completed claim. If it
meets all criteria for an online adjusted claim, then the payment
request with summary of the claim data and damages is sent to the
client's claim department in a batch transmission. Protocol for
transmission may be established with client. Once the claim is transferred
to the client, the claim is closed and its status is saved in the
record; i.e. referred for adjustment, payment requested, pending,
closed at insured's request.
[0195] If the claim has been referred to an adjuster, then the
claim is closed and the record is marked as referred to an adjuster.
The claim, once referred to an adjuster, cannot be referred back
to the system 10 for adjustment.
[0196] The client must choose the dollar threshold within which
a claim can be approved using the online adjusting process. The
system 10 may use $5,000 as this threshold. The total dollar damages
estimated (item 31 on page 5) is checked against this threshold.
If the loss exceeds $5,000, then the adjuster/client is immediately
notified of the claim and the client's customer is notified that
an adjuster has been assigned.
[0197] When the claim damage pages are completed within the 30,
60 or 90 days as chosen by the client and the total damages (item
295) exceed the $5,000 threshold, as described above, the loss is
assigned to an adjuster. This is so even in the case where the initial
estimate (item 31) was below the threshold initially.
[0198] If the loss occurs off premises (item 22) the claim is immediately
assigned to an adjuster when the claim report is completed.
[0199] The system 10 runs each word in the "description of
loss" (item 37) against a list of key words. The client can
choose the key words by the type of policy they offer. Those key
word can include a broad range of descriptive terms to allow the
program to tightly limit the automatic payment of each claim or
it can include a very limited number of words, allowing claims to
pass and be electronically adjusted without an adjuster assigned.
[0200] In the personal lines example, if only building damages
are claimed, then the list of key words is different than if personal
property damages are also claimed and included. This may also vary
by policy prefix. By this it is meant that some policies (identified
by a prefix e g. CBX) will only use the building and personal property
(PP) list (List A). Other policy prefix types may require a different
list of key words (List B).
[0201] "Building & PP" keywords are List A. "Damages
Include PP" is List B.
[0202] For List A (bldg & PP) if a key word for the list matches
any word in the Description of Loss (item 37), then the claim is
immediately assigned to an adjuster. For List B (includes PP) if
a key word is not present in the Description of Loss (item 37) the
loss is assigned out to an adjuster.
[0203] It has been recognized that the system may get a claim with
a policy prefix that is identified as not being applicable to List
A, but only have building damages. In this case, List A would be
used. If personal property damage were added to the claim, List
B would then have to apply.
[0204] For example a claim may be submitted with a policy prefix
that is not specifically associated with List A. However, only building
damages (Bldg.) are claimed (no personal property). In this case,
only List A would be used.
[0205] In another example, a claim has both building and personal
property damages, the policy prefix that is not specifically directed
to List A and therefore List B will apply. List B requires one of
the keywords in List B to be in the description of loss (item 37).
If not, there is no match and the loss is assigned to an adjuster
after recording the information on the claim. If a word in the description
of loss (item 37) matches the List B keyword the claim continues
to be adjusted electronically.
[0206] In another example, the policy prefix is identified from
a list of certain prefixes to use List A. If a keyword in the Description
of Loss (item 37) matches a word from the List A the loss is assigned
out to an adjuster.
[0207] Each phrase in the key words must match exactly. For example,
if the key word is "power surge", the word "power"
itself will not be sufficient to cause an adjuster to be assigned.
The key words that may be used in "List A" for Personal
Lines is as follows: surge, electrical surge, power surge, power
failure, utility interruption, ordinance, law, earthquake, quake,
flood, surface water, waves, pump, sump pump, property in transit,
shipment, missing property, lost property, lost, missing, neglect,
intentional, defective, maintenance, credit card, fraud, checks,
money order, war, terrorism, municipality, code, penalty, insect,
cracking, settling, cracking, bulging, expansion, shrinkage, wear,
tear, wear and tear vacant, mechanical, mechanical breakdown, smog,
animals, birds, under construction, rust, corrosion, deterioration,
nuclear, atomic, invasion, governmental, pollutant, contaminant,
shortage, mysterious, disappear, indirect, sewer backup, sewer,
sewage, drain backup, backup of sewer, backup of drain, mold, fungus,
wet rot, dry rot, rot, rotten and converted.
[0208] Key words that may be used for List B (words must match
or claim is referred to an adjuster) may be as follows: fire, lightning,
wind, windstorm, hail, storm, explosion, riot, civil, civil commotion,
aircraft, plane, vehicle, car, smoke, vandalism, mischief, malicious
mischief, theft, falling, weight of ice, weight of snow, water,
freezing, volcano and volcanic.
[0209] The lists of damaged items (items 68-87) and description
column (items 105-175) may be compared with a list of key word called
"property not covered" as follows: animals, animal, birds,
bird, fish, property of others, automobile, car, vehicle, motor
vehicle, land, money, cash, checks, sentimental, sentimental value,
leased property, lease, leased, crops, growing crops, property sold,
property in transit, missing, credit, credit card, credit fraud,
electronic funds, loss assessment, neighbor, cousin and parent.
[0210] If item 35 is checked yes or chosen in a drop down menu
indicating a third party may be responsible the claim is automatically
assigned to an adjuster once the client's customer completes the
claim report.
[0211] If emergency services are required in any of items 39-43,
then an adjuster is assigned to investigate immediately when the
claim report is completed. This is client controlled to determine
at what level the adjuster is involved.
[0212] The type of loss drop down (item 20) may include the following
list of losses: fire, smoke, wind, hail, vandalism, theft, burglary,
robbery and other.
[0213] Employee dishonesty is not applicable to a Personal Lines
type claim.
[0214] The client's customer enters the deductible amount. On personal
lines type policies this can be $100 to $5,000 and can vary incrementally.
If a zero deductible is chosen, then the loss may be assigned to
an adjuster. Each client will provide parameters for the deductible
to be entered by their customer.
[0215] Once the claim report exceeds the threshold time allowed
by the client, it is assigned out to an adjuster. For example, if
the time to submit damages is 30 days and the claimant exceeds 30
days, an assignment of the claim is made to an adjuster.
[0216] Turning now to the page/item rules, page 1 (FIG. 2) may
identify the personal lines carrier and the claim process. Page
2 (FIG. 3) may provide explanatory information as follows.
Personal Lines Insurance Company
[0217] Our customers, insureds and agents may now report a claim
online to be immediately adjusted, paid and closed, if possible.
Some claims may require additional information before they can be
concluded. If you, you will be contacted by an adjuster. Please
enter your policy number and name as it appears on your policy.
[0218] Page 3 (FIG. 4) may provide explanatory information as follows.
[0219] The icon from the fast track claim welcome screen takes you
to the client's introduction page. It is proprietary to the client
in style based upon that client's wants and needs for a Personal
Lines insurance company. It may provide specific information to
file the claim.
Personal Lines Insurance Company
[0219] [0220] Please report your claim by completing the online
claim report questionnaire. Once completed a claim number will be
assigned and provided to you to complete your claim. You have 30
days to gather information about your damages and complete the online
claim. [0221] For building damages you should estimate the cost
to repair or replace the damaged property. You may know some of
the material if you intend to do repairs yourself, allowing a reasonable
charge for your own labor. If you need a contractor you may search
on the list of approved contractors in your area, or obtain one
of your own choosing. For the estimate you will need to provide
the breakdown of costs online. [0222] For personal property, also
referred to as contents, you will need to list each item, its description;
age by month and year, original cost and cost to replace today.
To obtain replacement cost at this time or before replacing you
must agree to comply with the policy conditions that require you
to replace the property. As such, you must agree online that the
property will be replaced. [0223] If you have incurred additional
living expense. This is expense to continue living when you are
unable to live in your own home due to damage or destruction you
must itemize the cost/expense you will incur. Hotel charges, additional
rent, phone, and laundry. These expenses must be over and above
your normal everyday charges. If you will require and extended time
an indicate this so an adjuster may contact you as soon as possible.
[0224] Should you have questions please use the toll free number
or contact us by email at homeowners com. Once the claim report
and damages are reported and acknowledged your claim may be adjusted
and concluded online or an adjuster will be assigned. You will be
notified immediate if an adjuster is assigned.
[0225] Page 3 (FIG. 4) requires the claimant (client's customer)
who is signing-on to check a box (item 2) agreeing to the terms
and conditions of the program. This will be required in addition
to the name and relation to the named insured to continue.
[0226] Item 3 requires entry of the full name of the person entering
the site. This will be included within the claim record as the person
reporting the claim.
[0227] Item 4 requires entry of the relationship to the named insured.
A drop down box may be provided that allows entry of the relationship
(e.g., as the named insured, a resident relative (indicate which)
or agent). This will also be included within the claim record.
[0228] Item 5 allows the claimant to enter a claim number. This
is to signify a new claim or follow-up on an existing claim. If
new, it takes the customer to the claim instruction page. This is
retained in the claim record and on the log.
[0229] Item 6 allows the claimant to enter the date the loss is
reported. This is retained in the claim record and within the log.
Item 7 indicates activation of the NEXT icon which takes the claimant
to Page 4.
[0230] Page 4 is used substantially the same as in the self-insured
model. Page 5 is used somewhat differently.
[0231] For example, item 9 allows the claimant to enter a policy
number. In this regard, most policy numbers have two parts, a prefix
and a number e g. PRO 00223547. This is client specific and is used
by the client to identify their insured.
[0232] Item 10 allows entry of the effective date of the policy.
This date must be after the date of loss, item 18, or the claimant
will be asked to confirm that the date is correct. If the claimant
indicates that the entered date is correct and is before the policy
date, then the loss will be assigned to an adjuster.
[0233] Items 11 and 12 allows entry of ownership information. Selection
of boxes 11 or 12 on the claim report may activate a drop down menu
to determine if the premises are owned, rented or leased.
[0234] Item 13 allows entry of an address. In this case, the street
address of the premises insured. Items 14-19 are used in a manner
similar to the self-insured claim.
[0235] Item 20 may be a drop down menu. The drop down menu may
include a line for customer to choose various types of loss. This
type of loss will go on the log. Loss types may include fire, lightning,
burglary, theft, robbery, water, wind, flood, vehicle, vandalism,
smoke, and other.
[0236] Item 21 may allow entry of a location of loss. It is compared
with item numbers 13 and 14 earlier in the claim report and if the
location of loss is different then the location described in 13
and 14, the claim would be declined and assigned to an adjuster
for investigation.
[0237] Item 22 and 23 allow selection of whether the loss occurred
on or off premises. Boxes 22 and 23 can be drop down menus. If an
off premises loss if selected, the claim is declined and assigned
out to an adjuster for investigation.
[0238] Items 24-29 are used somewhat differently. The text associated
with item 25 may be changed to Personal Property. Items 24-29 allow
the claimant to choose whether there is building damage, personal
property, furniture, clothing, tools, money, securities, jewelry,
additional living expense, or other damage. The claimant may chose
more than one. Items 24-29 can be a drop down menus.
[0239] Item 30 is an interactive box that allows the claimant to
enter a narrative of the types of property damages that are not
already included in the boxes checked for personal property, jewelry,
etc.
[0240] Item 31 allows the claimant to enter an estimate of the
total dollar amount of all damages. Item 31 may also include a drop
down menu that allows someone to choose a dollar range (e.g., 1
to 1000; 1001 to 2,560; 2501 to 3,500; 3,501 to 5,000; 5001 to 7,500;
7,501 to 10,000).
[0241] Items 32-34 are used in a manner that is substantially the
same as the self-insured model. Items 35 and 36 allows the claimant
to make a selection of whether a third party is legally responsible
for damage. The entry can be a yes or no. Alternately, items 35
and 36 may be provided as a drop down menus of various third party
options.
[0242] Item 37 is used in a manner substantially the same as in
the self-insured model.
[0243] When Item 38 is activated, the claim is saved and assigned
a claim number once this page is accurately completed. It takes
the claimant to the next screen. If the Emergency Box was checked
in the initial page from the claim instructions, then the claimant
it taken to page 6, which is the emergency research page. Otherwise
activation of the NEXT softkey 38 takes the claimant to page 7 if
building damages were indicated, otherwise page 8 if personal property
was indicated or page 9 if additional living expense were claimed.
If more than one category was entered on items 24 thru 29, then
the system 10 takes the claimant thru these damage screens sequentially.
[0244] Once the claim report is complete and emergency contact
are requested, some claims are declined for online adjusting and
must be handled by an adjuster. The client may request all claims
be completed online as opposed to just those being adjusted electronically.
For personal lines this will require a substantial database. Once
the claim is assigned to an adjuster the data and future claim information
goes with the client and the claim on the system 10 is closed and
marked assigned to adjuster.
[0245] Those claims assigned to the adjuster and retained on the
system 10 will require an adjuster authorization/approval once the
client's customer submits the online information for damages. All
claims reported may end in a pending or open status for a specified
time, 30, 60, and 90 days, or maybe longer. A claim number is assigned
at this point and can be referred to later by the claimant to come
back online and complete various damage screens to conclude and
submit the claim online for settlement.
[0246] Page 6 (FIGS. 8-9) are used somewhat differently. For example,
item 39 allows the claimant to select the Adjuster Box 39 for serious
and large loss. When the Adjuster Box is checked, the claim is reported
by email or pager on a priority basis to the insurance company for
an adjuster to be assigned and to make the phone call to the emergency
cell phone number of the claimant. The client will determine how
these are to be reported
[0247] Item 40 allows the claimant to indicate that they need emergency
services for water, fire or smoke restoration. In this case, the
claimant checks box number 40 and the adjuster (or vendor) is sent
the emergency cell phone number by pager. The client will determine
which vendor, if any, will be assigned to receive emergency notification.
[0248] Activation of item 41 allows a claimant to request salvage
teams to remove damaged merchandise. The cell phone number of the
claimant is sent by pager to a vendor. Again, the client will determine
which salvage vendor is on the program.
[0249] Activation of item 42 allows the claimant to request an
investigation and expert (especially if others may be legally responsible
for property damage). Again, the cell phone number of the claimant
is sent by pager to the investigator. This may first go to an adjuster
and the adjuster will determine what type of expert and who needs
to be assigned, if any.
[0250] Activation of item 43 allows the claimant to request a building
contractor or construction team. The contractor is notified by pager.
The insurance company will determine if their contract repair vendor
list can be utilized and how.
[0251] Activation of the SUBMIT item 44 causes the target of all
the boxes, 39-43, which were checked to receive a priority e-mail
or page advising them of the emergency number that was collected
from the claim report Item 32. The system 10 would send an e-mail
to the claimant at the email address that they provided in the claim
report advising them that the emergency claim report of damage was
received and they will be contacted shortly. If they do not hear
from somebody shortly, then the system 10 will provide an alternative
phone number the claimant can call in an emergency.
[0252] If from the claim report (FIGS. 6-7), the claimant clicks
NEXT 38 and in the claim instruction page (FIG. 5), they did not
identify this as an emergency, then the system 10 would take the
claimant to the damage pages. The damage pages depend upon what
was identified as being damaged in the claim report, items 24 thru
30. For example if the building (item 24) was damaged it would start
with page 7.
[0253] If Personal Property (item 25, 26, 27, 29 and 30) were checked
on the claim report, the claimant would get the personal property/contents
damage screen, which is page 8. If additional living expense is
indicated by checking Box 28, then page 9 (FIGS. 13-14) would need
to be completed. This follows for each class of damage with a specific
page.
[0254] Page 7 (FIGS. 9-10) may also be used somewhat differently.
Items 46-53 are directed to damage to the building. The legent of
item 49 is changed to Garage. Item 54 is the claim number and may
start with numbers specific to the client.
[0255] Item 55 allows entry by the claimant of a job number assigned
for building repairs by the preferred contractor, if any. If no
preferred contractor is assigned this can be left blank. The claimant
may need to indicate whether a preferred contractor was selected.
[0256] Item 56 is the total estimated building damages. This is
not the amount claimed.
[0257] Item 57-59 can be a drop down menu that allows the claimant
to enter whether or not he has an estimate. If yes, the claimant
is prompted to enter the appropriate information in interactive
boxes 60-66. If no, the customer receives information to contact
a contractor. This may coincide with the use of item 55 to enter
the contractor number and allows the system 10 to determine if it
is a preferred contractor. Items 60-66 are contingent on the answer
to item 57.
[0258] Item 67-88 are used similarly to the self-insurance model.
Item 89, 91 & 92 requires the claimant to enter name, phone
number and e-mail of the estimator for the contractor providing
the estimate.
[0259] Item 90 requires the claimant to agree to direct damages.
This is a required item that must be checked to continue.
[0260] Item 91 and 92 require the claimant to enter the office
phone number and e-mail address of the estimator for the contractor,
if any, who will do the work. If there is none, the system 10 provides
a drop down menu to indicate there is no estimator.
[0261] Activation of the NEXT softkey 93 causes the system 10 to
go to the Personal Property Damage (page 8), in the case where personal
property/contents (personal property includes jewelry, money, tools,
anything that is not real property or additional living expense)
had been identified on the claim report (page 5, item 25). If not,
the claimant is taken to Additional Living Expense (page 9), in
the case where additional living expense is identified on page 5
item 28. Otherwise the system 10 proceeds to the Sworn Statement,
page 10.
[0262] Page 8 (FIGS. 11-12) may also be used somewhat differently.
For example, items 94-98 can be eliminated and do not apply to personal
lines.
[0263] Item 97 lists the claim number. Each page will always have
the claim number of the assigned claim. One claim number is provided
for each occurrence/claim reported and one claim may include damages
such as building, personal property and additional living expense.
[0264] Items 99-104 identifies salvage through a series of questions
and rules. In personal lines, the system 10 asks if there is salvage,
yes or no. If yes, a salver needs to be notified and the claim is
assigned to an adjuster if the client doesn't wish to use salvers
direct.
[0265] Items 105-175 are used by the customer to enter information
about damaged personal property. The column for division, quantity,
sell price can be eliminated. The claimant still needs an item number
and description. Mark down is changed to Original Cost. Cost is
changed to Replacement Cost. Amount Claimed is the same as Replacement
Cost for each item and totals are taken to the bottom, item 175.
If the client is paying replacement cost up front once the customer
agrees to replace, item 176, then there are no further calculations.
[0266] Item 176 requires the client to agree the replace the property
in accordance with the policy terms and conditions that require
replacement in order to collect replacement cost coverage. Verification
of replacement is difficult. Therefore the client's customer must
agree by selecting item 176, replacement of property. The wording
for the agreement is changed to reflect this condition.
[0267] Item 177 "NEXT" continues and goes to Additional
Living Expense (page 9), if these types of damages are applicable
to this claim. If not, it goes to the Sworn Statement in Proof of
Loss (page 10).
[0268] Page 9 is used in a manner that is somewhat different than
the use in the self-insured model. Item 178 is the claim number,
again this is on every page.
[0269] Items 179-229 is eliminated for personal lines. Items 230-255
is also eliminated for personal lines.
[0270] Items 256-281 provide information about Additional Living
Expense. The Acct. No. can be changed to Incurred or Estimated and
the claimant must choose one of the two categories. The client may
require all claims with estimated additional living expense over
a certain dollar parameter be reported to the company for an adjuster
to be assigned. The system 10 allows up to $1,000 estimated or incurred
additional living expense.
[0271] Total for Additional Living expense, Item 281, is carried
to the Sworn Statement In proof of Loss on page 10, Item 294. Items
281, 283 and 284 are eliminated for personal lines.
[0272] Item 286 requires that the claimant agree that all costs
will be incurred. If it is not checked, then the claim can not continue
with the NEXT icon 287.
[0273] The NEXT icon 227 takes the claimant to the final document
for the claim, the sworn statement in proof of loss on page 10.
[0274] Page 10 (FIGS. 16-17) are also used somewhat differently.
Item 288, the claim number carries over and is on every page. Item
289 is the same as item 20 from the claim report found on page 5.
Item 290 is the same as item items 18 and 19 from the claim report
found on page 5. It states the date and time of the loss. Item 291
is the same as item 37 on the claim report found on page 5. This
provides a detailed description of the loss. The word "is"
as the end of this item can be deleted. Item 292 is the same as
total building damages found in item 88 on page 7. It carries forward.
[0275] Item 293 is the same as the total content damages item 175
found on page 8. It carries forward. Merchandise is changed to Personal
Property.
[0276] Item 294 is the same as total additional living expense
item 281 found on page 9. It carries forward.
[0277] Item 295 adds and totals here items 292, 293 and 294. Item
296 is taken from General Rule 16 for deductibles. The claimant
must enter the amount of their deductible to continue. The system
10 may use a $500 deductible.
[0278] Item 297 is the net claim and is determined by subtracting
the deductible, item 296 from the total damages, item 295. The result
is entered in item 297.
[0279] Item 298 requires the claimant to agree to a statement verifying
the validity of the claim. The check mark has the same force and
effect as a signature. A space may also be provided where the person
is required to type in their name and e-mail address.
[0280] The final icon 299 is SUBMIT. The claim report with the
damage pages and proof of loss are emailed to the client's accounting
department and others as identified on the distribution list. Additionally,
the person that agreed to the terms, item 298, and entered their
name and email address is on the distribution.
[0281] A specific embodiment of method and apparatus for processing
insurance claims has been described for the purpose of illustrating
the manner in which the invention is made and used. It should be
understood that the implementation of other variations and modifications
of the invention and its various aspects will be apparent to one
skilled in the art, and that the invention is not limited by the
specific embodiments described. Therefore, it is contemplated to
cover the present invention and any and all modifications, variations,
or equivalents that fall within the true spirit and scope of the
basic underlying principles disclosed and claimed herein. |