Patent Application
20090144094
1. Field of the Invention
This invention relates to the field of technologies for offering and processing claims under an insurance policy, and more particularly, an insurance policy that provides coverage for lost income to an ill person for hospital confinement or a caregiver providing assistance to the ill person.
2. Description of the Related Art
Most workers at some point over their careers miss work due to illness or caring for a dependent or family member that is ill. Although health insurance may cover the medical expenses of the person who is ill, the ill person often loses income due to inability to work. A caregiver of such ill person must often take unpaid leave from work. Thus, in addition to coverage of loss of pay to the person who is ill, there is a need to provide coverage for the caregiver who loses income as a result of having to take time from work to care for an ill person such as a dependent or family member.
Generally described, various embodiments of the present invention provide an insurance policy which confers a benefit to a policy participant when the participant or a covered family member is confined to a hospital due to sickness or injury, or the participant misses work as a result of his or her own or a covered family member's sickness or injury. This benefit can be used by the policy participant as he or she sees fit to cover such out-of-pocket costs as travel expenses, lodging, child care, etc. or to supplement lost income due to missed work related to the care of a covered family member. Benefits under such a policy may be paid in addition to or independent of other insurance policies and benefits for any related illnesses. Systems and methods for issuing such an insurance policy and processing a claim under such an insurance policy are also provided.
According to one aspect of the present invention, a hospital confinement and care insurance policy is provided. The policy confers benefits in the form of one or more payments to be made to a policy participant as the result of the participant or a covered family member being confined to a hospital due to sickness or injury, or the participant missing work as a result of his or her own or a covered family member's sickness or injury.
Another aspect of the present invention is a system for issuing a hospital confinement and care insurance policy. The system is comprised of a processor and a memory coupled to the processor that stores a computer program executable by the processor. The processor executes the computer program to receive applicant data related to a prospective policy participant. Executing the computer program, the processor applies one or more business rules stored in the memory to the applicant data to determine whether the prospective participant qualifies for a hospital confinement and care insurance policy. The processor executes the computer program to transmit the hospital confinement and care insurance policy to the policy participant, if the policy participant is determined to qualify for the hospital confinement and care insurance policy.
Another aspect of the invention is a system for processing a claim under a hospital confinement and care insurance policy. The system is comprised of a processor and a memory connected to the processor that stores a computer program executed by the processor. The processor executes the computer program to receive a claim under the hospital confinement and care insurance policy from a policy participant, i.e., a policyholder of a hospital confinement and care insurance policy. The processor executes the computer program, causing such processor to determine whether the policy participant is eligible for one or more benefits provided by the hospital confinement and care insurance policy. If so, then the processor further executes the computer program to calculate the benefit amount and authorizes payment to the policy participant.
Yet another aspect of the present invention is a method of issuing a hospital confinement and care insurance policy. The method is comprised of the steps of receiving applicant data related to a prospective policy participant; determining, based at least in part on the applicant data, whether the prospective policy participant qualifies for the hospital confinement and care insurance policy; and, if the prospective policy participant does qualify, then issuing the hospital confinement and care insurance policy to the policy participant.
Another aspect of the present invention is a method of processing a hospital confinement and care insurance policy claim. The method is comprised of the steps of receiving a hospital confinement and care insurance policy claim from a policy participant; determining whether the policy participant is eligible for one or more benefits as the result of the participant or a covered family member being confined to a hospital due to sickness or injury, or the participant missing work as a result of his or her own or a covered family member's sickness or injury; and if the policy participant is eligible for a benefit, then authorizing payment of the benefit to the policy participant.
Yet another aspect of the present invention is a method of offering a hospital confinement and care insurance policy. The method is comprised of the steps of providing a hospital confinement and care insurance application to an applicant, wherein the hospital confinement and care insurance policy provides a benefit to a policy participant if the participant or a covered family member is confined to a hospital due to sickness or injury, or the participant misses work as a result of his or her own or a covered family member's sickness or injury; receiving the applicant's information from the applicant and determining whether the applicant is qualified to become a policy participant; and, if the applicant is so authorized, then issuing the hospital confinement and care insurance policy to the applicant, so that the applicant thus becomes a policy participant.
These and other aspects of the present invention are more fully described herein.
Having thus described the invention in general terms, reference will now be made to the accompanying drawings, which are not necessarily drawn to scale, and wherein:
a is an illustration of one embodiment of a computer that can be used to practice aspects of the present invention;
b is an embodiment of a processing system having a distributed communication and processing architecture that may be used to practice aspects of the present invention;
Appendix 1 is an example of an insurance policy document according to one embodiment of the present invention.
The present invention now will be described more fully with reference to the accompanying drawings, in which some, but not all embodiments of the invention are shown. Indeed, this invention may be embodied in many different forms and should not be construed as limited to the embodiments set forth herein. Rather, these embodiments are provided so that this disclosure will satisfy applicable legal requirements. Like numbers refer to like elements throughout.
As will be appreciated by one skilled in the art, the present invention may be embodied as a method, a data processing system, or a computer program product. Accordingly, the present invention may take the form of an entirely hardware embodiment, an entirely software embodiment, or an embodiment combining software and hardware aspects. Furthermore, the present invention may take the form of a computer program product on a computer-readable storage medium having computer-readable program instructions (e.g., computer software) embodied in the storage medium. More particularly, the present invention may take the form of web-implemented computer software. Any suitable computer-readable storage medium may be utilized including hard disks, CD-ROMs, optical storage devices, or magnetic storage devices.
The present invention is described below with reference to block diagrams and flowchart illustrations of methods, apparatuses (i.e., systems) and computer program products according to an embodiment of the invention. It will be understood that each block of the block diagrams and flowchart illustrations, and combinations of blocks in the block diagrams and flowchart illustrations, respectively, can be implemented by computer program instructions. These computer program instructions may be loaded onto a general purpose computer, special purpose computer, or other programmable data processing apparatus to produce a machine, such that the instructions which execute on the computer or other programmable data processing apparatus create a means for implementing the functions specified in the flowchart block or blocks.
These computer program instructions may also be stored in a computer-readable memory that can direct a computer or other programmable data processing apparatus to function in a particular manner, such that the instructions stored in the computer-readable memory produce an article of manufacture including computer-readable instructions for implementing the function specified in the flowchart block or blocks. The computer program instructions may also be loaded onto a computer or other programmable data processing apparatus to cause a series of operational steps to be performed on the computer or other programmable apparatus to produce a computer-implemented process such that the instructions that execute on the computer or other programmable apparatus provide steps for implementing the functions specified in the flowchart block or blocks.
Accordingly, blocks of the block diagrams and flowchart illustrations support combinations of means for performing the specified functions, combinations of steps for performing the specified functions and program instruction means for performing the specified functions. It will also be understood that each block of the block diagrams and flowchart illustrations, and combinations of blocks in the block diagrams and flowchart illustrations, can be implemented by special purpose hardware-based computer systems that perform the specified functions or steps, or combinations of special purpose hardware and computer instructions.
In several of the embodiments of the invention referenced herein, a “computer” is referenced. The computer may be, for example, a mainframe, desktop, notebook or laptop, or a hand held device such as a data acquisition and storage device, etc. In some instances the computer may be a “dumb” terminal used to access data or processors over a network. Turning to
The processor 1 also communicates with various peripherals or external devices using an I/O bus 6. In the present embodiment, a peripheral I/O controller 7 is used to provide standard interfaces, such as RS-232, RS-422, DIN, USB, or other interfaces as appropriate to interface various input/output devices. Typical input/output devices include local printers 18, a monitor 8, a keyboard 9, and a mouse 10 or other typical pointing devices (e.g., rollerball, trackpad, joystick, etc.).
The processor 1 typically also communicates using a communications I/O controller 11 with external communication networks, and may use a variety of interfaces such as data communication oriented protocols 12 such as X.25, ISDN, DSL, cable modems, etc. The communications controller 11 may also incorporate a modem (not shown) for interfacing and communicating with a standard telephone line 13. Finally, the communications I/O controller may incorporate an Ethernet interface 14 for communicating over a LAN. Any of these interfaces may be used to access the Internet, intranets, LANs, or other data communication facilities.
Finally, the processor 1 may communicate with a wireless interface 16 that is operatively connected to an antenna 15 for communicating wirelessly with another device, using for example, one of the IEEE 802.11 protocols, 802.15.4 protocol, or a standard 3G wireless telecommunications protocols, such as CDMA2000 1x EV-DO, GPRS, W-CDMA, or other protocol.
An alternative embodiment of a processing system that may be used is shown in
Those skilled in the art of data networking will realize that many other alternatives and architectures are possible such as, for example, the handheld devices contemplated herein and can be used to practice the principles of the present invention. The embodiments illustrated in
A hospital confinement and care insurance policy (also referred to as a “hospital confinement care indemnity policy”), according to one embodiment of the invention, comprises hospital confinement and care benefits that provide one or more payments to a policyholder as the result of policyholder or a covered family member being confined to a hospital due to sickness or injury, or the policyholder missing work as a result of his or her own or a covered family member's sickness or injury.
An example of a hospital confinement and care insurance policy is provided in Appendix 1, according to one embodiment of the invention. In this exemplary embodiment, four benefit categories are available to the policy participant, or “named insured”, as detailed on pages 9-10 of Appendix 1:
In this exemplary embodiment of the invention, the scope of persons covered by the hospital confinement and care insurance policy depends on the type of coverage selected by the policy participant. As provided on page 5 of Appendix 1, a participant can select Individual coverage, covering only himself or herself; Named Insured/Spouse Only coverage, under which only the participant and his or her legally married spouse are covered persons; One-Parent Family coverage, covering the participant and his or her dependent children; or Two-Parent Family coverage, where the participant, his or her spouse, and their dependent children all qualify as covered persons. Further, in this example, a hospital confinement is defined as a covered person being registered as an inpatient at a qualifying hospital or being assigned a bed for a predefined period of time (e.g. 23 or more hours) as an outpatient at such a facility. Consecutive confinements are generally considered the same confinement unless the result of an entirely unrelated sickness or injury or separated by 30 or more days of no confinement in any institution or facility. Other definitions also apply to this embodiment of the hospital confinement and care insurance policy as presented on pages 3-6 of Appendix 1.
Each benefit payable under a hospital confinement and care insurance policy may be subject to maximums or other limitations. For example, in the exemplary embodiment shown in Appendix 1, benefit A is conferred for a maximum of 365 days per confinement, while benefit B is limited to a minimum of 5 days and a maximum of 90 days or the length of the confinement, whichever is less. Benefit C is paid for a maximum 5 days for individual coverage or 10 days for family coverage per policy year, and not conferred for any day covered by benefit A or B. Further, benefit D is limited to 12 payments per covered confinement. It is to be recognized that these maximums and limitations are only exemplary in nature and that other maximums or limitations are considered within the scope of the embodiments of the invention.
In addition, the scope of coverage may be further limited by policy exclusions and limitations. For example, pages 6-7 of Appendix 1 provide exclusionary periods for pre-existing conditions and other sickness diagnosed before the effective date of the policy as well as sickness or injury which will not qualify a covered person for benefits under the hospital confinement and care insurance policy, such as those resulting from:
The hospital confinement and care insurance policy provides a policy schedule that details the named insured, i.e. the policy participant, the type of coverage elected, the effective dates of the coverage, and the premium amount to be paid. In the exemplary embodiment depicted on page 2 of Appendix 1, the policy schedule also includes the mode of payment selected by the policy participant, e.g. monthly, quarterly, annually, etc., as well as the policy number and coverage indicators for the policy. The policy schedule is signed by representatives of the Insurance Company offering the policy indicating acceptance of the policy conditions by the insurer.
The system further includes an office 50 in communication with the handheld device 40, and an Insurance Company computer 60 in communication with the office 50. The office 50, which may be operated directly by the Insurance Company or by some other entity affiliated with the Insurance Company, includes at least an interface 55 to facilitate the communication of applicant data between the handheld device 40 and the Insurance Company computer 60. The interface 55 may be any known interface including, for example, a docking station that is connected to an IT infrastructure, such as a Local Area Network (LAN), Wide Area Network (WAN), or the Internet. Data can, therefore, be communicated from the office 50 to the Insurance Company computer 60 via any known means of communicating data including, for example, via the Internet, via a cable connection, by fax, via a telephone network, or even by a human operator located at the office 50.
Alternatively, the computing device 40 can be configured to communicate with the insurance company computer 60 directly without the need for office 50 and the interface 55. The computing device 40 can communicate with the Insurance Company computer 60 via a communications network such as the Internet, WAN, one or more LANs, wireless network, cellular network, etc.
The Insurance Company computer 60 includes at least a hospital confinement and care insurance policy issuance module 62. The module 62 can be configured to retrieve data from, and store data to, a database 64. As shown, the database 64 contains policy data 65 which defines the coverage, terms, limitations, exclusions, etc. of the insurance policy as well as the criteria for acceptance of an applicant for coverage or adjudicating claims under the hospital confinement and care insurance policy. Applicant data 66 related to a prospective applicant or policy holder can also be stored in the database 64. Further, business rules 67 can each be stored in the database 64 and accessed by the hospital confinement and care insurance policy issuance module 62 upon execution by the Insurance Company Computer 60. The business rules 67 define the rules that govern the acceptance or rejection of an applicant for coverage under the policy, or the rules that govern adjudication of a claim under the policy. For example, the Insurance Company Computer 60 can be configured to compare applicant data 66 of a prospective applicant to policy data 65 and apply the business rules 67 to determine whether the prospective applicant qualifies for coverage under the policy.
In addition, the Insurance Company computer 60 includes at least one storage device 250, such as a hard disk drive, a floppy disk drive, a CD-ROM drive, or optical disk drive, for storing information on various computer-readable media, such as a hard disk, a removable magnetic disk, or a CD-ROM disk. As will be appreciated by one of ordinary skill in the art, each of these storage devices 250 is connected to the system bus 220 by an appropriate interface. The storage devices 250 and their associated computer-readable media provide nonvolatile storage for a personal computer. It is important to note that the computer-readable media described above could be replaced by any other type of computer-readable media known in the art. Such media include, for example, magnetic cassettes, flash memory cards, digital video disks, and Bernoulli cartridges.
A number of program modules may be stored by the various storage devices 250 and within RAM 245. Such program modules include an operating system 260, and the hospital confinement and care insurance policy issuance module 270. The hospital confinement and care insurance issuance module 270 controls certain aspects of the operation of the Insurance Company computer 60, as is described in more detail below, with the assistance of the processor 210 and the operating system 260.
Also located within the Insurance Company computer 60 is a network interface 280, for interfacing and communicating with other elements of a computer network. It will be appreciated by one of ordinary skill in the art that one or more of the Insurance Company computer 60 components may be located geographically remotely from other Insurance Company computer 60 components. Furthermore, one or more of the components may be combined, and additional components performing functions described herein may be included in the Insurance Company computer 60.
Like the Insurance Company computer 60, a number of program modules may be stored by the various storage devices 350 and within RAM 345. Such program modules include an operating system 360, and an applicant data processing module 370. The applicant data processing module 370 controls certain aspects of the operation of the Computing Device 40, as is described in more detail below, with the assistance of the processor 310 and the operating system 360.
In other embodiments, the process could likewise begin with a prospective policy participant entering his or her own applicant data directly into an application form provided by the Insurance Company, and sending the application form to the Insurance Company. The application form could be in hard copy, requiring, for example, that the prospective policy participant enter the applicant data by hand, and then mail or fax the form to the Insurance Company. The applicant data could then be entered into the Insurance Company computer 60 by, for example, an Insurance Company employee. Alternatively, the application form could be provided over the Internet on a website operated by the Insurance Company, or by some other company affiliated with the Insurance Company. In this case the prospective policy participant could merely enter the data into the online version of the application form and then send the data electronically to the Insurance Company computer 60. In yet another embodiment, the prospective policy participant may contact an Insurance Company operator directly, by telephone or by other means, and communicate the applicant data to the operator, the data is then input into the Insurance Company computer 60 by the operator or another associated individual.
Once the Insurance Company computer 60 has received the applicant data 66, in Step 506, the Insurance Company computer 60 stores the applicant data 66 in a database 64 on the Insurance Company computer 60. The processor 210 executes the hospital confinement and care insurance policy issuance module 62 to apply business rules 67, which are also stored in the database 64 on the Insurance Company computer 60, to the applicant data 66 to determine whether the prospective policy participant qualifies for the hospital confinement and care insurance policy (Step 508). This may include, for example, checking the applicant's name and address to determine whether they are valid, authenticating the applicant to ensure that the applicant is who he/she claims to be, determining whether the applicant is financially responsible based on a credit or payment history check, for example, determining whether the medical history and status of applicant and other persons to be covered are within risk parameters of the policy, determining whether the applicant and other persons to be covered have pre-existing conditions that should be excluded from policy coverage, determining whether the applicant is of legal age to enter a binding contract in the State in which a policy is sought, etc.
If the Insurance Company computer 60 determines that the applicant is not qualified for the policy based on the applicant data 66 and business rules 67, then the Insurance Company computer 60 rejects the application. Conversely, upon a determination by the Insurance Company computer 60 that the prospective policy participant qualifies for the hospital confinement and care insurance policy, in Step 510 the Insurance Company issues the hospital confinement and care insurance policy to the policy participant by, for example, generating policy data 65 that is specific to the prospective policy participant, storing the policy data 65 in the database 64, and transmitting the policy data 65 to the policy participant. The policy data 65 may be sent, for example, electronically, by mail, by fax or delivered by hand, to the policy participant directly, or via the salesperson.
Like the Insurance Company computer 60 and the Computing Device 40, a number of program modules may be stored by the various storage devices 750 and within RAM 745. Such program modules include an operating system 760, and a claim processing module 770. The claim processing module 770 controls certain aspects of the operation of the Claim Processing Server 650, as is described in more detail below, with the assistance of the processor 710 and the operating system 760.
If, at Step 806, it is found that the sickness or injury qualifies under policy provisions for benefit, the Claims Processing Server 60 executes the Claim Processing Module 770, in one embodiment, to determine the benefit to be conferred as a result of the claim under each of the benefit categories described above. If, for example, it is determined at step 808 that the claim for benefit results from a covered hospital confinement of a covered person, the module proceeds to calculate the benefit to be paid under benefit category A at step 812, based on the number of days of confinement subject to any maximum limit and other limitations specified in the policy. The module then calculates the benefit to be paid under benefit category B at step 814, based on the number of days of confinement subject to the minimum and maximum limitations described above. The module then calculates the benefit to be paid under benefit category D at step 816, based on the number of days of confinement subject to the limit on the number of payments described above. And finally, the module calculates the benefit to be paid under benefit category C at step 818, based on the number of days of work missed by the policy participant, the benefits already paid under benefit categories A and B, and the maximum limitations based on the type of coverage elected by the policy participant.
If, however, it is determined at step 808 that the claim for benefit does not result from a covered hospital confinement, the Claim Processing Server 650 continues to execute the Claim Processing Module 770 to determine at step 810 whether the claim results in the policy participant missing work to care for a covered person suffering from a contagious disease or recovering from a covered outpatient surgery. If so, the module calculates the benefit to be paid under benefit category C at step 818, based on the number of days of work missed by the policy participant and the maximum limitations based on the type of coverage elected by the policy participant.
As will be understood by those of ordinary skill in the art, the steps of process described above need not be performed in the order in which they are described above. For instance, it is not necessary that the Claim Processing Server 650, as it executes the Claim Processing Module 770, determine whether the sickness or injury qualify under the policy provisions before determining whether the claim results from a covered hospital confinement or missed work by the policy participant, as long as all necessary determinations are made to assess what benefits the policy participant should receive.
Many modifications and other embodiments of the invention will come to mind to one skilled in the art to which this invention pertains having the benefit of the teachings presented in the foregoing descriptions. Accordingly, it should be understood that the invention is not to be limited to the specific embodiments disclosed and that modifications and other embodiments are intended to be included within the scope of the appended exemplary inventive concepts. Although specific terms are employed herein, they are used in a generic and descriptive sense only and not for purposes of limitation.
The present application claims the full benefit and priority of U.S. provisional patent application Ser. No. 60/868,256, filed Dec. 1, 2006, entitled Systems And Methods For Hospital Confinement And Care Insurance Policy. The entire contents of the aforementioned application is incorporated herein by reference.
| Number | Date | Country | |
|---|---|---|---|
| 60868256 | Dec 2006 | US |
