GB2460922A - Determining amounts for claims settlements using likelihood values - Google Patents

Abstract

Systems and methods that include determining and displaying amounts for use in settling insurance claims are disclosed. Closed claims that match an open claim are automatically identified 400 using a computer system based on one or more characteristics of the open claim. A likelihood value associated with at least one of the matching closed claims is determined 402. An amount for use by an adjuster in settling the open claim is determined 404 based on the likelihood value for at least one of the matching claims. A most likely amount and most likely range associated with the open claim may be determined 406 based on the likelihood values.

Description

SYSTEM AND METHOD FOR DETERMiNING AND DISPLAYING

AMOUNTS FOR CLAIMS SETTLEMENT USING LIKELIHOOD VALUES

BACKGROUND OF THE INVENTION

doftheInvefltiOfl ,4 rrmriifPr_imn1fmefltM values. For any given insurer, there may be a number of precedent claims in the insurer's closed claim database that embody the best practices for a particular candidate claim; however, finding and presenting these claims to the insurer's claim team as a basis for fh ccmni1jtjpfe claim may not be nossible due to the sheer size of the database and the to process open claims, bodily injury data for the open claims are entered into the system. For one or more of the open claims, precedent claims that match the open claim are identified based on characteristics of the open claim. A value for one or more of the matching precedent claims ir1iiited 11rnor the nreviniiglv iletermined eaualization values.

of similar claims associated with the candidate claims. A difference between the total general damages value for the candidate claims and total representative general damages value for the sets of similar claims is calculated.

In some embodiments, claims in a set of similar claims are grouped into two or more zones based on the values of the claims. A representative value for the set of similar claims may be based on values determined for claims in one or more of the zones, (such as an average value for the claims in a midzone). The representative value for the set of similar claims may be compared to the value for a candidate claim.

BR1EFDFSCRIPT!ON.QTJ!I INi A better understanding of the present invention may be obtained when the following detailed description of preferred embodiments is considered in conjunction with the following drawings, in which: FIG. I illustrates a computer system suitable for implementing various embodiments.

FIG. 2 illustrates matching of candidate claims to precedent claims according to one embodiment.

FIG. 3 illustrates a summary report for a set of precedent claims for a soft tissue injury according to one embodiment.

FIG. 4 illustrates a summaiy report for a set of precedent claims for a fracture injury according to one embodiment.

FIG. 5 illustrates grouping of a claim set into zones according to one embodiment.

FIG. 6 illustrates determining an amount for use in settling an open claim using likelihood estimation according to one embodiment.

FIG. 7 illustrates determining amounts for settling open claims using a likelihood function according to one embodiment.

FIG. 8 shows a set of matches for an open claim.

FIG. 9 is a graph of likelihood values fur a data set for an open claim.

FIG. 10 illustrates displaying likelihood values for a set of precedent claims matching an open claim according to one embodiment.

FIG. 11 illustrates a display of likelihood values fur a set of claims matching an open claim according to one embodiment.

FIG. 12 illustrates displaying summary amounts to a user based on a display mode selected by the user.

FIG. I 3 illustrates determining equalization values based on defined equalization criteria for a system and processing open claims using the determined equalization values.

FIG, 14 illustrates determining recommended settlement amounts and ranges with adjustments to adjusted general damages values for matching precedent claims.

1 c 1htrntec dptermjnirnj n effectiveness of a nrocess using a closed claim -to -Computer system 250 may include a memory medium on which computer programs according to various embodiments may be stored. The term "memory medium" is intended to include an installation medium, eg., a CD-ROM, a computer system memory such as DRAM, SRAM, EDO A A 11(11 T1($1( IiiPdi Y a hard drive or In some embodiments, a back office system may be provided. Back office users may handle more complex business processes and processes that remain active over a longer period of time. The back office may include access to management reports. Through the back office, t, erdpr tn nrcivide advice embodiments, a monetary amount may be expressed in the form of a currency, such as dollars, euros, or yen.

As used herein, "likelihood value" generally refers to a value corresponding to or representing the likelihood of a condition or event. For example, a likelihood value may provide 1*1 11- UIFh 1111r 1ncM claim whether that prior claim may have relevance to the current claim.

FIG. 2 illustrates matching of candidate claims to precedent claims according to one embodiment. At 300, one or more claims are identified that are similar to a candidate claim based e1im The identification of similar claims may be may be used in combination with a general assessment tool. In one embodiment, an adjuster may use COLOSSUS�, available from Computer Sciences Corporation, as a general assessment tool. Thus, an adjuster may have a general assessment program and a catalog of the diiizter in 1eterminin an atrnrooriate value for the claim and to particular injuries vary from state to state and county to county, and litigation stage, i.e., whether the claim was settled with or without attorney representation and whether a suit was filed.

Once the relative values of jurisdictions injuries, treatments and other claim attributes rnd by these as well as other FIG. 5 illustrates grouping of a claim set into zones according to one embodiment.

At 340, claims are identified that are similar to a candidate claim. At 342, an initial grouping of the claims is made. At 344, the sum of the squared errors is calculated by taking 1tr fndinc the difference between each value and the mean, To illustrate a sum of the squared errors calculation in a simple example, a set of 100 values are to fit into 2 clusters. Cluster A and cluster B may be divided into zones using the following approach: I. Sort the values into ascending sequence, 2. Initially set the dividing line such that it splits the values equally, 50 values on each side of the line -therefore 50 values for cluster A and 50 for B. 3. Calculate the sum squared error for cluster A by finding the mean of the 50 values in A and then taking the square of the difference between the mean and each value in A, and summing them, and then do the same for B. The total squared error is the sum of the squared errors for A and B. 4. Move the dividing line up and down in single value increments, and redistribute the values accordingly between A and B, then recalculate the total error. Continue until the total error cannot be reduced any more. In mathematical terms, the foregoing description is a regression to find the best split by descending the squared error surface.

Table I is an example of a set of similar claims for which can be grouped into zones according to one embodiment. Table 2 is an example of a sequence of iterations used to group the claims in Table 1. To simplify the illustration, only two zones (Group A and Group B) are determined in the example.

ID V alue (S N 4,200.00 0 5,000.00 5,100.00 5,200.00 5300.00 1 ABLE 2:

_ _-

__ 1eanS) jror Iteration 1 Groun A M, N, 0 4,400.00 56ft000.00 GrounB P 1) R ___ 520000 2O00000 --. edEnor0000 iter!JU A M, N,0,P 4 575 00 652,400 00 r Q,R_____ 5,250.00 5,0O4 _________ _____ __________ 657,400.00 Iteration 3 Group A IM, N 4,1OO.O0 20,000.00 then 1 minus the average ratio, all squared. Therefore, if the claim is very similar to the candidate claim then the weight will be close to 1, while if it has significant dissimilarities then the weight can be close to zero (e.g., 0.0025).

The weighted average is then calculated by multiplying each precedent claim!s value (e.g. FIG. 7 illustrates determining amounts for settling open claims using a likelihood function according to one embodiment. At 420, a set of claims (e.g., closed claims) that match an open claim is determined. At 422, a function is determined with respect to each of the matching rntn ic dprived for each claim in the set of CWW1 10001001. A unique claim number identifies each of the matching claims. Column 446 indicates a rating for each closed claim. Column 448 indicates an adjusted dollar value for each of the closed claims. Column 450 indicates a general damages value before adjustment.

I 1 1 - Tb l,l-cl precedent claims. At 474, a graph of likelihood values associated with the matching precedent claims as a function of amount is displayed. At 476, one or more ranges of amounts are indicated on the graph.

FIG. 11 illustrates a display of likelihood values for a set of claims matching an open 1 AO1\ 1 --) Window may include the following columns: Date Run, Matched Cases, Lkly GD Amnt, Lkly GD High, Lkly GD Low, Lkly Med Amt, Lkly Med Low, LkIy Med High The Lkly High'Low' amounts may correspond to the Most Likely Low and High er nn Siimmai. Graphs, Compare With and/or Repo user. In other embodiments, a system may compute amounts only when the user selects a particular mode. For example, if the system default is to display likelihood values, the system might not calculate least squares values unless and until the user selects a least squares display mode.

(,rnrnI vdHP F�iII1Ii7ation Values subsequent batch process) at various times after the initial installation of a program. For example, the equalization values may be updated on a periodic basis, such as annually or quarterly.

In some embodiments, equalization values are detenmned based on the particular P. hcet1 nn nne eiistomer's nast data, baselined tissue injury, while another claim may relate to only a soft tissue injury. A general damages value relating to the soft tissue-only claim may be adjusted using baselined equalization values to increase or decrease the value relative to a combination injury claim.

pnii1tirin yitpri incJiuIe what a dominant injury of a claim is. For wages (e.g, actual lost wages or expected lost wages), or a combination thereof. Thus, a recommended settlement may be calculated as follows: Adjusted General Damages Amount precedents + Adjustments pending claim = Adjusted Recommended Settlement Amount irriilr mclflnpr + Wages Incurred + Wages Expected -Wages Offset -Comparative Negligence (multiplied as a percentage of the subtotal amount and then subtracted) -Contribution Percent Amount (multiplied as a percentage of the subtotal amount and then subtracted) OR Contribution Dollars -Other Offsets = Recommended Settlement Amount As used in the preceding equation, "Adjusted Settled GD amount of catalog claim" may exclude specials and disfigurement, but include other offsets. The above formula may be applied to settlement values and ranges. For example, the above formula may be applied to a most likely settlement amount and a most likely settlement range.

tSusla For a least squares display, the formula described above for Recommended Settlement Amount may be applied to the final high, average, and low amounts that are displayed in the Adjusted Generals column based on a least squares method. After the Recommended Settlement amounts have been calculated for the claims catalog, those amounts may be displayed in the Recommended Settlement column. The amounts can be calculated each time the user navigates to the screen if the specials, offsets, or disfigurement have been updated since the previous re-in. Any amounts that are calculated to be less than zero may be displayed as a $0' in this column (i.e. negative amounts are not displayed). The following is an example display of values based on a least squares method: Adjusted General Damages: Recommended Settlement: High: $5,500 High: $7,500 Average: $3,500 Average: $5,500 Low: $2,000 Low: $4,000 The following is an example display of adjustments for a pending claim: Specials/Offsets and Disfigurement for the Current Claim Disfigurement: $5,000 Net Medicals $2,000 Net Wages $1,400 Negligence Percent: 60 % Contribution Percent: 40 % Contribution Dollars: Other Offsets: $1,000 Total: For a likelihood display, the display may contain fields named "Most Likely Settlement Amount" and "Most Likely Settlement Range" and appear in the corresponding locations as the current amount fields located in the Adjusted Generals section. The amounts can be calculated and stored each time the user navigates to the screen if the specials, offsets, or disfigurement have been updated since the previous rerun. Any amounts that are calculated to be less than zero may be displayed as a $0' in this column (i.e. we will not display negative amounts). The following is an example display of values based on maximum likelihood: Adjusted Generals Most Likely Amount: 4,290 Most Likely Range: $4,000 4,700 Recommended Settlement Most Likely Settlement Amount: $7,290 Most Likely Settlement Range: $7,000 7,700 In the discussion above with respect to FIGS. 2, 6, and 7, a system is used for settling L. outstanding claims (a "production" environment). Each candidate claim is an open claim for which an estimate of value is desired for purposes of settling the claim. In support of this process, the system provides an adjuster with access to data on closed claims that match the open iid tn evi1iite a claim estimation.

candidate claim. The representative value may be based on a statistical value such as mean, median, or mid-zone value of the precedent clairns At 366, if there are additional candidate claims, the system repeats the sequence of precedent claim identification (362) and determination of a representative value (364) for each of the represented by the number of precedent claims matched to the candidate claim. Each data set could be one precedent claim or many precedent claims.

At 382, a representative general damages value is determined for the set of precedent 1' nf the ndichite claims. The representative general damages value At 392, an impact percentage is calculated based on the total accumulated difference.

The impact percentage may be determined by dividing the total accumulated difference by the total accumulated general damages for the candidate claims. The impact percentage may be pynrpcced in the followinu formula: and claims W, X, and Y for candidate 2). In other embodiments, a mid-zone average may be a weighted average. For example, each of claims 0, P, Q, and R may each be given a different weight depending on their degree of similarity to candidate claim 1.

The fnfril nf each value cateorv is accumulated to yield the total associated with all Whether a claim will use the soft tissue spine matching or the demonstrable matching component may be an important consideration.

in various embodiments, similar claims may be found using the following steps: 1. Identify whether the major injury is predominantly a soft tissue spinal injury type or a demonstrable injury If soft tissue spinal injury: 1. Search the settled claim database for claims that have at least one of the soft tissue spine injuries the current claim contains 2. Filter the claims whose medical attributes are not within certain pre-defined tolerances of the attributes of the current claim 3. From the matches display a subset of claims which have attributes closest to the current claim If demonstrable injury: 1. Retrieve the pain and suffering seventies for all the injuries, treatments and complications which are contained in the current claim 2. Identify all the major body parts injured for the current claim 3. Identify the most injured major body part 4. Find the dominant medical feature (injury, treatment or complication, or combination of them) 5. Search the settled claims database for all of the claims having the same dominant medical feature 6. From the matches display a subset of claims which have the closest attributes to the current claim Deciding Whether a Claim is Demonstrable or Not A claim may be defmed to be predominantly demonstrable if it falls into any of the following categorieS 1. It has no soft tissue spinal injuries 2. It contains an invasive medical procedure (diagnostic or surgical) 3. It is one of the following injuries a. Amputation b. Closed Fracture C, Open fracture d. Dislocation e. Fracture dislocation Crush injury g. Internal throat injuries h. Intervertebral disc herniations or ruptures i. Intra-abdominal injuries j. Intra-pelvic injuries k. Intra-thoracic injuries 1. Ligament injuries (but not a shoulder ligament injury) 4. It has any of the following, but no soft tissue spine injuries a. Lacerations b. Concussion c. Contusions d. Superficial injuries e. Sprain strain injuries Shoulder ligament injuries, lacerations, concussion, contusions, superficial injuries and sprain strain injuries may not be indicators, by themselves, of whether a case is demonstrable or not. For instance, there are many whiplash claims that also include shoulder ligament injuries. In these cases the shoulder injuries are not treated, other than as part of the whiplash injury by therapeutic treatment. If the shoulder ligament injury were treated surgically then the case would be considered demonstrable, as per rule 3 above).

Deciding Whether a Claim has Only Trivial Injuries Trivial injuries are defined as the injuries for which no matching priority rules exist.

Injuries such as contusions, untreated lacerations, and superficial injuries are trivial injuries.

If a claim contains only trivial injuries then the system may find matches for the most significant of the trivial injuries, as defined by the injury hierarchy, set out under "Injury Hierarchy" in the Section explaining rule priority considerations.

If a claim contains both only trivial injuries and a soft tissue spine injury then the system may use the presence of the trivial injuries as matching criteria if the injury filter is set to ight".

This is explained in the injury section within "Filters" described below.

Matching for Soft Tissue Spine In an embodiment, the two broad classes of claim information that will be used in the matching are treatment duration and treatment level, there being a correlation between treatment duration and treatment level. Treatment time defines injury stabilization time or the time taken for an injury to reach maximum improvement. Treatment level can involve multiple types of therapeutic treatment. For instance, this can be any combination of chiropractic, physical therapy, other therapy, GP consultation and specialist doctor consultation. Other treatment can involve various 1 --and third columns for the fourth row, which has the 5 GP visits in the first column).

Intermediate values for GP visits, such as 4 visits, result in piecewise linear extrapolation of the second and third columns to derive the low and high bound.

Piecewise linear extrapolation may be defined as: (x2 -xi) where y is the extrapolated value; x is the number of GP visits; Xj is the value from the first column which is less than x; x2 is the value from the first column which is greater than x; y is the value from either the second or third colunms (depending on whether we are predicting the lower or upper bound) which corresponds to the Xi value from the first column; and similarly y2 corresponds with x2.

Using 4 GP visits as the actual value results in bounds of 3 to 5,66667, which are rounded to 3 to 6.

S ecialist Treatment Consultations L..

The tables for GP and specialist are almost identical, except that if the actual specialist visits is zero then only claims with zero specialist visits will be matched. This is different from the treatment of GP visits, where if the actual visits are zero claims with zero or 1 GP visits will be matched.

Both the GP and specialist tables differ from the therapeutic treatment tables below, in that for the higher values in column I the corresponding bands (columns 2 and 3) are broader upwards more than downwards. For example, for 20 GP visits the band is between 15 and 30 visits, whereas for therapeutic treatment it is 15 to 25. Even for therapeutic treatment of 70 visits the band is equally distributed, being from 55 to 85 -a difference of 15 either side. For the OP 3.

and specialist it is regarded that there comes a point where additional treatment no longer impresses as to the severity of the injury, and it suggestive of over-servicing. For this reason the band is larger on the high side.

lrwt' thh1 entries can be altered to reflect a particular (fhr thrmnv inhi1es treatment jven by practitioners of osteopathy, naturopathy, transcends both the initial injury and the operative treatment, and becomes the dominant medical feature of this claim. Determining the most severely injured body part therefore takes into account all three of these considerations injuries, treatments and complications, or a combination of these.

The dominant medical feature of a case can be specified by the adjuster using the system's user interface, or failing this, can be determined by the system.

Establishing the Most injured Body Part In some embodiments, if the user has not specified the dominant medical feature of a case then the system can perform this function. In order to do this the system: 1 () * Retrieves all the medical facts about the case, the injuries, treatments, complications and impairments * Accesses its own database tables to retrieve medical attributes corresponding to these case medical facts * Using its own algorithms it derives the overall severity of each major body part. The major body parts include the head, chest, abdomen, pelvic area, the spine, arms and legs.

* Determining the dominant medical feature of the most injured body part Retrieving Medical Codes Each case can have any number of medical attributes associated with it. These can be a number of injuries, treatments and complications, in any combination. For each of these instances there is a corresponding character code (there is a seventh character denoting sidedness), which is constrained to be from a list of treatment, or complication codes predefined with each injury code tracked by the system.

In certain embodiments, predefined treatment and complication codes may be derived from a series of mappings within the system. Injury may be mapped to treatment, injury may be mapped to complication, and complication may be mapped to treatment. For each injury code, the system may have a list of treatments the injury may require, these are sorted as "expected" and "possible" treatments. For example if the injury were an open fracture of the tibia, the treatment list might contain: * Amputation or re-amputation * Osteotomy * Limb shortening or lengthening procedures * Arthroplasty Arthrodesis o Open reduction of fracture o External fixation 3/ * Traction * Closed reduction of fracture * Immobilization * Removal of internal fixation device * Physical therapy * Debridement of open fracture site * Walking aids * Diagnostic studies * Prescribed medication.

In addition, the list can include treatments for potential complications which will vary depending on the type of complication that occurred. This might include such procedures as fasciotomy, osteoarthrotomy, nerve or vascular repair. Medical procedures are considered only as past and future procedures, there is no notion of initial treatment or subsequent treatment, and these are considered simply as past treatment. Similarly, for each injury code, the system can have a list of potential complications that might arise from the injury. In the case of our fractured tibia this * Associated vascular * Associated nerve injury * Avascular necrosis * Osteomyelitis * Osteoarthritis * Compartment syndrome * Deep vein thrombosis * Nonunion * Malunion * Delayed union.

Complication and treatment mapping may be derived from medical references including: I. Apley's System of Orthopaedics and Fractures 6th Edition 2. Attorney's Textbook of Medicine: Manual of Traumatic Injuries Volumes l3 3. Attorney's Textbook of Medicine 3 Edition Volumes ll 8 4. Vertebral Musculoskeletal Disorders -Corrigan & Maitland 5. Essentials of Surgery -Scientific Principles and Practice -Lippincott Raven publication 6. Current Surgical Diagnosis & Treatment 10th Edition -Appleton & Lange publication 7. Rehabilitation Medicine Delisa Gans -3 Edition Lippincott Raven publication 8. The Disability Advisor 3 Edition -Pressley Reed Medical Severity Attributes of Medical Codes After the medical codes are entered against a case, a table may be accessed which defines a number of attributes for each medical code. in some embodiments, the pain and suffering severity scale is used to derive overall medical severity fbr each injured body part, given the medical facts regarding the case being considered.

A pain and suffering severity scale can represent relative severity between injuries, treatments and complications respectively. The severity applied may be in isolation to the frfmpnt nr rnmnlicption it is applied to. For example the severity applied to injured body part only. The "most injured" body part may be the body part with the highest combined value on the pain and suffering severity scale (described above). All the medical codes present in the case may be visible to all the rules, thus rules can reference medical codes 1 I I I I \ Matthew Bender publication 4. Attorneys Textbook of Medicine 3rd Edition -Volumes 1-18 -Matthew Bender publication 5. Vertebral Musculoskeletal Disorders -Corrigan & Maitland 6. Essentials of Surgery -Scientific Principles and Practice Lippincott -Raven publication 7. Current Surgical Diagnosis & Treatment * 10Ih Edition -Appleton & Lange publication 8. American Medical Associations "Guides to the Evaluation of Permanent Impairment * Edition 9. Rehabilitation Medicine Delisa Gans -3'' Edition Lippincott * Raven publication In general the hierarchy of injury may be: 1. Loss of vision 2. Major amputations 3. Fracture dislocations to major joints 4. Fractures 5. Intra-abdominal injuries 6. lntra-pelvie injuries 7. Intra-thoracic injuries 8. Dislocations 9. Ligament and tendon injuries 10. Sprain and strain injuries 11. Lacerations 12. Contusions 13. Superficial injuries Within each of these injury groups there may also exist another hierarchy. For example, for fractures clearly a fractured femur is much more serious than fractured toe. Similarly, the removal of a kidney is much more serious than the removal of a gallbladder. Of course, a fractured toe is a trivial injury compared to any significant intra-abdominal injury. Therefore the injury hierarchy when applied to the body as a whole is not a strict one, but only a guide to the placement of different injuries in a pain and suffering medical severity scale. When applied to a body part this injury hierarchy is more constant though still with exceptions. In the arm for example, generally amputations would precede fracture dislocations and fractures and dislocations, which would precede ligament injuries, sprains strains and contusions and superficial injuries.

Injury complications can be either localized or systemic, and like injury type has a hierarchy which is along the following: 1. Life threatening, such as septicemia, peritonitis or pneumonia 2. Brain complications such as intracranial hematoma -subdural, subarachnoid or epidural hematoma, cerebral edema or posttraumatic epilepsy 3. Cranial nerve involvement such as vertigo, tinnitus or loss of smell and taste 4. Vascular complications such as crush syndrome, hypovolemic shock, deep vein thrombosis, compartment syndrome or hemorrhage 5. Thoracic complications such as pneumothorax, hemothorax, pneumothorax or pleural edema 6. Treatment complications such as fistula or adhesions 7. Bone complications such as osteomyelitis, avascular necrosis, bony union difficulties or limb deformities 8. Joint complications such as osteoarthritis, synovitis, joint stiffliess or joint laxity 9. Pelvic complications such as hematuria, ureteral or urethral strictures 10. Localized infections Although a hierarchy exists, it may not be strictly followed in all cases. For example, osteoarthritis of the hip is not the same as osteoarthritis of the little finger.

In one embodiment, a treatment hierarchy includes, but is not limited to: 1. Amputation 2. Major chest surgery such as thoracotomy 3. Removalof the eye 4. Organ removal such as kidney or spleen 5. Other abdominal surgery 6. Pelvic surgery 7. Skull procedures such as craniotomy or craniectomy 8. Joint surgery such as spinal fusion, arthrodesis or arthroplasty 9. Bone surgery such as fracture reductions, sequestrectomy or osteotomy 10. Ligament and tendon repairs Ii. Vascular repair 12. Fascia repair The above hierarchy is a guide as to the severity of treatments. For instance the amputation of the arm at the shoulder is far more severe than the amputation of the little finger. Accordingly there will be considerable overlap between treatments in the hierarchy in terms of where medical seventies could be allocated.

Some injuries can be exceptional and therefore not be close to others of their kind in the hierarchy. For instance, a true dislocation of the knee (a tibiofernoral dislocation) is an orthopedic emergency with the loss of the limb possible unless it is treated promptly and professionally.

Even then the outcome will be guarded. Within the same injury category, dislocations, will be hip dislocations for instance. These latter dislocations do not present the same orthopedic emergency nor are they likely to have the same medical outcome. So in this case, dislocations of the knee would be regarded as the most severe form of dislocation and would rate as a more severe injury in the overall hierarchy of injury than it would have otherwise.

There are also instances where a combination of medical features can have significant implications for the matching process. For instance, a laceration of the upper arm requiring nerve repair implies that a 3 degree peripheral injury is present. Such nerve injuries can lead to significant impairment of the limb. On the other hand, a laceration to the upper arm with vascular repair is also a significant injury but is unlikely to have the same pessimistic outcome or associated impairment of the limb. Thus the first combination of injuly and complication could be more serious than the second.

There are no specific rules to match the medical outcome with regard to permanent impairment. Impairments are addressed in the filters section below.

Filters In some embodiments, filters are used to constrain, refine or relax the criteria that are used in iS finding matching closed claims. The starting settings of the filters can be specified on a company wide basis, at a user level, or at a specific claim level (once set by the user). Example filter settings are: * Tight * Enabled * Loose * Ignore The settings above are constraints on the range of values that will be used in the search for precedent claims. A "tight" setting for a parameter, such as age, will constrain the search only finding claims whose claimant is in a narrower age band. The "loose" setting will widen the band of claimant ages that can be returned.

The settings of "enabled" and "ignore" refer to parameters whose potential values are Boolean (constrained to the values of yes or no). Gender is an example of a Boolean values attribute it is either enabled and only claims with the correct gender will be returned or ignored and claims involving both sexes will be returned.

Not all filter values have all the same potential settings. Example filter values are: * State and County * Age * Gender * Injuries Impairment * Litigation stage State and County The state/county filter can take the values "tight", "loose" and "ignore". The "tight" setting will constrain the search to ensure that all claims returned match the county of the current claim. A "loose" setting will allow claims within the same state to be returned, using all counties within the corresponding state. An "ignore" setting will seek claims anywhere throughout the United States, including the nominated state and county. Age

For each age (or range of ages), "tight" and "loose" may be defined. For example, a "tight" setting for a 40 year old may be from age 30 to 45, and a "loose" setting for a 40 year old may be from 25 to 55. Example settings include: manta _ Loose ___ To a e

-_

In the above example. the table has entries for ages 0 and 120. Though few claimants will have these particular ages, they are included to provide lower and upper bounds of theoretical potential ages. For claimants whose age falls in between two values in the first column, such as age 9, then the values used representing the age range will be intermediate values from the other columns. For example, if the setting for age is "tight" then, since age 9 is halfway between ages 8 and 10 (which appear in the claimant age colunm), the derived low age value will be 6 (half way between 5 and 7 which are the corresponding value for ages 8 and 10) and the high bound will be 13 (between 12 and 14 from the high column).

Gender The gender settings are "enable" and "ignore", which correspond to matching the claimant's gender or returning claims involving both sexes respectively.

Injuries The settings for injuries are "tight" and "loose" only For cases whose dominant injury is demonstrable (therefore non-whiplash) the "tight" setting constrains the matching to include precedent claims whose medical attributes match all the medical attributes of the current claim, excluding any trivial injuries. These medical attributes are governed by the medical rules as specified below. A "loose" setting widens the matching to claims which have the same dominant medical feature as the current claim (the dominant medical feature is described elsewhere in this document).

For claims that are predominantly of a soft tissue spinal nature the "tight" and "loose" setting can have different effects. A "tight" setting may constrain the matching to only return claims which have at least one of the whiplash type injuries of the current claim, and which have trivial demonstrable injuries if the current claim also has them or that do not have any trivial injuries if the current claim also does not have them. For example, for a case with a cervical sprain and a chest contusion the cases returned will include any that have a cervical sprain and another trivial demonstrable injury (not necessarily a chest contusion). A "loose" setting may remove the constraint of requiring to include or exclude the trivial demonstrable injuries. For the above example, claims would be returned which had a cervical sprain, but regardless of whether they also had any trivial demonstrable injuries.

Impairment In a similar manner to the treatment of an age filter, impairment is constrained to be between two values. Different values are used for "tight" and "loose". Example settings include: Claimant Tight Loose whole person Jprment Impairment Impairment to Impairment impairment to from _____ from 0 0.. .. p..

0.1 0.1 0.5 0.1 3 4 6 3 8 8 12 7 1 13 L---23 [ so 40 __J 60 3s 70 L � iiL_ L � Litigation Stage In one embodiment, potential values for litigation stage are "direct", "unlitigated" and "suit". The values for the filter are "enable" and "ignore". A setting of "enable" constrams the matching to return claims which have the same litigation stage, as the current claim. A setting of "ignore" will return claims regardless of their litigation stage.

Attorney Representation In an embodiment, a filter may be applied depending on whether a claimant is represented by an attorney. In another embodiment, a filter may be applied depending on whether a claimant is represented by a particular attorney or a defined set of particular attorneys.

Accident Data In an embodiment, a filter may be applied depending on whether EDR data is available for the accident that gave rise to the claim. In an embodiment, a filter may be applied depending on whether EDR data for the accident indicates that an injury was a low-impact injury.

Failback In some embodiments, if insufficient claims are matched the filters may be relaxed in order to expand the search.

In order of priority the filters are relaxed in the following order, assuming filters are originally set at tightest setting 1. Injury is set to "loose" 2. Gender is set to "ignore" 3. Age is set to "loose" 4. Age is set to "ignore" 5. Jurisdiction (state and county) is set to "loose" 6. Litigation stage is set to "ignore" 7. Jurisdiction is set to "ignore" For example if insufficient claims are Ibund then the first fallback for the filters is to set the injury filter to "loose". If there are still insufficient claims then the gender filter is set to ignore".

Filters may be relaxed in the above sequence until either enough claims are found or the 3() relaxation of the filters has been exhausted.

1f in relaxing a filter, a large number t' claims are returned, other filters already relaxed may be re-tightened in order to optimize the closeness olthe matched claims attributes until it reaches close to the minimum number of claims required For example, if during filter relaxation reached the 6th stage (setting the litigation stage to "ignore"), and suddenly the number of claims matched rises to 100 then all the filters whose priority is less than 6 may be re-tigthened, and then, if not enough matches are found, may be relaxed again in turn until the minimum threshold is reached.

This task may be repeated several times to optimize the closeness of the matched claims.

In certain embodiments, one or more of any of the characteristics used for filters described herein may be used as equalization criteria. Such equalization criteria may be used instead of or in addition to, the application of various filters. For example, the system might filter claims based gender and adjust values using equalization values based on age.

In one embodiment the minimum number of claims used in the filter optimization is set to 6.

Ranking the Matching Claims In some embodiments, matching claims are ranked on a numerical scale. For example, Rank 1 matches may be the best fit, but claims of Rank 4 are still similar claims. It is the number of claim attributes and to what degree they differ between a matched claim and the current claim that determine the rating a matched claim receives. Example attributes considered when determining ranking level are: I. Dominant injury treatment or complication 2. Jurisdiction 3. Litigation stage 4. Age 5. Impairment 6. Secondary injuries For soft tissue spine additionally: 7. Treatment time 8. Number of GP visits 9. Number of chiropractor visits 10. Number of physical therapy visits 11. Number of specialist visits Within each rating displayed the claims are sorted by increasing General Damages Deriving Adjusted General Damages There will be instances where the claims that have been returned by the matching process will not be absolute matches for the current claim. For example, the dominant medical feature may match, but secondary medical features may be different Or if insufficient cases were found in the nominated stage and county then claims can be returned from another jurisdiction This difference in jurisdiction can be reflected in difi�rent settlement values for similar claims In both cases, the General Damages from the original settlement should be adjusted to reflect different jurisdiction or different secondary medical features. All returned claims may include the actual General Damages paid as well as the adjusted General Damages.

r'iirrtt c'1iim invrulvetl a fracture of the humerus only and the In an embodiment, each medical code used by the system may be assigned a Pain and Suffering severity which represents the General Damages severity relativity. These relativities follow in general the injury, treatment and complication hierarchies described above. Each -I-.

2. Intracranial hematoma, head vascular injury or cerebral edema 3. Fractured skull or concussive injury with epilepsy 4. Fractured skull or concussive injury with trigeminal neuralgia or cranial nerve injury 5. Fractured skull or concussive injury with hearing loss 6. Fractured skull or concussive injury with loss of smell and taste 7. Fractured skull or concussive injury with craniotomy, craniectomy or other skull surgery 8. Fractured skull or concussive injury with vertigo or tinnitus 9. Open skull or facial fracture or laceration of face or scalp with osteomyelitis 10. Skull, orbit or nose fracture with rhinorrhea or otorrhea 11. Fractured skull without skull surgical procedures 12. Fractured jaw (mandible or maxilla) 13. Fractured facial bone (zygoma or orbit) 14. Fractured nose iS. Laceration to the eye 16. Concussive injury 1 7. Laceration to the scalp, ear, eyelid, mouth or face Explanation Loss of sight may be the highest level of severity, followed by head injuries with accompanying intracranial hemorrhage such as epidural, subdural and subarachnoid hemorrhage.

While recovery from intracranial hemorrhage may take place, some residual cerebral dysfunction may also exist. Posttraumatic epilepsy is a serious consequence of head injury which depending on its severity may have a profound affect on an individuals ability to lead a normal life style.

Head injuries with associated cranial nerve trauma may result in sensory loss (hearing, smell and taste). Injuries to the acoustic nerve may produce vertigo or tinnitus or both, again these complications depending on the severity of the symptoms can seriously affect a person's ability to lead a normal life. Skull surgery is an indication that some serious brain or vascular injury or complication was involved. Facial fractures may have both a functional and disfiguring aftermath.

Jaw fractures (mandible or maxilla) can heal with dysfunction to mastication and may even be disfiguring. Zygoma and orbit fractures may heal with disfigurement, similarly nasal fractures.

The main implication for lacerations to the head region is disfigurement. Eye lacerations can be simple or extremely serious.

The severity order described above is not absolute, for example, an eye laceration with visual impairment clearly would be a more serious injury than where it currently lies within this hierarchy. Debilitating epilepsy or vertigo or tinnitus would also be higher in the hierarchy than suggested above. Chest

1. Thoracic injuries involving open thoracic or abdominal surgery 2. Life threatening respiratory or cardiac complications (including flail chest, hemothorax, pneumothorax, pneumohemothorax, myocardial contusion, mediastinal emphysema or pneumonia) 3. Intercostal neuralgia 4. Fractured ribs or sternum a. Fractures of five or more ribs Fractures to 5, 6, 7 or 8 or more rib fractures b. Fractures of 4 ribs Fractures to 3 to 6 ribs c. Fractures of 3 ribs Fractures of 2 to 5 ribs d. Fracture of 2 ribs Fractures of up to 3 ribs or the sternum e. Fracture of 1 rib Fracture of 1 or 2 rubs or the sternum f. Fracture of the sternum Fractures of the sternum or I or 2 ribs 5. Lacerations or fractures to the internal throat structures 6. Internal thoracic contusions 7. Contusions to the internal throat structures 8. Laceration to the external throat 9. Laceration to the breast 10. Laceration to the chest wall Explanation Chest injuries requiring open chest surgery (thoracotomy) or an abdominal approach (laparotomy) may be the most potentially serious thoracic injury. Thoracotomy for example is one of the most invasive surgical procedures that can be undertaken. Then follows thoracic trauma with life threatening respiratory complications. Intercostal neuralgia is a painful and often intractable condition so it has been placed high in the severity hierarchy. Sternum and rib fractures follow. They are sometimes associated with lung complications such as pneomothorax or hemothorax, in which case they would be considered more serious an injury than a corresponding fracture without lung complication. Internal throat lacerations may be ranked higher than contusions in the overall chest severity hierarchy, lacerations to internal structures or organs are generally more serious than contusions.

Abdomen 1. Internal abdominal surgical removal or reconstruction (nephrectomy, spienectomy, colostomy, ileostomy or jejunostomy) 2. Peritonitis 3. Fistula 4. Pancreatitis 5. Abscess or cyst 6. Adhesions or incisional hernia 7. Paralytic ileus 8. Internal abdominal open surgery via laparotomy 9. Internal abdominal surgery via laparoscopy 10. Abdominal injuries without surgical intervention Explanation Abdominal hierarchy is generally reflected by removal or repair or reconstruction to major abdominal organs and trauma or surgical complications. Removal of a kidney (nephrectomy) would be seen as the most serious abdominal injury because of its potential to be life threatening should the remaining kidney be injured or become diseased in the future. Removal of the spleen (splenectomy) puts the individual (particularly if he or she is young) at risk of very serious infection (postsplenectomy sepsis) and requires ongoing medication to prevent against infection.

Injuries to the small or large bowel requiring surgery indicate serious abdominal injuries.

Peritonitis heads the severity for abdominal complications Fistula, abscess, cyst, adhesions and incisional hernia are all suggestive of possible further surgery. Abdominal injury with repair by laparotomy is considered more invasive than repair by laparoscope.

Pelvis and Uritogenital Pelvic fracture includes both open and closed fractures.

1. Internal pelvic surgery or laparotomy 2. lntra-pelvic laceration of internal organs (bladder, ureter, urethra) 3. Pelvic fistula 4. Urethral or ureteral stricture or associated urethral, ureter or bladder injury 5. Osteomyelitis of the pelvis 6. Fracture of the pelvis or dislocation of the pelvic ring 7. Laparoscopic surgical repair of internal organs 8. lntra-pelvic contusion of internal organs 9. Lacerations to the testes 10. Lacerations of the penis 11, Lacerations to the scrotum 12. Lacerations to the vulva 13. Contusions of the testes Explanation Lacerations to the bladder, ureter or urethra requiring surgical repair or reconstruction are considered to be the most severe pelvic injuries, followed by complications such as fistula or stricture of the ureter or urethra. Pelvic fractures are serious injuries but not considered as serious as injuries to the urinary system aforementioned. Genital lacerations can be minor or serious injuries, this would be determined by any residual impairment that resulted. As with other body parts it is again pointed out this severity hierarchy is not inflexible and the order shown can change depending on factual circumstances of a claim. Spine

Spinal fractures include open and closed fractures of the spine. Fractures, dislocations and fracture dislocations to any spinal region include such injuries to any specific level within the spinal region.

I, Fracture dislocations or dislocations of the cervical spine 2. Fracture dislocations or dislocations of the thoracic spine 3. Fracture dislocations or dislocations of the lumbar spine 4. Spinal adhesions Any spinal region 5. Osteomyelitis of the spine Any spinal region 6. Associated spinal nerve injury Any spinal region 7. Traumatic spondylolisthesis Any spinal region 8. Fractures of the cervical spine 9. Fractures of the thoracic spine 10. Fractures of the lumbar spine ii. Fractures of the sacrum 12. Fractures of the tailbone (coccyx) 13. Disc herniations or ruptures of the cervical spine requiring surgery 14. Disc herniations or ruptures of the thoracic spine requiring surgery 15. Disc herniations or ruptures of the lumbar spine requiring surgery 16. Disc herniations or ruptures of the cervical spine not requiring surgery 17. Disc herniations or ruptures of the thoracic spine not requiring surgery 18. Disc herniations or ruptures of the lumbar spine not requiring surgery 19. Spondylosis Any spinal region 20. Decubitus ulcer 21. Bed sores Explanation Fracture dislocations and dislocations of the spine head the severity hierarchy, vertebral fractures although serious injuries are not considered as severe. Dislocations of the vertebral column have graver potential consequences than fractures because of the increased possibility of spinal cord damage. The cervical region is regarded as potentially a more serious region to be involved than the thoracic or lumbar regions. Spinal complications then follow, followed by fractures. Disc hemiations or ruptures requiring disc surgery are ranked higher than those without though of course this may not necessarily follow. Because a disc injury isn't surgically treated does not necessarily mean it is less serious than one operated on. Arm

1. Amputations at the shoulder Any above elbow amputation 2. Amputations of the upper arm Forearm, elbow or above amputation 3. Amputation at the elbow Elbow, forearm and upper arm amputations 4. Amputation at the forearm Hand, wrist, elbow, forearm or upper arm amputations 5. Amputations of the hand or wrist Hand, wrist, forearm or elbow amputations 6. Amputations of the thumb Whole thumb or partial amputation 7. Amputations of other finger Amputation of whole finger or partial amputation 8. Crush injuries to the arm or hand with associated surgery (fasciotomy nerve repair vascular repair) 9, Volkmann's contracture 10. Reflex sympathetic dystrophy 11. Lacerations of the shoulder or upper arm requiring nerve repair 3rd degree nerve injury to the median, axillary or ulnar nerves 12. Lacerations of the elbow or forearm requiring nerve repair 3rd degree nerve injury to the radial or ulnar nerves 13. Crossunion of radius Synostosis involving the radius and ulna 14. Lacerations of the wrist or hand requiring nerve repair 3rd degree nerve injury to the radial or digital nerves 15. Lacerations of the thumb requiring nerve repair 3' degree digital nerve injury 16. Amputations of the fingers 17. Avascular necrosis of humerus, radius or ulna 18. Avascular necrosis of the shoulder bones (scapula or clavicle) 19. Avascular necrosis of the carpal bones (scaphoid, lunate, pisiform, hamate, capitate, triquetral, trapeziod, trapezium) 20. Avascular necrosis of metacarpal, thumb or finger 21. Osteomyelitis of humerus, radius or ulna 22. Osteomyelitis of the shoulder bones (scapula or clavicle) 23. OsteornyelitiS of the carpal bones (scaphoid, lunate, pisiform, hamate, capitate, triquetral, trapeziod, trapezium) 24. Osteomyelitis of metacarpal, thumb or fmger 25. Deep vein thrombosis of the arm 26. Nonunion of humerus, radius or ulna 27. Nonunion of the shoulder bones (scapula or clavicle) 28. Nonunion of the carpal bones (scaphoid, lunate, pisiform, hamate, capitate, triquetral, trapeziod, trapezium) 29. Nonunion of metacarpal, thumb or finger 30. Osteoarthritis of shoulder, elbow or wrist 31. OsteoarthritiS of hand, thumb or fingers 32. Delayed Union of humerus, radius or ulna 33. Delayed Union of the shoulder bones (scapula or clavicle) 34. Delayed Union of the carpal bones (scaphoid, lunate, pisiform, hamate, capitate, iS triquetral, trapeziod, trapezium) 35. Delayed Union of metacarpal, thumb or finger 36. Malunion of humerus, radius or ulna 37. Malunion of the shoulder bones (scapula or clavicle) 38. Malunion of the carpal bones (scaphoid, lunate, pisiform, hamate, capitate, triquetral, trapeziod, trapezium) 39. Malunion of metacarpal, thumb or finger 40. Fracture dislocation or dislocation of the shoulder 41. Fracture dislocation or dislocation of the elbow 42. Fracture dislocation or dislocation of the wrist 43. Fracture dislocation or dislocation of the hand 44. Fracture dislocation or dislocation of the thumb 45. Lacerations of the hand or wrist requiring tendon repair 46. Lacerations of the thumb requiring tendon repair 47. Associated tendon injury of hand, thumb or fingers 48. Lacerations of the fingers requiring tendon repair 49. Lacerations of the shoulder or upper arm requiring tendon repair 50. Lacerations of the elbow or forearm requiring tendon repair 51. Associated tendon injury of shoulder, upper arm, elbow, forearm or wrist With any other injury 52. Fracture of the humerus 53. Fractures of the forearm bones (radius or ulna) 54. Fractures of the shoulder bones (scapula or clavicle) 55. Crush injury to the thumb with associated surgery (fasciotomy nerve repair vascular repair) 56. Crush injuries to the fingers with associated surgery (fasciotomy nerve repair vascular repair) 57. Crush injury to the thumb not requiring surgery 58. Crush injuries to the fingers not requiring surgery 59. Fractures of the carpal bones (scaphoid, lunate, pisiform, hamate, capitate, triquetral, trapeziod, trapezium) 60. Fractures of the first metacarpal (of the thumb) 61. Fractures of the second to fiflh metacarpals (of the fingers) 62. Fractures of the thumb 63. Fracture dislocation or dislocation of the fingers 64. Fractures of the fmgers 65. Ligament injuries to the wrist with associated surgery 66. Ligament injuries to the hand with associated surgery 67. Ligament injuries to the shoulder with associated surgery 68. Ligament injuries to the elbow with associated surgery 69. Ligament injuries to the thumb with associated surgery 70. Ligament injuries to the fingers with associated surgery 71. Associated vascular injury With any other injury 72. Lacerations of the shoulder or upper arm requiring vascular repair 73. Lacerations of the elbow or Ibrearm requiring vascular repair 74. Lacerations of the fingers requiring nerve repair 75. Associated nerve injury of the arm 76. Lacerations of the wrist or haid requiring vascular repair 77. Lacerations of the thumb requiring vascular repair 78. Lacerations of the fingers requiring vascular repair 79. Sprains and strains of the shoulder with associated surgery 80. Sprains and strains of the wrist with associated surgery 81. Sprains and strains of the elbow with associated surgery 82. Sprains and strains of the thumb with associated surgery 83. Sprains and strains of the fingers with associated surgery 84. Crush injuries to the ann or hand not requiring surgery 85. Ligament injuries to the wrist not requiring surgery 86, Ligament injuries to the hand not requiring surgery 87. Ligament injuries to the shoulder not requiring surgery 88. Ligament injuries to the elbow not requiring surgery 89. Ligament injuries to the thumb not requiring surgery 90. Ligament injuries to the fingers not requiring surgery 91. Bursitis, synovitis, tendonitis or tenosynovitis of shoulder, elbow or wrist 92. Bursitis, synovitis, tendonitis or tenosynovitis of hand, thumb or fingers 93. Sprains and strains of the shoulder not requiring surgery 94. Sprains and strains of the wrist not requiring surgery 95. Sprains and strains of the elbow not requiring surgery 96. Sprains and strains of the thumb not requiring surgery 97. Sprains and strains of the fingers not requiring surgery 98. Lacerations of the shoulder or upper arm not requiring surgery 99. Lacerations of the elbow or forearm arm not requiring surgery 100. Lacerations of the wrist or hand not requiring surgery 101. Lacerations of the thumb not requiring surgery 102. Lacerations of the fmgers not requiring surgery Explanation In the above listing, traumatic amputations head the severity order i.e. the limb or part thereof was severed in the accident. Crush injury to the arm or hand follows, crush injuries might be expected to result in some vascular or peripheral nerve damage with resulting muscle and fascia dysfunction. Next in severity hierarchy is major peripheral nerve injury, minor nerve injuries are not surgically treated, those that are suggest degree nerve injuries, and some residual dysfunction might be expected to result. Fracture complications come next in the order.

Osteomyelitis and avascular necrosis are serious bone complications, the former being an infection and the latter a bone vascular problem. Nonunion is considered the most significant of the bony union complications (with the exception of cross union). Fracture dislocations and dislocations of major joints are considered slightly more severe than fractures. Obviously not all fractures or fracture dislocations or dislocations are treated alike in terms of injury hierarchy.

There is considerable severity overlap between these injuries with their complications and potential treatments. What may be ranked as a moderately severe injury may in fact end up a more serious injury than some ranked higher in severity, this however can be related by the adjuster as the "dominant injuiy", Leg 1, Amputations at the hip Amputation at the hip or through the thigh 2. Amputations though the thigh Hip, thigh, knee or lower leg amputations 3 Amputations at the knee Amputation though thigh, knee or lower leg 4. Amputations through the lower leg Amputations through thigh, knee, lower leg, ankle or foot 5. Amputation at the ankle Amputations through knee, lower leg, ankle or foot 6. Amputations through the foot Amputations through lower leg, ankle or foot 7. Fracture dislocations or dislocations of the knee 8. Fracture dislocations or dislocations of the hip 9. Lacerations of the hip or thigh requiring nerve repair 3rd degree nerve injury to the femoral or sciatic nerves 10. Lacerations of the knee or lower leg requiring nerve repair 3 degree nerve injury to the peroneal, popliteal, tibial or other nerves 11. Crush injuries of the leg or foot requiring surgery (fasciotomy nerve repair vascular repair) 12. Nonunion of femur, patella, tibia or fibula 13. Nonunion of tarsal bones(calcaneus, cuhoid, navicular, talus or cuneiforms) 14, Deep vein thrombosis of the leg 15. Avascular necrosis of femur, patella. tibia or fibula I 6. Avascular necrosis of tarsal hones (calcaneus, cuhoid, navicular, talus or cuneiforms) 17. Avascular necrosis of metatarsals, sesamoids or toes 18. Osteomyelitis of acetabulum, femur, patella, tibia or fibula 19. OsteomyelitiS of tarsal bones(calcaneUs, cuboid, navicular, talus or cuneiforms) 20. Osteomyelitis of metatarsals, sesamoids or toes 21. OsteoarthritiS of hip, knee or ankle 22. OsteoarthritiS of foot or toes 23. Delayed union of acetabulum, femur, patella, tibia or fibula 24. Fractures of the femur 25. Fractures of the hip (acetabulum) 26. Fractures of the tibia 27. Amputation of the toes Any toes, whole or part 28. Nonunion of metatarsals, sesamoids or toes 29. Delayed union of tarsal bones (calcaneus, cuboid, navicular, talus or cuneiforms) 30. Delayed union of metatarsals or toes 31. Malunion of acetabulum, femur, patella, tibia or fibula 32. Malunion of tarsal bones (calcaneus, cuboid, navicular, talus or cuneiforms) 33. Malunion of metatarsals or toes 34. Fracture dislocations or dislocations of the ankle 35. Fracture dislocations or dislocations of the foot 36. Fractures of the hind foot (talus and calcaneus) 37. Ligament injuries of the knee requiring surgery 38. Sprain strain injuries of the knee requiring surgery 39. Ligament injuries of the ankle requiring surgery 40. Sprain strain injuries of the ankle requiring surgery 41. Ligament injuries of the hip requiring surgery 42. Sprain strain injuries of the hip requiring surgery 43. Sprain strain injuries of the thigh requiring surgery 44. Ligament injuries of the foot requiring surgery 45. Sprain strain injuries of the foot requiring surgery 46. Fracture dislocations or dislocations of the patella 47. Fractures of the patella 48. Fractures of the fibula 49. Fractures of the tarsal bones (cuboid, navicular, first, second and third cuneiforms, tibial and fibular sesamoids) 50. Crush injuries of the toes requiring surgery (fasciotomy nerve repair vascular repair) 51. Ligament injuries of the toes requiring surgery 52. Fractures of the forefoot (metatarsals) 53. Fracture dislocations or dislocations of the toes 54. Fractures of the toes 55. Associated vascular injury 56. Sprain strain injuries of the toes requiring surgery 57. Lacerations of the ankle or foot requiring tendon repair 58. Lacerations of the toes requiring tendon repair 59. Lacerations of the hip or thigh requiring tendon repair 60. Lacerations of the knee or lower leg requiring tendon repair 61. Lacerations of the hip or thigh requiring vascular repair 62. Lacerations of the knee or lower leg requiring vascular repair 63. Lacerations of the ankle or foot requiring nerve repair 64. Lacerations of the toes requiring nerve repair 65. Lacerations of the ankle or foot requiring vascular repair 66. Lacerations of the toes requiring vascular repair 67. Crush injuries of the leg or foot not requiring surgery 68. Crush injuries of the toes not requiring surgery 69. Ligament injuries of the knee not requiring surgery 70. Ligament injuries of the ankle not requiring surgery 71. Ligament injuries of the hip not requiring surgery 72. Ligament injuries of the foot not requiring surgery 73. Ligament injuries of the toes not requiring surgery 74. Associated tendon injury of hip, upper leg, knee, lower leg or ankle 75. Associated tendon injury of foot or toes 76. Associated nerve injury 77. Bursitis, syovitis, tendonitis or tenosynovitis of hip, knee or ankle 78. Bursitis, synovitis, tendonitis or tenosynovitiS of foot or toes 79. Sprain strain injuries of the knee not requiring surgery 80. Sprain strain injuries of the hip not requiring surgery 81. Sprain strain injuries of the thigh not requiring surgery 82. Sprain strain injuries of the ankle not requiring surgery 83. Sprain strain injuries of the foot not requiring surgery 84. Sprain strain injuries of the toes not requiring surgery 85. Lacerations of the hip or thigh not requiring surgery volatile memory such as a magnetic media, e.g., a hard drive, or optical storage. The memory medium may comprise other types of memory as well, or combinations thereof.

In addition, the memory medium may be located in a first computer in which the programs are executed, or may be located in a second different computer that connects to the first computer over a network, such as the Internet. In the latter instance, the second computer may provide program instructions to the first computer for execution. The term "memory medium" may include two or more memory mediums that may reside in different locations, e.g., in different computers that are connected over a network.

In some embodiments, a computer system at a respective participant location may include a memory medium(s) on which one or more computer programs or software components according to one embodiment of the present invention may be stored. For example, the memory medium may store one or more programs that are executable to perform the methods described herein. The memory medium may also store operating system software, as well as other software for operation of the computer system.

In some embodiments, users (e.g., claims adjusters, process evaluators, FSO personnel) may access or operate elements of a computer system via a network such as a WAN or LAN. In certain embodiments, users may have web-enabled access to a system (e.g., via internet browser).

Further modifications and alternative embodiments of various aspects of the invention may be apparent to those skilled in the art in view of this description. Accordingly, this description is to be construed as illustrative only and is for the purpose of teaching those skilled in the art the general manner of cariying out the invention. It is to be understood that the forms of the invention shown and described herein are to be taken as embodiments. Elements and materials may be substituted for those illustrated and described herein, parts and processes may be reversed, and certain features of the invention may be utilized independently, all as would he apparent to one skilled in the art after having the benefit of this description of the invention.

Changes may be made in the elements described herein without departing from the spirit and scope of the invention as described in the following claims.

Claims (113)

1. WHAT IS CLAIMED IS: 1. A computer-implemented method, comprising: a computer system automatically identifiing one or more closed claims that match an open claim based on one or more characteristics of the open claim; the computer system determining a likelihood value associated with at least one of the matching closed claims; and determining an amount for the open claim based at least in part on the likelihood value for at least one of the matching closed claims.
2. 2. The method of claim 1, wherein determining the likelihood value at least one of the matching claims comprises maximum likelihood estimation.
3. 3. The method of claim 1, wherein the amount for the open claim is a most likely amount.
4. 4. The method of claim I, wherein the most likely amount corresponds to the matching closed claim with the highest likelihood value of the likelihood values associated with the matching closed claims.
5. 5. The method of claim I, wherein the open claim is an insurance claim.
6. 6. The method of claim 1, wherein the amount is a general damages amount.
7. 7. The method of claim I, wherein the amount is a medicals amount.
8. 8. The method of claim 1, further comprising determining a most likely range associated with the open claim based at least in part on the likelihood value associated with at least one of the matching closed claims.
9. 9. The method of claim 1, further comprising determining which of the matching closed claims fall into a predetermined range within a likelihood curve for the matching closed claims.
10. 10. The method of claim 9, wherein the predetermined range is about the top quartile of the likelihood curve for the matching closed claims.
11. ii. The method of claim 10, further comprising determining a most likely settlement amount, wherein the recommended settlement amount is based at least in part on the determined amount for the open claim.
12. 12. The method of claim 1, wherein the most likely settlement amount includes at least one adjustment for disfigurement, medical expenses, lost wages, comparative negligence, or contribution.
13. 13. The method of claim 1, wherein determining a likelihood value associated with a least one of the matching closed claims comprises determining likelihood values associated with at least two matching closed claims, wherein the determined amount for the open claim is based at least in part on the highest likelihood value of the determined likelihood values.
14. 14. The method of claim 1, further comprising adjusting an amount for at least one of the matching closed claims based on at least one characteristic of the matching closed claim.
15. 15. The method of claim 14, further comprising using the amount adjusted for the at least one matching closed claim to determine a recommended settlement amount for the open claim.
16. 16. The method of claim 14, wherein the amount for the open claim is based at least in part on a most likely value,
17. I 7. The method of claim 1, wherein determining a likelihood value associated with a least one of the matching closed claims comprises calculating a kernel density estimate associated with the matching closed claim.
18. 18. The method of claim 17, wherein calculating a kernel density estimate associated with the matching closed claim comprises determining a bandwidth for the kernel density estimate.
19. 19. The method of claim 18, wherein the bandwidth is determined using a solve-the-equation plug-in method.
20. 20. The method of claim 17, wherein the kernel density estimate is based on an estimation of a fast density derivative.
21. 21. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises determining whether a major injury for the open claim is predominantly a demonstrable injury or not a demonstrable injury.
22. 22. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises determining a most injured body part for the open claim.
23. 23. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises determining one or more medical codes for at least one injury to a claimant for the open claim.
24. 24. The method of claim 23, wherein determining an amount fbr the open claim comprises determining a combined value for at least one body part if more than one medical code is determined for the injury.
25. 25. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises identifying a dominant medical feature associated with at least one injury to a claimant for the open claim.
26. 26. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises ranking or rating at least one of the matching claims.
27. 27. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises applying at least one filter to a set of closed claim data.
28. 28. The method of claim 27, wherein at least one of the applied filters considers the identity of a representing attorney.
29. 29. The method of claim 27, wherein at least one of the applied filters considers whether the EDR data indicates that an injury associated with the claim was low-impact.
30. 30. The method of claim 27, further comprising selecting at least one filter setting, wherein the filter settings include at least two filter settings, wherein at least one of the setting is looser than at least one other of the settings.
31. 31. The method of claim 27, further comprising: changing at least one filter setting to be tighter or looser after the matching closed claims are identified; and identifying an updated set of matching closed claims based on the tightened or loosened filter setting.
32. 32. The method of claim I, further comprising displaying at least one likelihood value associated with at least one of the matching closed claims,
33. 33. A system, comprising: means for identifying one or more closed claims that match an open claim based on one or more characteristics of the open claim; means for determining a likelihood value associated with at least one of the matching closed claims; and means for determining an amount for the open claim based at least in part on the likelihood value for at least one of the matching closed claims.
34. 34. A tangible, computer readable medium comprising program instructions, wherein the program instructions are computer-executable to implement: identifying one or more closed claims that match an open claim based on one or more characteristics of the open claim; determining a likelihood value associated with at least one of the matching closed claims; and determining an amount for the open claim based at least in part on the likelihood value for at least one of the matching closed claims.
35. 35. A computer-implemented method, comprising: a computer system automatically identifying one or more closed claims that match an open claim based on one or more characteristics of the open claim; the computer system automatically determining a likelihood value associated with at least one of thc matching closed claims; the computer system displaying the likelihood value associated with at least one of the matching closed claims; and the computer system displaying one or more amounts for use in settling the open claim, at least one of the amounts being based at least in part on an amount for a matching closed claim associated with at least one displayed likelihood value.
36. 36. The method of claim 35, wherein displaying the likelihood value associated with at least one of the matching closed claims comprises displaying a likelihood curve.
37. 37. The method of claim 35, wherein the displayed amounts are adjusted general damages amounts.
38. 38. The method of claim 35, wherein the displayed amounts are medicals amounts.
39. 39. The method of claim 35, wherein the displayed amount are most likely amounts.
40. 40. The method of claim 35, wherein least one likelihood value is displayed as a position on a graph.
41. 41. The method of claim 35, wherein the display of at least one likelihood value includes the display of a numerical value.
42. 42. The method of claim 35, wherein determining a likelihood value associated with at least one of the matching closed claims includes determining a likelihood value associated with each of two or more closed claims.
43. 43. The method of claim 42, wherein displaying at least one likelihood value comprises displaying at least two likelihood values associated with two or more of the matching closed claims.
44. 44. The method of claim 43, wherein displaying at least two likelihood values comprises displaying a graph of at least two of the likelihood values as a function of amount.
45. 45. The method of claim 44, wherein displaying at least one likelihood value comprises displaying a graph of likelihood values associated with all of the matching closed claims.
46. 46. The method of claim 43, wherein displaying at least one likelihood value comprises displaying a graph of likelihood values associated with all of the matching closed claims.
47. 47. The method of claim 35, further comprising displaying one or more ranges of amounts for the open claim.
48. 48. The method of claim 47, wherein at least one of the one or more ranges is displayed as a band in an x-y graph showing likelihood versus amount.
49. 49. The method of claim 47, wherein at least one of the one or more displayed ranges of amounts is a most likely range.
50. 50. The method of claim 47, wherein the at least one of the displayed ranges is about the top quartile of the likelihood curve for the matching closed claims.
51. 51. The method of claim 47, further comprising displaying a summary of amounts for at least one of the one or more ranges.
52. 52. The method of claim 35, wherein the at least one likelihood value is displayed in a first display mode, the method further comprising: receiving an input from a user selecting to select a second display mode; and displaying a representative value for the open claim in the second display mode.
53. 53. The method of claim 52, wherein the representative value is determined from a sum of the least squares for values for two or more of the matching closed claims.
54. 54. The method of claim 52, further comprising setting a default display mode during installation of a claimsmatching program.
55. 55. A system, comprising: means for identifying one or more closed claims that match an open claim based on one or more characteristics of the open claim; means for determining a likelihood value associated with at least one of the matching closed claims; means for displaying the likelihood value associated with at least one of the matching closed claims; and means for displaying one or more amounts for use in settling the open claim, at least one of the amounts being based at least in part on an amount for a matching closed claim associated with at least one displayed likelihood value.
56. 56. A tangible, computer readable medium comprising program instructions, wherein the program instructions are computerexecutable to implement: identifying one or more closed claims that match an open claim based on one or more characteristics of the open claim; determining a likelihood value associated with at least one of the matching closed claims; displaying the likelihood value associated with at least one of the matching closed claims; and displaying one or more amounts for use in settling the open claim, at least one of the amounts being based at least in part on an amount for a matching closed claim associated with at least one displayed likelihood value.
57. 57. A computer-implemented method, comprising: a computer system automatically identifying two or more closed claims that match an open claim based on one or more characteristics of the open claim; the computer system automatically determining a likelihood value associated with at least two of the matching closed claims; and the computer system displaying a graph of the likelihood values associated with at least two of the matching closed claims as a ftinction of amount.
58. 58. The method of claim 57, wherein the graph is an x-y graph, wherein the x axis is amount and the y axis is likelihood value.
59. 59. The method of claim 57, wherein displaying a graph of the likelihood values associated with at least two of the matching closed claims as a function of amount comprises displaying a likelihood curve.
60. 60. The method of claim 57, wherein the amounts are adjusted general damages amounts.
61. 61. The method of claim 57, wherein the amounts are medicals amounts.
62. 62. The method of claim 57, wherein the amounts are most likely amounts.
63. 63. The method of claim 57, wherein the graph is an x-y graph, wherein the x axis is amount and the y axis is likelihood value, wherein the y-axis includes a numerical scale.
64. 64. The method of claim 57, wherein the graph is an x-y graph, wherein the x axis is amount and the y axis is likelihood value, wherein the y-axis does not include a numerical scale.
65. 65. The method of claim 57, wherein the at least one likelihood value is displayed as a numerical value.
66. 66. The method of claim 57, further comprising displaying one or more ranges of amounts for the open claim.
67. 67. The method of claim 66, wherein at least one of the one or more ranges is displayed as a band.
68. 68. The method of claim 66, wherein at least one of the one or more displayed ranges of amounts is a most likely range.
69. 69. The method of claim 66, wherein at least one of the one or more displayed ranges is about the top quartile of the likelihood curve for the matching closed claims.
70. 70. The method of claim 66, further comprising displaying a summa of amounts for at least one of the ranges. 72.
71. 71. A system, comprising: means for identifying one or more closed claims that match an open claim based on one or more characteristics of the open claim; means for determining likelihood values associated with at least two of the matching closed claims; and means for displaying a graph of the likelihood values associated with at least two of the matching closed claims as a function of amount.
72. 72. A tangible, computer readable medium comprising program instructions, wherein the program instructions are computerexecutable to implement: identifying one or more closed claims that match an open claim based on one or more characteristics of the open claim; determining likelihood values associated with at least two of the matching closed claims; and displaying a graph of the likelihood values associated with at least two of the matching closed claims as a function of amount.
73. 73. A computerimplemented method, comprising: a computer system receiving a selection of one or more equalization criteria from a defined list; the computer system determining equalization values from a set of closed claim data based on the selected equalization criteria; for at least one open claim, /) providing bodily injury data for the open claim; the computer system automatically identifying one or more precedent claims that match the open claim based on one or more characteristics of the open claim; the computer system adjusting a value for one or more of the matching precedent claims using one or more of the equalization values; and determining an amount for the open claim based at least in part on at least one adjusted value.
74. 74. The method of claim 73, wherein the amount is a general damages value for the open claim.
75. 75. The method of claim 73, wherein the amount is a recommended settlement amount fbr the open claim.
76. 76. The method of claim 73, wherein the selection by a user of the one or more equalization criteria is made during installation of a claims-matching program.
77. 77. The method of claim 73, further comprising determining a likelihood value associated with at least one of the precedent claims, wherein the amount for the open claim is based at least in part on the likelihood value.
78. 78. The method of claim 73, wherein the amount for the open claim is determined by: determining an adjusted general damages amount for the open claim based at least in part on at least one equalized value; and increasing or decreasing the adjusted general damages amount based on at least one pending claim adjustmenL
79. 79. The method of claim 73, wherein the equalization criteria comprises a locality of an accident.
80. 80. The method of claim 73, wherein the equalization criteria comprises a substate locality of an accident.
81. 81. The method of claim 73, wherein the equalization criteria comprises a claim type.
82. 82. The method of claim 73, wherein the equalization criteria comprises a county of an accident.
83. 83. The method of claim 73, wherein the equalization criteria comprises secondary injuiy type.
84. 84. The method of claim 73, wherein the equalization criteria comprises jurisdiction.
85. 85. The method of claim 73, wherein the adjusting a value of at least one of the matching precedent claims comprises applying at least one business rule.
86. 86. The method of claim 73, wherein identi1ring the one or more precedent claims that match an open claim comprises applying at least one filter.
87. 87. The method of claim 73, wherein identiling the one or more precedent claims that match an open claim comprises receiving at least one selection from user specif'ing at least one filter and applying the at least one filter.
88. 88. The method of claim 73, wherein identil'ing the one or more precedent claims that match an open claim comprises determining whether a major injury for the open claim is predominantly a demonstrable injury or not a demonstrable injury.
89. 89. The method of claim 73, wherein identing the one or more precedent claims that match an open claim comprises determining a most injured body part for the open claim.
90. 90. The method of claim 73, wherein identiling the one or more precedent claims that match an open claim comprises determining one or more medical codes for at least one injury to a claimant for the open claim.
91. 91. The method of claim 73, wherein identif'ing the one or more precedent claims that match an open claim comprises identifring a dominant medical feature associated with at least one injury to a claimant for the open claim.
92. 92. A system, comprising: means for receiving a selection by a user of one or more equalization criteria from a defined list; means for determining equalization values from a set of closed claim data based on the selected equalization criteria; and for at least one open claim: means for providing bodily injury data for the open claim; means for identiling one or more precedent claims that match an open claim based on one or more characteristics of the open claim; means for adjusting a value for one or more of the matching precedent claims using one or more of the equalization values; and means for determining an amount for the open claim based at least in part on at least one adjusted value.
93. 93. A tangible, computer readable medium comprising program instructions, wherein the program instructions are computerexecutable to implement: receiving a selection by a user of one or more equalization criteria from a defined list; determining equalization values from a set of closed claim data based on the selected equalization criteria; for at least one open claim: providing bodily injury data for the open claim; identif.iing one or more precedent claims that match an open claim based on one or more characteristics of the open claim; adjusting a value for one or more of the matching precedent claims using one or more of the equalization values; and determining an amount for the open claim based at least in part on at least one adjusted value.
94. 94. A computer-implemented method, comprising: a computer system automatically identifiing one or more precedent claims that match an open claim based on one or more characteristics of the open claim; the computer system adjusting a value of one or more of the matching precedent claims using one or more equalization values determined from a set of closed claim data, wherein the equalization values are based on equalization criteria, the equalization criteria relating to at least one personal characteristic for one or more claimants of the matching precedent claims; and determining an amount for the open claim based at east in part on at least one adjusted value.
95. 95. The method of claim 94, wherein the at least one personal characteristic comprises a type of injury to at least one claimant.
96. 96. The method of claim 94, wherein the at least one personal characteristic comprises whether an injury to at least one claimant is a combination injury.
97. 97. The method of claim 94, wherein the at least one personal characteristic comprises the age of at least one claimant.
98. 98. The method of claim 94, wherein the at least one personal characteristic comprises the gender of at least one claimant.
99. 99. A computer-implemented method, comprising: a computer system automatically identifying one or more precedent claims that match an open claim based on one or more characteristics of the open claim; the computer system adjusting a value of one or more of the matching precedent claims using one or more equalization values determined from a set of closed claim data, wherein the equalization values are based on equalization criteria, the equalization criteria relating to at least one characteristic relating to an accident giving rise to the matching precedent claim; and determining an amount for the open claim based at least in part on at least one adjusted value.
100. I 00. The method of claim 99, wherein the accident is a vehicle accident, wherein at least one of the characteristics relating to the accident comprise whether the electronic data recorder data indicate a low impact collision.
101. 101. A computer-implemented method, comprising: a computer system automatically identifiying one or more precedent claims that match an open claim based on one or more characteristics of the open claim; the computer system adjusting a value of one or more of the matching precedent claims using one or more equalization values determined from a set of closed claim data, wherein the equalization values are based on equalization criteria, the equalization criteria relating to at least one characteristic relating to negotiation or settlement of the matching precedent claim; and determining an amount for the open claim based at least in part on at least one adjusted value.
102. 102. The method of claim 101, wherein at least one of the characteristics relating to negotiation or settlement for the matching precedent claim comprises a litigation type.
103. 103. The method of claim 101, wherein at least one of the characteristics relating to negotiation or settlement for the matching precedent claim comprises an identity of an attorney who represented one or more claimants for the matching precedent claim.
104. 104. The method of claim 101, wherein at least one of the characteristics relating to negotiation or settlement for the matching precedent claim comprises the nature of evidence for the claim.
105. 105. The method of 104, wherein the open claim arises from a vehicle accident, wherein the nature of the evidence comprises whether or not electronic data recorder data exists for at least one vehicle in the accident,
106. I 06. A computer-implemented method, comprising: a computer system automatically identifying one or more precedent claims that match a pending claim based on one or more characteristics of the pending claim; the computer system determining a likelihood value for at least one of the matching precedent claims; the computer system determining a general damages amount based at least in part on the likelihood value for at least one of the matching precedent claims; the computer system calculating one or more pending claim adjustments, wherein at least one of the pending claim adjustments is based on an amount associated with the pending claim; and applying at least one of the pending claim adjustments to the general damages amount to determine a recorrimended settlement amount.
107. 107. The method of claim 106, further comprising displaying the recommended settlement amount.
108. 108. The method of claiml 06, further comprising updating the recommended settlement amount based on at least one change to an amount associated with the open claim.
109. 109. The method of claim 106, further comprising determining at least one range for a recommended settlement.
110. 110. The method of claim 106, wherein the general damages amount for the open claim is a most likely amount.
111. iii. The method of claim 106, wherein the most likely amount corresponds to the matching precedent claim with the highest likelihood value.
112. 112. The method of claim 106, wherein the open claim is an insurance claim.
113. 113. The method of claim 106, further comprising determining a most likely range for the pending claim based at least in part on one of the likelihood values.114. 1he method of claim 106, further comprising determining which of the matching precedent claims fall into a predetermined range within a likelihood curve for the matching precedent claims.115. The method of claim 114, wherein the predetermined range is about the top quartile of the likelihood curve for the matching precedent claims.116. The method of claim 106, further comprising determining a most likely settlement amount, wherein the recommended settlement amount is based at least in part on the estimated amount.117. The method of claim 106, further comprising grouping one or more of the matching precedent claims into one or more zones, wherein the recommended settlement amount is based at least in part on a value associated with at least one of the zones.118. The method of claim 117, wherein the one or more zones comprises a mid-zone.119. The method of claim 118, wherein the recommended settlement amount is based on a value associated with a mid-zone.120. The method of claim 106, wherein the one or more pending claim adjustments comprise lost wages associated with the pending claim.121. The method of claim 106, wherein the one or more pending claim adjustments comprise medical expenses estimated or actually incurred for the pending claim.122. The method of claim 106, wherein the one or more pending claim adjustments comprise special damages associated with the pending claim.123. The method of claim 106, wherein the one or more pending claim adjustments comprises an amount for disfigurement associated with the pending claim.124. The method of claim 106. wherein the one or more pending claim adjustments comprise an amount for comparative negligence associated with the pending claim.125. The method of claim 106, wherein the one or more pending claim adjustments comprise an amount for contribution associated with the pending claim.126. A system, comprising: means for identifying one or more precedent claims that match an pending claim based on one or more characteristics of the pending claim; means for determining a likelihood value for at least one of the matching precedent claims; means for determining a general damages amount based at least in part on the likelihood value for at least one of the matching precedent claims; means for calculating one or more pending claim adjustments, wherein at least one of the pending claim adjustments is based on an amount associated with the pending claim; and means for applying one or more pending claim adjustments to the general damages amount to determine a recommended settlement amount I 27. A tangible, computer readable medium comprising program instructionS, wherein the program instructions are cornputerexecutable to implement: identifying one or more precedent claims that match an pending claim based on one or more characteristics of the pending claim; determining a likelihood value for at least one of the matching precedent claims; determining a general damages amount based at least in part on the likelihood value for at least one of the matching precedent claims; calculating one or more pending claim adjustments, wherein at least one of the adjustments is based on an amount associated with the pending claim; and applying at least one of the pending claim adjustments to the general damages amount to determine a recommended settlement amount