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Insurance Abstract
An insurance enrollment and underwriting method includes comprising
providing a first user interface with one or more controls for enabling
a user to specify one or more health conditions in an enrollment
application for pet health insurance. Data representing one or more
health conditions specified through the first user interface is
received and electronically processed, flagging each condition as
a condition that is acceptable, precluded, or for manual review.
Insurance Claims
1. An insurance enrollment and underwriting method, comprising:
providing a first user interface with one or more controls for enabling
a user to specify one or more health conditions in an enrollment
application for pet health insurance; receiving data representing
one or more health conditions specified through the first user interface;
and electronically processing the data representing the one or more
health conditions and electronically flagging each condition as
a condition that is acceptable, precluded, or for manual review.
2. The method of claim 1, further comprising: returning a second
user interface presenting information indicating declined enrollment
if at least one of the conditions is flagged as precluded; returning
a third user interface presenting information indicating approved
enrollment, if all of the conditions are flagged as acceptable;
and returning a fourth user interface presenting information indicating
the need for a manual review if none of the conditions is flagged
as precluded and at least one of the conditions is flagged manual
review.
3. The method of claim 2, further comprising following a return
of the third user interface establishing an electronic record associated
with an active policy for pet health insurance, the electronic record
containing the data representing one or more health conditions specified
through the first user interface and data representing an effective
date for the policy.
4. The method of claim 3, further comprising: providing a fifth
user interface having controls for enabling a user to submit a claim
with respect to the active policy, the controls enabling the user
to specify a diagnosis for which coverage is requested; receiving
data representing the diagnosis; electronically processing the data
representing the diagnosis with the electronic record associated
with the active policy comparing the data representing the diagnosis
with the data representing one or more health conditions specified
through the first user interface and comparing a date of the claim
with the data representing the effective date of the active policy.
5. The method of claim 4, wherein electronically processing includes
flagging the diagnosis as limited where the comparison of the data
representing the diagnosis with the data representing one or more
health conditions reveals that the diagnosis is for a condition
identified by the data representing one or more health conditions;
and otherwise determining if the diagnosis is for a suspect condition
or a non-suspect condition and: flagging the diagnosis as covered
if the diagnosis is for a non-suspect condition; flagging the diagnosis
for manual review if the diagnosis is for a suspect condition.
6. The method of claim 5, wherein determining comprises: determining
the diagnosis to be for a non-suspect condition if a difference
between the date of the claim and the effective date of the active
policy exceeds a predetermined duration; otherwise determining the
diagnosis to be for a non-suspect condition.
7. The method of claim 6, comprising selecting the predetermined
duration according to the diagnosis.
8. The method of claim 5, further comprising: returning a sixth
user interface presenting information indicating claim approval
if the diagnosis is flagged approved; returning a seventh user interface
presenting information indicating claim limitation, if the diagnosis
is flagged as limited; and returning an eighth user interface presenting
information indicating the need for a manual claim review if the
diagnosis is flagged for manual review.
9. An insurance enrollment and underwriting method, comprising:
providing client computing devices for use by each of a plurality
of pet health care providers, each client computing device being
operable to display user interfaces and to receive and transmit
user input; providing a selected one of the client computing devices
with a first user interface with one or more controls for enabling
a user to specify one or more health conditions in an enrollment
application for pet health insurance; receiving data representing
one or more health conditions specified through user input received
at the selected one of the client computing devices in response
to a display of the first user interface; and electronically processing
the data representing the one or more health conditions and electronically
flagging each as a condition that is acceptable, precluded, or manual
review; returning a second user interface to the selected one of
the client computing devices if at least one of the conditions is
flagged as precluded, the second user interface presenting information
indicating declined enrollment; returning a third user interface
to the selected one of the client computing devices if all of the
conditions are flagged as acceptable, the third user interface presenting
information indicating approved enrollment; and returning a fourth
user interface to the selected one of the client computing devices
if none of the conditions is flagged as precluded and at least one
of the conditions is flagged manual review, the fourth user interface
presenting information indicating the need for a manual review.
10. The method of claim 9, further comprising following a return
of the third user interface establishing an electronic record associated
with an active policy for pet health insurance, the electronic record
containing the data representing one or more health conditions specified
through the first user interface and data representing an effective
date for the policy.
11. The method of claim 10, further comprising: providing a fifth
user interface to a selected one of the client computing devices,
the fifth user interface having controls for enabling a user to
submit a claim with respect to the active policy, the controls enabling
the user to specify a diagnosis for which coverage is requested;
receiving data representing the diagnosis specified through user
input received at the selected one of the client computing devices
in response to a display of the fifth user interface; electronically
processing the data representing the diagnosis with the electronic
record associated with the active policy comparing the data representing
the diagnosis with the data representing one or more health conditions
specified through the first user interface and comparing a date
of the claim with the data representing the effective date of the
active policy; flagging the diagnosis, wherein flagging comprises:
selecting a predetermined duration according to the diagnosis; determining
the diagnosis to be for a pre-existing condition where the comparison
of the data representing the diagnosis with the data representing
one or more health conditions reveals that the diagnosis is for
a condition identified by the data representing one or more health
conditions; determining the diagnosis to be for a non-suspect condition
if a difference between the date of the claim and the effective
date of the active policy exceeds the predetermined duration; determining
the diagnosis to be for a suspect condition if a difference between
the date of the claim and the effective date of the active policy
does not exceed the predetermined duration; flagging the diagnosis
as limited if the diagnosis is determined to be for a pre-existing
condition; flagging the diagnosis as covered if the diagnosis is
determined not to be for a pre-existing condition and is also determined
to be non-suspect; flagging the diagnosis for manual review if the
diagnosis is determined not to be for a pre-existing condition and
is also determined to be suspect; returning a sixth user interface
to the selected one of the client computing devices if the diagnosis
is flagged approved, the sixth user interface presenting information
indicating claim approval; returning a seventh user interface to
the selected one of the client computing devices if the diagnosis
is flagged as limited, the seventh user interface presenting information
indicating claim limitation; and returning an eighth user interface
to the selected one of the client computing devices if the diagnosis
is flagged for manual review, the eighth user interface presenting
information indicating the need for a manual claim review.
12. A computer readable medium and computer executable instructions
for: providing a first user interface with one or more controls
for enabling a user to specify one or more health conditions in
an enrollment application for pet health insurance; receiving data
representing one or more health conditions specified through the
first user interface; and electronically processing the data representing
the one or more health conditions and electronically flagging each
as a condition that is acceptable, precluded, or manual review.
13. The medium of claim 12, having further instructions for: returning
a second user interface presenting information indicating declined
enrollment if at least one of the conditions is flagged as precluded;
returning a third user interface presenting information indicating
approved enrollment, if all of the conditions are flagged as acceptable;
and returning a fourth user interface presenting information indicating
the need for a manual review if none of the conditions is flagged
as precluded and at least one of the conditions is flagged manual
review.
14. The medium of claim 13, having further instructions for, following
a return of the third user interface, establishing an electronic
record associated with an active policy for pet health insurance,
the electronic record containing the data representing one or more
health conditions specified through the first user interface and
data representing an effective date for the policy.
15. The medium of claim 14, having further instructions for: providing
a fifth user interface having controls for enabling a user to submit
a claim with respect to the active policy, the controls enabling
the user to specify a diagnosis for which coverage is requested;
receiving data representing the diagnosis; electronically processing
the data representing the diagnosis with the electronic record associated
with the active policy comparing the data representing the diagnosis
with the data representing one or more health conditions specified
through the first user interface and comparing a date of the claim
with the data representing the effective date of the active policy.
16. The medium of claim 15, wherein the instructions for electronically
processing include instructions for: flagging the diagnosis as limited
where the comparison of the data representing the diagnosis with
the data representing one or more health conditions reveals that
the diagnosis is for a condition identified by the data representing
one or more health conditions; and otherwise determining if the
diagnosis is for a suspect condition or a non-suspect condition
and: flagging the diagnosis as covered if the diagnosis is for a
non-suspect condition; flagging the diagnosis for manual review
if the diagnosis is for a suspect condition.
17. The medium of claim 16, wherein the instructions for determining
include instructions for: determining the diagnosis to be for a
non-suspect condition if a difference between the date of the claim
and the effective date of the active policy exceeds a predetermined
duration; otherwise determining the diagnosis to be for a non-suspect
condition.
18. The medium of claim 17, having further instructions for selecting
the predetermined duration according to the diagnosis.
19. The medium of claim 16, having further instructions for: returning
a sixth user interface presenting information indicating claim approval
if the diagnosis is flagged approved; returning a seventh user interface
presenting information indicating claim limitation, if the diagnosis
is flagged limited; and returning an eighth user interface presenting
information indicating the need for a manual claim review if the
diagnosis is flagged for manual review.
20. An insurance enrollment and underwriting system, comprising:
an enrollment engine operable to provide a first user interface
with one or more controls for enabling a user to specify one or
more health conditions in an enrollment application for pet health
insurance; an underwriting engine operable to receive and electronically
process data representing one or more health conditions specified
through the first user interface and to electronically flag each
as a condition that is acceptable, precluded, or manual review.
21. The system of claim 20, wherein the enrollment engine is operable
to: return a second user interface presenting information indicating
declined enrollment if at least one of the conditions is flagged
as precluded; return a third user interface presenting information
indicating approved enrollment, if all of the conditions are flagged
as acceptable; and return a fourth user interface presenting information
indicating the need for a manual review if none of the conditions
is flagged as precluded and at least one of the conditions is flagged
manual review.
22. The system of claim 21, wherein, following a return of the
third user interface, the underwriting engine is operable to establish
an electronic record associated with an active policy for pet health
insurance, the electronic record containing the data representing
one or more health conditions specified through the first user interface
and data representing an effective date for the policy.
23. The system of claim 22, further comprising: a claim submission
engine operable to provide a fifth user interface having controls
for enabling a user to submit a claim with respect to the active
policy, the controls enabling the user to specify a diagnosis for
which coverage is requested; and a claim adjusting engine operable
to receive data representing the diagnosis and to electronically
process the data representing the diagnosis with the electronic
record associated with the active policy comparing the data representing
the diagnosis with the data representing one or more health conditions
specified through the first user interface and to compare a date
of the claim with the data representing the effective date of the
active policy.
24. The system of claim 23, wherein the claim adjusting engine
is operable to: flag the diagnosis as limited where the comparison
of the data representing the diagnosis with the data representing
one or more health conditions reveals that the diagnosis is for
a condition identified by the data representing one or more health
conditions; and otherwise to determine if the diagnosis is for a
suspect condition or a non-suspect condition and: flag the diagnosis
as covered if the diagnosis is for a non-suspect condition, or flag
the diagnosis for manual review if the diagnosis is for a suspect
condition.
25. The system of claim 24, wherein the claim adjusting engine
is operable to determine if the diagnosis is for a suspect condition
or a non-suspect condition by: determining the diagnosis to be for
a non-suspect condition if a difference between the date of the
claim and the effective date of the active policy exceeds a predetermined
duration; otherwise determining the diagnosis to be for a suspect
condition.
26. The system of claim 25, wherein the claim adjusting engine
is operable to select the predetermined duration according to the
diagnosis.
27. The system of claim 24, wherein the claim submission engine
is operable to: return a sixth user interface presenting information
indicating claim approval if the diagnosis is flagged approved;
return a seventh user interface presenting information indicating
claim limitation, if the diagnosis is flagged limited; and return
an eighth user interface presenting information indicating the need
for a manual claim review if the diagnosis is flagged for manual
review.
28. An insurance enrollment and underwriting system, comprising:
client computing devices each positioned in a pet related location,
each client computing device operable to display user interfaces
and to receive and transmit user input; an enrollment engine operable
to provide a first selected one of the client computing devices
with a first user interface with one or more controls for enabling
a user to specify one or more health conditions in an enrollment
application for pet health insurance; an underwriting engine operable
to: receive data representing one or more health conditions specified
through user input received at the first selected one of the client
computing devices in response to a display of the first user interface;
and electronically process the data representing the one or more
health conditions and electronically flagging each as a condition
that is acceptable, precluded, or manual review; wherein the enrollment
engine is further operable to: return a second user interface to
the first selected one of the client computing devices if at least
one of the conditions is flagged as precluded, the second user interface
presenting information indicating declined enrollment; return a
third user interface to the first selected one of the client computing
devices if all of the conditions are flagged as acceptable, the
third user interface presenting information indicating approved
enrollment; and return a fourth user interface to the first selected
one of the client computing devices if none of the conditions is
flagged as precluded and at least one of the conditions is flagged
manual review, the fourth user interface presenting information
indicating the need for a manual review.
29. The system of claim 28, wherein, following a return of the
third user interface, the underwriting engine is operable to establish
an electronic record associated with an active policy for pet health
insurance, the electronic record containing the data representing
one or more health conditions specified through the first user interface
and data representing an effective date for the policy.
30. The system of claim 29, further comprising: a claim submission
engine operable to provide a fifth user interface to a second selected
one of the client computing devices, the fifth user interface having
controls for enabling a user to submit a claim with respect to the
active policy, the controls enabling the user to specify a diagnosis
for which coverage is requested; a claim adjusting engine operable
to: receiving data representing the diagnosis specified through
user input received at the selected one of the client computing
devices in response to a display of the fifth user interface; electronically
process the data representing the diagnosis with the electronic
record associated with the active policy comparing the data representing
the diagnosis with the data representing one or more health conditions
specified through the first user interface and comparing a date
of the claim with the data representing the effective date of the
active policy; select a predetermined duration according to the
diagnosis; determine the diagnosis to be for a pre-existing condition
where the comparison of the data representing the diagnosis with
the data representing one or more health conditions reveals that
the diagnosis is for a condition identified by the data representing
one or more health conditions; determine the diagnosis to be for
a non-suspect condition if a difference between the date of the
claim and the effective date of the active policy exceeds the predetermined
duration; determine the diagnosis to be for a suspect condition
if a difference between the date of the claim and the effective
date of the active policy does not exceed the predetermined duration;
flag the diagnosis as limited if the diagnosis is determined to
be for a pre-existing condition; flag the diagnosis as covered if
the diagnosis is determined not to be for a pre-existing condition
and is also determined to be non-suspect; flag the diagnosis for
manual review if the diagnosis is determined not to be for a pre-existing
condition and is also determined to be suspect; wherein the claim
submission engine is further operable to: return a sixth user interface
to the second selected one of the client computing devices if the
diagnosis is flagged approved, the sixth user interface presenting
information indicating claim approval; return a seventh user interface
to the second selected one of the client computing devices if the
diagnosis is flagged limited, the seventh user interface presenting
information indicating claim limitation; and return an eighth user
interface to the second selected one of the client computing devices
if the diagnosis is flagged for manual review, the eighth user interface
presenting information indicating the need for a manual claim review.
31. An insurance enrollment and underwriting system, comprising:
client computing devices each positioned in a pet related location,
each client computing device operable to display user interfaces
and to receive and transmit user input; means for providing a first
selected one of the client computing devices with a first user interface
with one or more controls for enabling a user to specify one or
more health conditions in an enrollment application for pet health
insurance; means for receiving data representing one or more health
conditions specified through user input received at the first selected
one of the client computing devices in response to a display of
the first user interface; means for electronically processing the
data representing the one or more health conditions and electronically
flagging each as a condition that is acceptable, precluded, or manual
review; means for returning a second user interface to the first
selected one of the client computing devices if at least one of
the conditions is flagged as precluded, the second user interface
presenting information indicating declined enrollment; means for
returning a third user interface to the first selected one of the
client computing devices if all of the conditions are flagged as
acceptable, the third user interface presenting information indicating
approved enrollment; and means for returning a fourth user interface
to the first selected one of the client computing devices if none
of the conditions is flagged as precluded and at least one of the
conditions is flagged manual review, the fourth user interface presenting
information indicating the need for a manual review.
32. The system of claim 31, further comprising means for establishing
an electronic record associated with an active policy for pet health
insurance, the electronic record containing the data representing
one or more health conditions specified through the first user interface
and data representing an effective date for the policy.
33. The system of claim 32, further comprising: means for providing
a fifth user interface to a second selected one of the client computing
devices, the fifth user interface having controls for enabling a
user to submit a claim with respect to the active policy, the controls
enabling the user to specify a diagnosis for which coverage is requested;
means for receiving data representing the diagnosis specified through
user input received at the second selected one of the client computing
devices in response to a display of the fifth user interface; means
for electronically processing the data representing the diagnosis
with the electronic record associated with the active policy comparing
the data representing the diagnosis with the data representing one
or more health conditions specified through the first user interface
and comparing a date of the claim with the data representing the
effective date of the active policy; means for selecting a predetermined
duration according to the diagnosis; means for determining the diagnosis
to be for a pre-existing condition where the comparison of the data
representing the diagnosis with the data representing one or more
health conditions reveals that the diagnosis is for a condition
identified by the data representing one or more health conditions;
means for determining the diagnosis to be for a non-suspect condition
if a difference between the date of the claim and the effective
date of the active policy exceeds the predetermined duration; means
for determining the diagnosis to be for a suspect condition if a
difference between the date of the claim and the effective date
of the active policy does not exceed the predetermined duration;
means for flagging the diagnosis as limited if the diagnosis is
determined to be for a pre-existing condition; means for flagging
the diagnosis as covered if the diagnosis is determined not to be
for a pre-existing condition and is also determined to be non-suspect;
means for flagging the diagnosis for manual review if the diagnosis
is determined not to be for a pre-existing condition and is also
determined to be suspect; means for returning a sixth user interface
to the selected one of the client computing devices if the diagnosis
is flagged approved, the sixth user interface presenting information
indicating claim approval; means for returning a seventh user interface
to the selected one of the client computing devices if the diagnosis
is flagged limited, the seventh user interface presenting information
indicating claim limitation; and means for returning an eighth user
interface to the selected one of the client computing devices if
the diagnosis is flagged for manual review, the eighth user interface
presenting information indicating the need for a manual claim review.
Insurance Description
CROSS REFERENCE TO RELATED APPLICATIONS
[0001] This Application Claims the priority of provisional application
60/736,981 Filed Nov. 15, 2005.
BACKGROUND
[0002] Pet health insurance is gaining popularity and proving a
useful tool for pet owners. Consumers of pet insurance, or any other
type of insurance for that matter, benefit when insurance providers
are able to implement efficient enrollment, underwriting, and claims
procedures. Insurance providers benefit when those same procedures
provide certainty as to the provider's potential exposure to claims.
[0003] The field of pet insurance has many inherent uncertainties
that can prevent providers from providing efficient enrollment,
underwriting, and claims services. For example, it would not be
unexpected that a less than truthful consumer would seek pet insurance
to cover expenses related to a pet's pre-existing condition. To
address this situation, provider's of pet insurance may take steps
to manually verify the pet's heath by contacting the pet's veterinarian
before deciding to issue a policy and before paying any claim. This
manual approach inflates insurance costs for the consumer. Eliminating
this manual approach without a viable alternative exposes the insurance
provider to unknown risks--also serving to inflate insurance costs.
DESCRIPTION OF THE DRAWINGS
[0004] FIG. 1 is a schematic illustration of an exemplary computer
network for use in implementing various embodiments of the present
invention.
[0005] FIG. 2 is a block diagram illustrating various logical elements
of the components of FIG. 1 according to an embodiment of the present
invention.
[0006] FIG. 3 illustrates an exemplary screen view of a an enrollment
interface according to an embodiment of the present invention.
[0007] FIG. 4 illustrates an exemplary screen view of a claim submission
interface according to an embodiment of the present invention.
[0008] FIG. 5 is an exemplary flow diagram illustrating an enrollment
and underwriting method according to an embodiment of the present
invention.
[0009] FIG. 6 is an exemplary flow diagram illustrating a claim
submission and adjusting method according to an embodiment of the
present invention.
[0010] FIG. 7 is an exemplary flow diagram illustrating steps taken
to flag a diagnosis according to an embodiment of the present invention.
[0011] FIG. 8 is an exemplary flow diagram illustrating steps taken
to determine whether a diagnosis is suspect according to an embodiment
of the present invention.
DETAILED DESCRIPTION
[0012] INTRODUCTION: Embodiments of the present invention provide
efficiencies in the enrollment, underwriting, and claims procedures
for pet health insurance.
[0013] NETWORK ENVIRONMENT: FIG. 1 schematically illustrates exemplary
network environment 10 for use in implementing various embodiments
of the present invention. Network 10 includes server computers 12-18
and client computers 20-24. Server computers 12-18 represent generally
any computing devices capable serving data and/or applications over
network 10. Client computers 20-24 represent generally any computing
devices capable of interacting with server computers 12-18 over
network 10.
[0014] Link 24 represents generally a cable, wireless, or remote
connection via a telecommunication link, an infrared link, a radio
frequency link, or any other connector or system of connectors that
provides electronic communication between client computers 20-24
and server computers 12-18. Link 24 may include an intranet, the
Internet, or a combination of both. Each portion of link 24 connecting
a given component one device to another may or may not be distinct
from the remaining portions of link 24. For example databases two
or more of server computers 12-18 may be directly connected to another
server computer via one or more separate and distinct links.
[0015] COMPONENTS: FIG. 2 is an exemplary block diagram showing
the logical components of server computers 12-18 and client computers
20-24. In this example, server computers 12-18 are labeled policy
server 12, claim server 14, GIS server 16, and customer data server
18.
[0016] Each client computer 20, 22, and 24 is shown to include
a browser 21, 23, and 25. Browsers 21, 23, and 25 represent generally
any programming that, when executed by a respective client computer
20, 22, or 24, is capable of causing the display of one or more
user interfaces through which a user can be informed and/or through
which a user can supply information to one or more of server computers
12-18. Information provided to a user can include advertisements
for pet health insurance, enrollment applications, claim submission
forms, responses to enrollment applications and claim submissions
as well as any other information related to pet health insurance.
[0017] As an example, client computer 20 may be accessed by a consumer--that
is--a pet insurance policy holder or a person seeking to obtain
a pet insurance policy. Client 22 may be accessed by an insurance
underwriter or claims adjuster. Client computer 24 may accessed
by a pet health provider or be given to a pet health provider to
be accessed by the health provider's customers. While only three
client computes are shown, network 10 may include any number of
client computers. In one implementation, a client computer may be
provided to each of any number of pet health care providers. Properly
positioned in a provider's waiting room or examining room, the client
computer can be used to advertise, to apply for a pet health insurance
policy, and to submit a claim on an existing policy.
[0018] Customer data server 18 is shown to include policy records
28 and location database 30. Policy records 30 represents generally
a collection of data records where each record contains data related
to a particular insurance policy for pet health insurance. That
data can include the name, address, and payment information of the
policy holder, identifying information for the covered pet, and
medical information for the pet. The medical information, for example,
can identify pre-existing conditions identified during enrollment
and any diagnoses and claims made during the policy's existence.
[0019] Location database 30 represents generally any collection
of data identifying one or more physical locations. Data identifying
a particular location might define a geographic point--a specific
latitude and longitude for example. The data might instead define
a particular area or a boundary of that area.
[0020] Policy server 12 is shown to include enrollment engine 32
and underwriting engine 34. Enrollment engine 32 represents generally
any combination of hardware and/or programming capable of providing
client devices 20-24 with an enrollment user interface enabling
a user to specify one or more health conditions for a pet in when
enrolling for a pet insurance policy for that pet. As used, the
term "user" means any individual. A user, for example,
may be an insurance consumer, a pet health care provider, or even
an insurance provider employer such as an underwriter or claims
adjuster. The term health condition means information related to
a prior diagnosis, injury, and/or treatment. Enrollment engine 32
is also responsible for receiving data entered through the an enrollment
interface and for returning user interfaces containing data indicative
of approved enrollment, declined enrollment, and the need for a
manual review.
[0021] FIG. 3 illustrates an exemplary screen view of an enrollment
user interface 36 provided by enrollment engine 32 and displayed
by one of client computing devices 20-24. Enrollment user interface
36 includes controls 38-44. Controls 38 enable a user to provide
personal information identifying the pet owner's name and address.
Controls 40 enable the user to provide information concerning their
pet's name, sex, breed, age, and other characteristics. Control
42, shown as a scroll box, enables a user to select one or more
conditions that identify a past or current injury, diagnosis and/or
treatment for a pet to be insured. Controls 44 enable a user to
cause a client computing device 20-24 to submit data representing
information entered using controls 38-42 back to enrollment engine
32.
[0022] Returning to FIG. 2, underwriting engine 34 represents generally
any combination of hardware and/or programming capable of obtaining
data entered through enrollment interface 32 and received by enrollment
engine 32--that data representing one or more conditions. Underwriting
engine 34 is responsible for electronically processing that data
and to electronically flag each condition as a condition that is
acceptable, precluded, or for manual review. As an example, underwriting
engine 34 may have access to a database (not shown) of condition
in which each condition is associated with a flag or with data that
can be used to identify an appropriate flag base on one or more
variables such as a pet's breed, sex, and/or age. A condition for
one breed may call for an acceptable flag where the same condition
for another breed may call for a precluded flag or a manual review
flag. Accessing that database, underwriting engine 34 can then automatically
identify or determine an appropriate flag for each of a number of
conditions.
[0023] Where one or more conditions are flagged for declined enrollment,
underwriting engine 34 instructs enrollment engine 32 to return
a user interface containing information indicating declined enrollment.
Where no conditions are flagged for declined enrollment but one
or more conditions are flagged for manual review, underwriting engine
34 instructs enrollment engine 32 to return a user interface containing
information indicating the need for manual review. A manual review
flag indicates that an enrollment application should not be accepted
or declined in an automated fashion. An ultimate determination is
to be made after a more detailed review of items such as a pet's
medical history obtained from a veterinarian.
[0024] Where all conditions are flagged as acceptable, underwriting
engine 34 instructs enrollment engine 32 to return a user interface
containing information indicating approved enrollment. Such an interface
need not reflect actual approval. Instead it may simply indicate
an eligibility for pet health insurance coverage subject to receipt
of a completed application and payment or payment information such
as an authorization to charge a specified credit card or other account.
[0025] Where a policy is created, underwriting engine 34 is responsible
for causing a record associated with that policy to be added to
policy records 28. at record may, for example, contain data representing
an effective date for the policy as well as one or more health conditions,
if any, specified through an enrollment interface provided by enrollment
engine 32.
[0026] Claim server 14 is shown to include claim submission engine
46, claim adjusting engine 48, and diagnosis table 50. Claim submission
engine 46 represents generally any combination of hardware and/or
programming capable of providing client devices 20-24 with a claim
submission interface having controls enabling a user to submit a
claim with respect to an active policy for pet health insurance.
Those controls enabling a user to specify a diagnosis for which
coverage is claimed. The diagnosis may be for a pet's treatment
that is to be performed or that has already been performed. Claim
submission engine 46 is also responsible for receiving data entered
through the claim submission interface and for returning user interfaces
containing data indicative of claim approval, claim limitation,
or the need for manual review.
[0027] FIG. 4 illustrates an exemplary screen view of a claim submission
interface 52 provided by claim submission engine 46 and displayed
by one of client computing devices 20-24. Claim submission interface
52 includes controls 54-58. Controls 54 enable a user to provide
information identifying an active policy for pet health insurance,
a date of a claim, and a dollar amount. Controls 56, shown as a
scroll box, enables a user to select one or more conditions that
identify a diagnosis for which coverage is being claimed under the
identified policy. Controls 58 enable a user to cause a client computing
device 20-24 to submit data representing information entered using
controls 38-42 back to claim submission engine 46.
[0028] Returning to FIG. 2, claim adjusting engine 48 represents
generally any combination of hardware and/or programming capable
of obtaining the claim data entered through claim submission interface
52 and received by enrollment engine 32--that claim data representing
a claim date and a diagnosis. Claim adjusting engine 48 is responsible
for obtaining the record associated with the identified policy from
customer data server 18 and electronically process the claim data
with the associated record in order to electronically flag the diagnosis
as limited, covered, or for manual review.
[0029] To reiterate, the claim data entered through the claim submission
user interface includes data identifying a policy, a diagnosis,
and a claim date. The record associated with the identified policy
contains data identifying an effective date of the policy and one
or more conditions submitted to policy server 12 via an enrollment
user interface. Claims adjusting engine 48 flags a diagnosis as
limited where a comparison of the identified diagnosis with the
identified conditions from the policy record reveals that the diagnosis
is related to one or more conditions identified by the policy record.
[0030] Where a diagnosis is not flagged as limited, claim adjusting
engine 48 determines if the diagnosis is for a suspect condition.
If the diagnosis is determined to be non-suspect, claim adjusting
engine 48 flags the diagnosis as covered. If the diagnosis is determined
to be suspect, claim adjusting engine 48 flags the diagnosis for
manual review. A suspect diagnosis is one in which a duration between
an effective date of the policy and a claim date does not exceed
a predetermined duration. The predetermined duration may be dependent
upon the diagnosis as well as one or more other factors such as
pet breed, age and sex. A diagnosis for cancer may call for a longer
predetermined duration than a diagnosis for a laceration. Claims
adjusting engine 48 is responsible for comparing a predetermined
duration for an identified diagnosis with a difference between an
effective date of a policy and a claim date. Where the predetermined
duration exceeds the difference, the identified diagnosis is suspect.
Otherwise, it is not.
[0031] Where the identified diagnosis is flagged as limited, claim
adjusting engine 48 instructs claim submission engine 46 to return
a user interface containing information indicating claim limitation.
The term "claim limitation" may indicate claim denial
or, for example, it may indicate that there is a specified dollar
limit of coverage with respect to the diagnosis rather than exclusion
to coverage for a pre-existing condition. Where the identified diagnosis
is flagged for manual review, claim adjusting engine 48 instructs
claim submission engine 46 to return a user interface containing
information indicating the need for manual review.
[0032] Where the identified diagnosis is flagged approved, claim
adjusting engine 48 instructs claim submission engine 46 to return
a user interface containing information indicating claim approval.
Such an interface need not reflect actual claim approval. Instead
it may simply indicate an eligibility for approval pending submission
of a paid receipt or other proof of loss.
[0033] Diagnosis table 50 represents generally a collection of
data used by claim adjusting engine 48 to determine whether or not
a diagnosis is suspect. As an example, diagnosis table 50 may include
a series of entries with each entry identifying a diagnosis and
a predetermined duration for that diagnosis. In performing its task
of determining if an identified diagnosis is suspect, claim adjusting
engine 48 then can determine a predetermined duration for the identified
diagnosis by examining an entry from diagnosis table 50 for the
identified diagnosis.
[0034] ENROLLMENT AND UNDERWRITING METHODOLOGY: FIG. 15 is an exemplary
flow diagram that helps illustrate steps taken during an enrollment
and underwriting procedure. Initially, an enrollment interface is
provided (step 172). The enrollment interface has one or more controls
for specifying one or more health conditions. See enrollment interface
36 of FIG. 3 for an example. Data representing one or more health
conditions specified through the enrollment interface is received
(step 174). The data received in step 174 is processed (step 176)
so that each health condition can be flagged as a condition that
is acceptable, precluded, or for manual review (step 178).
[0035] An acceptable condition is one that will allow for an automated
approval for enrollment. A precluded condition is one that calls
for an automated denial of enrollment. A condition flagged for manual
review is a condition that requires a manual review of an enrollment
application and medical history to determine whether to approve
or deny enrollment.
[0036] It is next determined if any condition has been flagged
as precluded (step 180). If a precluded flag exists, a user interface
indicating declined enrollment is returned (step 182). Otherwise,
it is determined if any condition has been flagged for manual review
(step 184). If a manual review flag exists, an interface indicating
the need for manual review is returned (step 186).
[0037] Otherwise, an interface indicating approved enrollment is
returned (step 188). An electronic policy record is created (step
190). The record contains the data representing the one or more
conditions received in step 174 as well as an effective date for
the policy (step 190).
[0038] CLAIM ADJUSTING METHODOLOGY: FIG. 16 is an exemplary flow
diagram that helps illustrate steps taken during a claim adjusting
procedure. Initially a claim submission interface is provided (step
192). The claim submission interface has one or more controls for
specifying a policy and a diagnosis. See claim submission interface
52 of FIG. 4 for an example. Data, entered through the claim submission
interface representing a policy and a diagnosis are received (step
194). The data representing the diagnosis is electronically processed
with the policy record for the policy identified through the claim
submission interface (step 196) so that the diagnosis can be flagged
as limited, covered, or for manual review (step 198).
[0039] A diagnosis flagged as limited relates to a health condition
that existed prior to the effective date of the policy. A covered
diagnosis relates to a health condition that is not pre-existing
and for which coverage can be approved in an automated fashion without
manual review. A diagnosis flagged for manual review relates to
a suspect condition that may be pre-existing and would benefit from
a manual review of the claim and health records related to the diagnosis.
Examples for implementing step 198 are provided below with references
to the flow diagrams of FIGS. 17 and 18.
[0040] Continuing with FIG. 16, it is determined if the diagnosis
is flagged as limited (step 200). If pre-existing, a user interface
indicating claim limitation is returned (step 202). Otherwise, it
is determined If the diagnosis is flagged for manual review (step
204). If flagged for manual review, a user interface indicating
the need for manual review is returned (step 206). Otherwise, a
user interface indicating claim approval is returned (step 208).
It is noted that a diagnosis flagged as limited and a diagnosis
flagged for approval may both be approved and coverage for both
may be limited to a specified dollar limit of coverage.
[0041] FIGS. 17 and 18 are exemplary flow diagrams that helps illustrate
steps taken to flag a diagnosis as limited, covered, or for manual
review. Starting with FIG. 17, data representing the diagnosis is
compared with data representing one or more conditions specified
during enrollment and the effective date for the policy in question
(step 210). It is determined if the data representing the diagnosis
is related to one or more of those conditions (step 212). If related,
the diagnosis is flagged as limited (step 214). Otherwise, it is
determined if the diagnosis is for a suspect condition (step 216).
If suspect, the diagnosis is flagged for manual review (step 218).
Otherwise the diagnosis is flagged as covered (step 220). A suspect
condition is a condition that may be pre-existing can benefit from
a manual review.
[0042] FIG. 18 is an exemplary flow diagram that helps illustrate
steps taken to determine if a diagnosis is for a suspect condition.
Initially, a waiting period is selected according to the diagnosis
(step 222). Using a database such as diagnosis table 50 of FIG.
2, different diagnoses can electronically associated with different
waiting periods. For example, a diagnosis involving cancer may be
associated with a longer waiting period than a diagnosis involving
a laceration. A claim date is then compared with the effective policy
date (step 224). A difference between the claim date and the policy
date is calculated (step 226).
[0043] Next it is determined if the selected waiting period exceeds
the duration calculated in step 226. If it does, the diagnosis is
determined to be for a suspect condition (step 230). If it does
not, the diagnosis is determined to be for a non-suspect condition
(step 232).
[0044] CONCLUSION: While there are shown and described certain
embodiments of the invention, it is to be distinctly understood
that this invention is not limited thereto but may be variously
embodied to practice within the scope of the following claims.
[0045] The diagrams of FIGS. 1 and 2 show the architecture, functionality,
and operation of various embodiments of the present invention. A
number of the blocks are defined as programs. Each of those blocks
may represent in whole or in part a module, segment, or portion
of code that comprises one or more executable instructions to implement
the specified logical function(s). Each block may represent a circuit
or a number of interconnected circuits to implement the specified
logical function(s).
[0046] Also, the present invention can be embodied in any computer-readable
media for use by or in connection with an instruction execution
system such as a computer/processor based system or an ASIC (Application
Specific Integrated Circuit) or other system that can fetch or obtain
the logic from computer-readable media and execute the instructions
contained therein. "Computer-readable media" can be any
media that can contain, store, or maintain programs and data for
use by or in connection with the instruction execution system. Computer
readable media can comprise any one of many physical media such
as, for example, electronic, magnetic, optical, electromagnetic,
infrared, or semiconductor media. More specific examples of suitable
computer-readable media include, but are not limited to, a portable
magnetic computer diskette such as floppy diskettes or hard drives,
a random access memory (RAM), a read-only memory (ROM), an erasable
programmable read-only memory, or a portable compact disc.
[0047] The Exemplary screen views of FIGS. 3 and 4 are just that.
The merely provide examples of user interfaces displaying controls
for performing various tasks such as specifying health conditions
in an enrollment application and specifying a diagnosis when claiming
benefits.
[0048] Although the flow diagrams of FIGS. 5-8 show specific orders
of execution, the orders of execution may differ from that which
is depicted. For example, the order of execution of two or more
blocks may be scrambled relative to the order shown. Also, two or
more blocks shown in succession may be executed concurrently or
with partial concurrence. All such variations are within the scope
of the present invention.
[0049] The present invention has been shown and described with
reference to the foregoing exemplary embodiments. It is to be understood,
however, that other forms, details, and embodiments may be made
without departing from the spirit and scope of the invention that
is defined in the following claims. |