WO2017157030A1 - 医疗保险费折扣精算系统及方法 - Google Patents

医疗保险费折扣精算系统及方法 Download PDF

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Publication number
WO2017157030A1
WO2017157030A1 PCT/CN2016/105114 CN2016105114W WO2017157030A1 WO 2017157030 A1 WO2017157030 A1 WO 2017157030A1 CN 2016105114 W CN2016105114 W CN 2016105114W WO 2017157030 A1 WO2017157030 A1 WO 2017157030A1
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Prior art keywords
premium
amount
medical insurance
paid
policyholder
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PCT/CN2016/105114
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English (en)
French (fr)
Inventor
张贯京
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深圳市前海安测信息技术有限公司
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Publication of WO2017157030A1 publication Critical patent/WO2017157030A1/zh

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    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q40/00—Finance; Insurance; Tax strategies; Processing of corporate or income taxes
    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q40/00—Finance; Insurance; Tax strategies; Processing of corporate or income taxes
    • G06Q40/08—Insurance

Definitions

  • the present invention relates to the field of medical insurance actuarial calculation, and in particular to a medical insurance premium discount actuarial system and method
  • the main object of the present invention is to provide a system and method for discounting medical insurance premiums, which aims to solve the technical problem that the current medical insurance fee accounting system cannot accurately calculate the medical insurance premium discount of the policyholder.
  • the present invention provides a medical insurance premium discount actuarial system, which is operated in a cloud server, and the cloud server is connected to a medical insurance database, and the system includes: [0006] An insurance premium module for obtaining an insurance premium amount from a medical insurance database within a predetermined period of time
  • a risk assessment module configured to obtain health data of the insured from the medical insurance database, and establish a policy for assessing the risk of the insured according to the health data of the insured;
  • claim actuarial module configured to obtain, from the medical insurance database, the amount of the premium claim paid to the policyholder and store it in the list of the premium amount, and predict the refined calculation according to the policyholder's claim risk assessment model The amount of the premium claim paid to the policyholder, the error claim for the amount of the premium claim to be paid, and the amount of the premium claim to be paid is added to the premium amount when there is no error in the amount of the premium claim to be paid List;
  • a premium discount module is configured to calculate, according to the premium data and the premium claim amount in the premium amount list, a discount amount of the medical insurance premium of the policyholder within a predetermined period.
  • the premium discount module is further configured to calculate, according to the discount amount of the medical insurance premium of the policyholder within a predetermined period of time, the discount amount of the medical insurance premium of the policyholder during the renewal period.
  • the insured person's health data includes the insured's vital sign data, family genetic disease data
  • the claim actuarial module is further configured to compare the amount of the premium claim to be paid with the predetermined claim amount to verify the amount of the premium claim that needs to be paid to the policyholder within the predetermined time limit, and determine the need to pay Whether the amount of the premium claim has been wrong, when the amount of the premium claim to be paid is wrong, lock the list of the premium amount for write protection to prevent the occurrence of the wrong premium claim amount from being added to the list of premium amounts and generate an alarm notification insurance manager.
  • the premium discount module is further configured to determine, according to a predetermined incentive mechanism rule, rating data of the applicant, and the insurance premium data and the premium claim according to the rating data of the applicant and the premium amount list. The amount is used to calculate the discount amount of the medical insurance premium.
  • the present invention also provides a medical insurance discount actuarial method, which is applied to a cloud server, and the cloud server is connected to a medical insurance database, the method comprising the steps of: obtaining a policyholder from a medical insurance database within a predetermined period of time The amount of the premium, and add the amount of the premium paid to the list of premiums; obtain the health data of the insured from the medical insurance database, and build according to the health data of the insured Claiming risk assessment model for the insured person; obtaining the amount of the premium claim paid to the insured from the medical insurance database and storing it in the list of premiums; predicting the need to calculate the required amount within the predetermined period based on the insured's claims risk assessment model The amount of the premium claim paid to the insured; the error verification of the amount of the premium claim to be paid; the amount of the premium claim to be paid is added to the amount of the premium when there is no error in the amount of the premium claim to be paid In the list; calculate the discount amount of the medical insurance premium for the insured person within the predetermined
  • the medical insurance discount actuarial method further comprises the step of: calculating, according to the discount amount of the medical insurance premium of the policyholder within the predetermined time limit, the discount amount of the medical insurance premium of the policyholder during the renewal period.
  • the insured person's health data includes the insured's vital sign data, family genetic disease data, past medical history data, personal lifestyle index, living environment pollution index, incidence of infectious diseases in living areas, and traffic accidents. rate.
  • the medical insurance discount actuarial method further comprises the steps of:
  • the list of the premium amount is locked for write protection to prevent the occurrence of an error in the amount of the premium claim added to the premium amount list and an alarm message is generated to notify the insurance manager.
  • the step of calculating the discount amount of the medical insurance premium of the insured within the predetermined period according to the insurance premium data and the premium claim amount in the premium amount list further includes the steps of:
  • the medical insurance premium discount actuarial system and method of the present invention adopts the above technical solution, and the technical effects are as follows: It is possible to perform error verification on the amount of the premium claim that needs to be paid to the policyholder to accurately calculate The insured's medical insurance premium discount, the insured's claim amount from the medical insurance plan together with the insured's status level in the incentive mechanism to determine the insured's premium discount, can reduce the risk of claims and avoid attracting high-risk groups to purchase insurance plans. The unfavorable factors thus avoid the insurance company's loss of claims and improve the profitability of the insurance company.
  • FIG. 1 is a schematic diagram of an application environment of a preferred embodiment of the medical insurance premium actuarial system of the present invention
  • FIG. 2 is a block diagram showing a preferred embodiment of the medical insurance premium discount actuarial system of the present invention
  • FIG. 3 is a flow chart of a preferred embodiment of the medical insurance premium discount actuarial method of the present invention.
  • step S35 in FIG. 3 is a detailed flowchart of step S35 in FIG. 3.
  • FIG. 1 is an application environment diagram of a preferred embodiment of the medical insurance premium actuarial system of the present invention.
  • the medical insurance premium actuarial system 10 is installed and operated on the cloud server 1.
  • the cloud server 1 is communicably connected to the medical insurance database 2 via the database link 3 to obtain, from the medical insurance database 2, the amount of insurance premiums of the policyholder within a predetermined period, the health data of the applicant, and within a predetermined period of time.
  • the predetermined period refers to the period of time during which the policyholder plans medical insurance, such as half a year, one year, two years, five years or ten years.
  • the cloud server 1 is a cloud platform or a server in the cloud platform. Through the data transmission capability and data storage capability of the cloud server 1, the data in the medical insurance database 2 can be better processed and transmitted.
  • the database link 3 can be a kind of open database link such as JDBC or ODBC.
  • FIG. 2 is a block diagram showing a preferred embodiment of the medical insurance premium actuarial system of the present invention.
  • the medical insurance premium actuarial system 10 is applied to the cloud server 1, and the cloud server 1 includes, but is not limited to, the medical insurance premium actuarial system 10, the processing unit 11, and the storage unit 12.
  • the processing unit 11 can be a central processing unit (Central Processing
  • the storage unit 12 can be a read only storage unit ROM, an electrically erasable storage unit EEPROM, a flash memory unit FLASH or a solid hard disk.
  • the storage unit 12 includes a premium amount list 120 that stores the premium amount of the policyholder obtained from the medical insurance database 2 within a predetermined period, the amount of the premium claim that has been paid to the policyholder within the predetermined time limit, and The amount of the premium claim that needs to be paid within the predetermined period.
  • the medical insurance premium actuarial system 10 includes, but is not limited to, a premium module 101, a risk assessment module 102, a claim actuarial module 103, and a premium discount module 104.
  • the module referred to in the present invention refers to a series of computer program instruction segments that can be executed by the processing unit 11 of the cloud server 1 and capable of performing a fixed function, which is stored in the storage unit 12 of the cloud server 1.
  • the insurance premium module 101 is configured to obtain the insurance premium amount of the applicant from the medical insurance database 2 within a predetermined period of time, and add the premium amount of the payment to the premium amount list 120.
  • the medical insurance database 2 provides a data import interface (for example, an application program interface, an API), and a device or system that accesses the data import interface can obtain a premium amount from the medical insurance database 2.
  • the premium module 101 can invoke the API interface provided by the medical insurance database 2 to obtain the premium amount of the policyholder for a predetermined period of time.
  • the risk assessment module 102 is configured to obtain the insured's health data from the medical insurance database 2, and establish a policyholder's claims risk assessment model according to the insured's health data.
  • the insured's health data includes the insured's vital signs data, family genetic disease data, past medical history data, personal lifestyle index, living environment pollution index, incidence of infectious diseases in living areas, and traffic accidents. rate.
  • the claims risk assessment model can be used to predict or assess the amount of premium claims that an insurance company may need to pay to the policyholder for a predetermined period of time.
  • the claim actuarial module 103 is configured to obtain, from the medical insurance database 2, the amount of the premium claim that has been paid to the policyholder and store it in the premium amount list 120, and predict the calculation according to the policyholder's claim risk assessment model.
  • the step of the claim actuarial module 103 performing error verification on the amount of the premium claim to be paid includes: the claim actuarial module 103 performs the amount of the premium claim and the predetermined claim amount that need to be paid to the policyholder. A comparison to verify the amount of the premium claim that needs to be paid to the policyholder within a predetermined period of time, and when the amount of the premium claim to be paid is incorrect (ie, the amount of the premium claim to be paid exceeds the predetermined amount of the claim), the amount of the premium is locked
  • the list 120 is write protected to prevent the occurrence of an erroneous premium claim amount from being added to the premium amount list 120 and generating an alert message to notify the insurance manager.
  • the claim actuarial module 103 adds the amount of the premium claim for which no error occurred to the list of premium amounts 120.
  • the predetermined claim amount is determined based on the amount of the premium paid by the insured within a predetermined period of time, for example, the amount of the premium is 5,000 yuan, and the amount of the premium claim defined under the underwriting and claims model of the insurance company is 10,000. If the amount of the premium claim to be paid exceeds 10,000, the claim actuarial module 103 generates an alarm message to notify the insurance manager and locks the premium amount list 120 for write protection to prevent a claim error from occurring, thereby preventing the insurance company from bringing claims. loss.
  • the premium discount module 104 is configured to calculate, according to the premium data and the premium claim amount in the premium amount list 120, the discount amount of the medical insurance premium of the policyholder within the predetermined time limit, and according to the policyholder within the predetermined time limit.
  • the discount amount of the medical insurance premium is used to calculate the discount amount of the medical insurance premium for the insured person during the renewal period.
  • the premium discount module 104 calculates the discount amount of the medical insurance premium for the insured person within the predetermined period based on the ratio of the insurance premium data and the premium claim amount.
  • the term of renewal refers to the period of insurance after renewal of the policy period after the expiration of the predetermined period of the policyholder.
  • the premium discount module 104 is further configured to determine the level data of the policyholder according to the predetermined incentive mechanism rule, and according to the level data of the policyholder and the insurance premium data and the premium claim amount in the premium amount list. Calculate the discount amount of the medical insurance premium.
  • the incentive mechanism rule refers to the applicant's assessment of the physical health of the individual and guides the insured to perform a healthy exercise by participating in the health survey rules set by the insurance company.
  • the premium discount module 104 determines the level of the insured person according to the situation in which the policyholder applies the incentive mechanism rule. For example, if the insured person cooperates with the healthy exercise, the level is determined to be an excellent level; if the insured person basically cooperates with the healthy exercise, the rating is determined.
  • FIG. 3 it is a flow chart of a preferred embodiment of the medical insurance premium discount actuarial method of the present invention.
  • the medical insurance premium discount actuarial method is applied to the cloud server 1, and the method includes the following steps:
  • Step S31 the premium module 101 obtains the insurance premium amount of the policyholder within the predetermined time limit from the medical insurance database 2, and adds the paid premium amount to the premium amount list 120.
  • the medical insurance database 2 provides a data import interface (e.g., Application Program Interface, API) from which the device or system accessing the data import interface can receive the premium amount.
  • the premium module 101 can invoke the API interface provided by the medical insurance database 2 to obtain the premium amount of the policyholder for a predetermined period of time.
  • API Application Program Interface
  • Step S32 the risk assessment module 102 obtains the health data of the policyholder from the medical insurance database 2, and establishes the policyholder's claim risk assessment model according to the health data of the policyholder.
  • the insured's health data includes the insured's vital signs data, family genetic disease data, past medical history data, personal lifestyle index, living environment pollution index, incidence of infectious diseases in living areas, and traffic accidents. rate.
  • Step S33 the claim actuarial module 103 obtains the premium claim amount paid to the policyholder from the medical insurance database 2 and stores the premium claim amount paid to the policyholder in the premium amount list 120.
  • Step S34 the claim actuarial module 103 predicts, according to the policyholder's claims risk assessment model, the amount of the premium claim that needs to be paid to the policyholder within a predetermined period of time.
  • the claim actuarial module 103 can predict or evaluate the amount of the premium claim that the insurance company may need to pay to the policyholder within a predetermined period of time through the claims risk assessment model.
  • Step S35 The claim actuarial module 103 performs error verification on the amount of the premium claim that needs to be paid.
  • the specific refinement step of step S35 includes steps S351 to S353.
  • Step S36 the claim actuarial module 103 adds the amount of the premium claim that has not been erroneously added to the premium amount.
  • the amount list 120 Specifically, when there is no error in the amount of the premium claim to be paid (ie, the amount of the premium claim to be paid does not exceed the predetermined claim amount), the claim actuarial module 103 adds the amount of the premium claim in which the error has not occurred to the premium. The amount is in the list 120.
  • Step S37 the premium discount module 104 calculates the discount amount of the medical insurance premium of the policyholder within the predetermined time limit according to the premium data and the premium claim amount in the premium amount list 120.
  • the premium discount module 104 calculates the discount amount of the medical insurance premium for the insured person within a predetermined period based on the ratio of the premium data and the premium claim amount.
  • Step S38 The premium discount module 104 calculates the discount amount of the medical insurance premium of the policyholder during the renewal period according to the discount amount of the medical insurance premium of the policyholder within the predetermined time limit.
  • the renewal period refers to the insurance period after the applicant's predetermined period of time expires and the renewal period is followed by the renewal period.
  • a step may be further included between step S36 and step S37: the premium discount module 104 determines the level data of the policyholder according to the predetermined incentive mechanism rule, and according to the level data of the policyholder and the The insurance premium data and the premium claim amount in the premium amount list are used to calculate the discount amount of the medical insurance premium.
  • the incentive mechanism rule refers to the applicant's assessment of the physical health of the individual and guides the insured to perform a healthy exercise by participating in the health survey rules set by the insurance company.
  • the premium discount module 104 determines the level of the insured person according to the situation in which the policyholder applies the incentive mechanism rule.
  • the level is determined to be an excellent level; if the insured person basically cooperates with the healthy exercise, the rating is determined. It is a normal grade; if the insured does not cooperate with healthy exercise, the grade is rated as a bad grade.
  • the present invention uses the amount of the claim obtained by the insured from the medical insurance plan together with the status level of the insured in the incentive mechanism to determine the insured's premium discount, which can reduce the risk of the claim and avoid the disadvantage of the high risk group to purchase the insurance plan. Factors that can improve the profitability of insurance companies.
  • FIG. 4 is a detailed flowchart of step S35 in FIG.
  • the specific refinement step of step S35 includes the following steps:
  • Step S351 the claim actuarial module 103 compares the amount of the premium claim that needs to be paid to the policyholder and the amount of the predetermined claim to verify the amount of the premium claim that needs to be paid to the policyholder within the predetermined time limit.
  • the predetermined claim amount is determined according to the amount of the premium of the insured within the predetermined time limit. For example, the amount of the insurance premium is 5,000 yuan, and the amount of the premium claim defined by the insurance company's underwriting and claims model is 10,000.
  • Step S352 the claim actuarial module 103 needs to pay the insured person the amount of the premium claim within the predetermined time limit. If the amount of the premium claim is incorrect, step S353 is performed; if there is no error in the amount of the premium claim, step S36 in flowchart 3 is performed.
  • Step S353 when the amount of the premium claim to be paid is incorrect (that is, the amount of the premium claim to be paid exceeds the predetermined claim amount), the premium amount list 120 is locked for write protection to prevent the occurrence of the wrong premium.
  • the claim amount is added to the premium amount list 120 and an alarm message is generated to notify the insurance manager. If the insured's premium amount is 5,000 yuan during the predetermined period, and the premium claim amount is 10,000, if the amount of the premium claim to be paid exceeds 10,000, the claim actuarial module 103 generates an alarm message to notify the insurance manager and lock the office.
  • the list of premium amounts 120 is write protected to prevent claims errors from occurring, thereby preventing insurance companies from incurring claims losses.
  • the medical insurance premium actuarial system and method of the present invention adopts the above technical solution, and the technical effects are as follows: It is possible to perform error verification on the amount of the premium claim that needs to be paid to the policyholder to accurately calculate the medical insurance of the policyholder.
  • the discount the amount of the claim received by the insured from the medical insurance plan together with the status level of the insured in the incentive mechanism to determine the insured's premium discount, which can reduce the risk of claim and avoid the disadvantages of attracting high-risk groups to purchase insurance plans. It avoids the loss of claims by insurance companies and improves the profitability of insurance companies.

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Abstract

一种医疗保险费折扣精算系统及方法，该方法包括步骤：从医疗保险数据库中获取投保人在预定期限内的保险费数额并添加到保费数额列表（S31）；根据投保人的健康数据建立投保人的理赔风险评估模型（S32）；从医疗保险数据库中获取已支付给投保人的保费索赔数额并存储在保费数额列表（S33）；根据理赔风险评估模型预测精算出需要支付给投保人的保费索赔数额并进行差错验证（S34，S35）；当需要支付的保费索赔数额没有发生差错时将需要支付的保费索赔数额添加到保费数额列表（S36）；根据保费数额列表中的保险费数据和保费索赔数额计算投保人在预定期限内医疗保险费的折扣数额（S37）。通过对支付给投保人的保费索赔数额进行差错验证而精确计算投保人的医疗保险费折扣。

Description

发明名称：医疗保险费折扣精算系统及方法 技术领域
[0001] 本发明涉及医疗保险精算领域， 尤其涉及一种医疗保险费折扣精算系统及方法 背景技术
[0002] 医疗保险计划， 特别是个人医疗保险计划的优良管理很显然对于计划管理者进 行财务计划的可行性来说是非常重要的。 近年来， 医疗保险计划的管理出现了 以下改变： 一种关注是鼓励计划的投保人保持健康。 另一种关注是鼓励计划的 投保人管理他们的索赔的医疗保险计划的管理方法是基于支付给医疗保险计划 的保险费数额、 根据医疗保险计划所做出的索赔数额、 以及与保险计划有关的 激励机制中投保人的等级为投保人提供折扣。 这种方法总体来说解决了保险中 所固有的两个潜在问题， 即， 可以激励投保人索赔的道德风险以及吸引高危人 群来购买保险计划。 另外， 这种方法减轻了个人医疗保险中奖励疾病的倾向。
[0003] 然而， 由于很难确定支付给医疗保险计划的保险费数额以及根据医疗保险计划 所做出的索赔数额， 所以这种方法地实际执行存在技术困难。 这是因为， 如果 投保人改变其保险计划， 则所要支付的保险费数额就会突然变化。 同样， 如果 存在已提交但还未处理的索赔或存在尚未解决的索赔， 则索赔数额也会改变。 仅简单地描述已在计算期限内支付了多少保险费、 和已向投保人支付了多少索 赔， 并不能给出确定保险费折扣的精确数额。
技术问题
[0004] 本发明的主要目的在于提供一种医疗保险费折扣精算系统及方法， 旨在解决现 有医疗保险费核算系统不能精确计算出投保人的医疗保险费折扣的技术问题。 问题的解决方案
技术解决方案
[0005] 为实现上述目的， 本发明提供了一种医疗保险费折扣精算系统， 运行于云服务 器中， 所述云服务器连接至医疗保险数据库， 该系统包括： [0006] 保险费模块， 用于从医疗保险数据库中获取投保人在预定期限内的保险费数额
， 并将所述支付的保险费数额添加到保费数额列表中；
[0007] 风险评估模块， 用于从医疗保险数据库中获取投保人的健康数据， 并根据投保 人的健康数据建立投保人的理赔风险评估模型；
[0008] 索赔精算模块， 用于从医疗保险数据库中获取已支付给投保人的保费索赔数额 并存储在所述保费数额列表中， 根据投保人的理赔风险评估模型预测精算出在 预定期限内需要支付给投保人的保费索赔数额， 对所述需要支付的保费索赔数 额进行差错验证， 当所述需要支付的保费索赔数额没有发生差错吋将所述需要 支付的保费索赔数额添加到所述保费数额列表中；
[0009] 保费折扣模块， 用于根据所述保费数额列表中的保险费数据和保费索赔数额来 计算投保人在预定期限内医疗保险费的折扣数额。
[0010] 优选的， 所述保费折扣模块还用于根据投保人在预定期限内医疗保险费的折扣 数额来计算投保人在续保期限内医疗保险费的折扣数额。
[0011] 优选的， 所述投保人的健康数据包括投保人的生命体征数据、 家族遗传病数据
、 既往病史数据、 个人生活方式指数、 生活环境污染指数、 生活地区传染病发 病率以及交通事故发生率。
[0012] 优选的， 所述索赔精算模块还用于将所述需要支付的保费索赔数额和预定索赔 数额进行比较来验证在预定期限内需要支付给投保人的保费索赔数额， 判断所 述需要支付的保费索赔数额是否发生差错， 当所述需要支付的保费索赔数额发 生差错吋， 锁定所述保费数额列表进行写保护防止发生差错的保费索赔数额添 加到所述保费数额列表并产生报警信息通知保险管理人员。
[0013] 优选的， 所述保费折扣模块还用于根据预定的激励机制规则确定投保人的等级 数据， 以及根据所述投保人的等级数据以及所述保费数额列表中的保险费数据 和保费索赔数额来计算所述医疗保险费的折扣数额。
[0014] 本发明还提供了一种医疗保险折扣精算方法， 应用于云服务器中， 所述云服务 器连接至医疗保险数据库， 该方法包括步骤： 从医疗保险数据库中获取投保人 在预定期限内的保险费数额， 并将所述支付的保险费数额添加到保费数额列表 中； 从医疗保险数据库中获取投保人的健康数据， 并根据投保人的健康数据建 立投保人的理赔风险评估模型； 从医疗保险数据库中获取已支付给投保人的保 费索赔数额并存储在所述保费数额列表中； 根据投保人的理赔风险评估模型预 测精算出在预定期限内需要支付给投保人的保费索赔数额； 对所述需要支付的 保费索赔数额进行差错验证； 当所述需要支付的保费索赔数额没有发生差错吋 将所述需要支付的保费索赔数额添加到所述保费数额列表中； 根据所述保费数 额列表中的保险费数据和保费索赔数额来计算投保人在预定期限内医疗保险费 的折扣数额。
[0015] 优选的， 所述医疗保险折扣精算方法还包括步骤： 根据投保人在所述预定期限 内医疗保险费的折扣数额计算投保人在续保期限内医疗保险费的折扣数额。
[0016] 优选的， 所述投保人的健康数据包括投保人的生命体征数据、 家族遗传病数据 、 既往病史数据、 个人生活方式指数、 生活环境污染指数、 生活地区传染病发 病率以及交通事故发生率。
[0017] 优选的， 所述医疗保险折扣精算方法还包括步骤：
[0018] 将所述需要支付的保费索赔数额和预定索赔数额进行比较来验证在预定期限内 需要支付给投保人的保费索赔数额；
[0019] 判断所述需要支付的保费索赔数额是否发生差错；
[0020] 当所述需要支付的保费索赔数额发生差错吋， 锁定所述保费数额列表进行写保 护防止发生差错的保费索赔数额添加到所述保费数额列表并产生报警信息通知 保险管理人员。
[0021] 优选的， 所述根据所述保费数额列表中的保险费数据和保费索赔数额来计算投 保人在预定期限内医疗保险费的折扣数额的步骤还包括步骤：
[0022] 根据预定的激励机制规则确定投保人的等级数据；
[0023] 根据所述投保人的等级数据以及所述保费数额列表中的保险费数据和保费索赔 数额来计算所述医疗保险费的折扣数额。
发明的有益效果
有益效果
[0024] 本发明所述医疗保险费折扣精算系统及方法采用上述技术方案， 带来的技术效 果为： 能够对需要支付给投保人的保费索赔数额进行差错验证从而精确计算出 投保人的医疗保险费折扣， 投保人从医疗保险计划得到的索赔数额连同激励机 制中投保人的状态等级一起来确定投保人的保险费折扣， 可以减少索赔风险并 避免吸引高危人群来购买保险计划的不利因素， 从而避免了保险公司带来理赔 损失， 提高了保险公司的盈利能力。
对附图的简要说明
附图说明
[0025] 图 1是本发明医疗保险费折扣精算系统优选实施例的应用环境示意图；
[0026] 图 2是本发明医疗保险费折扣精算系统优选实施例的模块示意图；
[0027] 图 3是本发明医疗保险费折扣精算方法优选实施例的流程图；
[0028] 图 4是图 3中步骤 S35的细化流程图。
[0029] 本发明目的的实现、 功能特点及优点将结合实施例， 参照附图做进一步说明。
实施该发明的最佳实施例
本发明的最佳实施方式
[0030] 为更进一步阐述本发明为达成预定发明目的所采取的技术手段及功效， 以下结 合附图及较佳实施例， 对本发明的具体实施方式、 结构、 特征及其功效， 详细 说明如下。 应当理解， 此处所描述的具体实施例仅仅用以解释本发明， 并不用 于限定本发明。
[0031] 参照图 1所示， 图 1是本发明医疗保险费折扣精算系统优选实施例的应用环境示 意图。 在本实施例中， 所述医疗保险费折扣精算系统 10安装并运行于云服务器 1 。 所述云服务器 1通过通数据库链接 3与医疗保险数据库 2通信连接， 以从所述医 疗保险数据库 2中获取投保人在预定期限内的保险费数额、 投保人的健康数据、 以及在预定期限内已支付给投保人的保费索赔数额。 所述预定期限是指投保人 计划医疗保险的吋间周期， 例如半年、 一年、 两年、 五年或十年等。 需要说明 的是所述云服务器 1是一种云平台或云平台中的一台服务器， 通过云服务器 1的 数据传输能力及数据存储能力， 可以更好地处理与传输医疗保险数据库 2中的数 据。 所述数据库链接 3可以是一种 JDBC或 ODBC等幵放式数据库链接。
[0032]
[0033] 参照图 2所示， 图 2是本发明医疗保险费折扣精算系统的优选实施例的模块示意 图。 在本实施例中， 所述医疗保险费折扣精算系统 10应用于云服务器 1， 所述云 服务器 1包括， 但不仅限于， 医疗保险费折扣精算系统 10、 处理单元 11以及存储 单元 12。 所述的处理单元 11可以为一种中央处理器 （Central Processing
Unit, CPU) 、 微控制器 （MCU) 、 数据处理芯片、 或者具有数据处理功能的 信息处理单元。 所述的存储单元 12可以为一种只读存储单元 ROM, 电可擦写存 储单元 EEPROM、 快闪存储单元 FLASH或固体硬盘等。 所述存储单元 12包括保 费数额列表 120， 该保费数额列表 120存储有从医疗保险数据库 2获取的投保人在 预定期限内的保险费数额、 在预定期限内已支付给投保人的保费索赔数额以及 在预定期限内需要支付的保费索赔数额。
[0034] 在本实施例中， 所述的医疗保险费折扣精算系统 10包括， 但不局限于， 保险费 模块 101、 风险评估模块 102、 索赔精算模块 103及保费折扣模块 104。 本发明所 称的模块是指一种能够被所述云服务器 1的处理单元 11执行并且能够完成固定功 能的一系列计算机程序指令段， 其存储在所述云服务器 1的存储单元 12中。
[0035] 所述保险费模块 101用于从医疗保险数据库 2中获取投保人在预定期限内的保险 费数额， 并将所述支付的保险费数额添加到保费数额列表 120中。 所述医疗保险 数据库 2提供数据导入接口 （例如， 应用程序接口， Application Program Interface ， API) ， 接入该数据导入接口的设备或系统都可以从所述医疗保险数据库 2中 保险费数额。 所述保险费模块 101可以调用所述医疗保险数据库 2提供的 API接口 以获取投保人在预定期限内的保险费数额。
[0036] 所述风险评估模块 102用于从医疗保险数据库 2中获取投保人的健康数据， 并根 据投保人的健康数据建立投保人的理赔风险评估模型。 在本实施例中， 所述投 保人的健康数据包括投保人的生命体征数据、 家族遗传病数据、 既往病史数据 、 个人生活方式指数、 生活环境污染指数、 生活地区传染病发病率以及交通事 故发生率。 所述理赔风险评估模型可以用来预测或评估保险公司给投保人在预 定期限内可能需要支付的保费索赔数额。
[0037] 所述索赔精算模块 103用于从医疗保险数据库 2中获取已支付给投保人的保费索 赔数额并存储在所述保费数额列表 120中， 根据投保人的理赔风险评估模型预测 精算出在预定期限内需要支付给投保人的保费索赔数额， 对所述需要支付的保 费索赔数额进行差错验证， 当所述需要支付的保费索赔数额没有发生差错吋将 所述需要支付的保费索赔数额添加到所述保费数额列表 120中。
[0038] 在本实施例中， 所述索赔精算模块 103对所述需要支付的保费索赔数额进行差 错验证的步骤包括： 索赔精算模块 103将需要支付给投保人的保费索赔数额和预 定索赔数额进行比较来验证在预定期限内需要支付给投保人的保费索赔数额， 当所述需要支付的保费索赔数额发生差错 （即所述需要支付的保费索赔数额超 出预定索赔数额） 吋， 锁定所述保费数额列表 120进行写保护以防止发生差错的 保费索赔数额添加到所述保费数额列表 120并产生报警信息通知保险管理人员。 当所述需要支付的保费索赔数额没有发生差错吋， 索赔精算模块 103将没有发生 差错的保费索赔数额添加到所述保费数额列表 120中。 所述预定索赔数额是根据 投保人在预定期限内的保险费数额来确定的， 例如保险费数额为 5千元， 在根据 保险公司的核保和理赔模型定义的保费索赔数额为 1万。 如果需要支付的保费索 赔数额超出 1万， 则所述索赔精算模块 103产生报警信息通知保险管理人员并锁 定所述保费数额列表 120进行写保护， 以防止发生理赔差错， 从而避免保险公司 带来理赔损失。
[0039] 所述保费折扣模块 104用于根据所述保费数额列表 120中的保险费数据和保费索 赔数额来计算投保人在预定期限内医疗保险费的折扣数额， 以及根据投保人在 预定期限内医疗保险费的折扣数额来计算投保人在续保期限内医疗保险费的折 扣数额。 在本实施例中， 所述保费折扣模块 104根据所述保险费数据和保费索赔 数额的比例来计算投保人在预定期限内医疗保险费的折扣数额。 所述续保期限 是指在投保人预定期限期满后紧接着预定期限后进行续保吋的投保期限。
[0040] 所述保费折扣模块 104还用于根据预定的激励机制规则确定投保人的等级数据 ， 以及根据所述投保人的等级数据以及所述保费数额列表中的保险费数据和保 费索赔数额来计算所述医疗保险费的折扣数额。 在本实施例中， 所述激励机制 规则是指通过投保人通过参加保险公司设定的健康调査规则对投保人对个人身 体健康进行评估并引导投保人进行健康锻炼。 所述保费折扣模块 104根据投保人 适用所述激励机制规则的情况来确定投保人的等级程度， 例如投保人配合健康 锻炼， 则等级定为优良等级； 若投保人基本配合健康锻炼， 则等级定为普通等 级； 若投保人不配合健康锻炼， 则等级定为不良等级。 这种使用由投保人从医 疗保险计划得到的索赔数额连同激励机制中投保人的状态等级一起来确定投保 人的保险费折扣， 可以减少索赔风险并避免吸弓 I高危人群来购买保险计划的不 利因素， 从而可以提高保险公司的盈利能力。
[0041]
[0042] 参照图 3所示， 是本发明医疗保险费折扣精算方法的优选实施例的流程图。 结 合图 2所示， 在本实施例中， 所述的医疗保险费折扣精算方法应用于云服务器 1 ， 该方法包括以下步骤：
[0043] 步骤 S31， 保险费模块 101从医疗保险数据库 2中获取投保人在预定期限内的保 险费数额， 并将所述支付的保险费数额添加到保费数额列表 120中。 所述医疗保 险数据库 2提供数据导入接口 （例如， 应用程序接口， Application Program Interface, API) ， 接入该数据导入接口的设备或系统都可以从所述医疗保险数 据库 2中保险费数额。 所述保险费模块 101可以调用所述医疗保险数据库 2提供的 API接口以获取投保人在预定期限内的保险费数额。
[0044] 步骤 S32， 风险评估模块 102从医疗保险数据库 2中获取投保人的健康数据， 并 根据投保人的健康数据建立投保人的理赔风险评估模型。 在本实施例中， 所述 投保人的健康数据包括投保人的生命体征数据、 家族遗传病数据、 既往病史数 据、 个人生活方式指数、 生活环境污染指数、 生活地区传染病发病率以及交通 事故发生率。
[0045] 步骤 S33， 索赔精算模块 103从医疗保险数据库 2中获取已支付给投保人的保费 索赔数额并将已支付给投保人的保费索赔数额存储在所述保费数额列表 120中。
[0046] 步骤 S34， 索赔精算模块 103根据投保人的理赔风险评估模型预测精算出在预定 期限内需要支付给投保人的保费索赔数额。 在本实施例中， 所述索赔精算模块 1 03通过所述理赔风险评估模型可以预测或评估保险公司给投保人在预定期限内 可能需要支付的保费索赔数额。
[0047] 步骤 S35， 索赔精算模块 103对所述需要支付的保费索赔数额进行差错验证。 参 照图 4所示， 在本实施例中， 步骤 S35的具体细化步骤包括步骤 S351至 S353。
[0048] 步骤 S36， 索赔精算模块 103将没有发生差错的保费索赔数额添加到所述保费数 额列表 120中。 具体地， 当所述需要支付的保费索赔数额没有发生差错 （即所述 需要支付的保费索赔数额未超出预定索赔数额） 吋， 索赔精算模块 103将没有发 生差错的保费索赔数额添加到所述保费数额列表 120中。
[0049] 步骤 S37， 保费折扣模块 104根据所述保费数额列表 120中的保险费数据和保费 索赔数额来计算投保人在预定期限内医疗保险费的折扣数额。 在本实施例中， 所述保费折扣模块 104根据所述保险费数据和保费索赔数额的比例来计算投保人 在预定期限内医疗保险费的折扣数额。
[0050] 步骤 S38， 保费折扣模块 104根据投保人在预定期限内医疗保险费的折扣数额来 计算投保人在续保期限内医疗保险费的折扣数额。 在本实施例中， 所述续保期 限是指在投保人预定期限期满后紧接着预定期限后进行续保吋的投保期限。
[0051] 作为优选实施方式， 在步骤 S36与步骤 S37之间还可以包括步骤： 保费折扣模块 104根据预定的激励机制规则确定投保人的等级数据， 并根据所述投保人的等级 数据以及所述保费数额列表中的保险费数据和保费索赔数额来计算所述医疗保 险费的折扣数额。 在本实施例中， 所述激励机制规则是指通过投保人通过参加 保险公司设定的健康调査规则对投保人对个人身体健康进行评估并引导投保人 进行健康锻炼。 所述保费折扣模块 104根据投保人适用所述激励机制规则的情况 来确定投保人的等级程度， 例如投保人配合健康锻炼， 则等级定为优良等级； 若投保人基本配合健康锻炼， 则等级定为普通等级； 若投保人不配合健康锻炼 ， 则等级定为不良等级。 本发明使用由投保人从医疗保险计划得到的索赔数额 连同激励机制中投保人的状态等级一起来确定投保人的保险费折扣， 可以减少 索赔风险并避免吸弓 I高危人群来购买保险计划的不利因素， 从而可以提高保险 公司的盈利能力。
[0052]
[0053] 如图 4所示， 图 4是图 3中步骤 S35的细化流程图。 在本实施例中， 所述步骤 S35 的具体细化步骤包括如下步骤：
[0054] 步骤 S351， 索赔精算模块 103将需要支付给投保人的保费索赔数额和预定索赔 数额进行比较来验证在预定期限内需要支付给投保人的保费索赔数额。 在本实 施例中， 所述预定索赔数额是根据投保人在预定期限内的保险费数额来确定的 ， 例如保险费数额为 5千元， 根据保险公司的核保和理赔模型定义的保费索赔数 额为 1万。
[0055] 步骤 S352， 索赔精算模块 103在预定期限内需要支付给投保人的保费索赔数额 是否发生差错。 若所述保费索赔数额发生差错， 则执行步骤 S353 ; 若所述保费 索赔数额没有发生差错， 则执行流程图 3中的步骤 S36。
[0056] 步骤 S353， 当所述需要支付的保费索赔数额发生差错 （即所述需要支付的保费 索赔数额超出预定索赔数额） 吋， 锁定所述保费数额列表 120进行写保护以防止 发生差错的保费索赔数额添加到所述保费数额列表 120并产生报警信息通知保险 管理人员。 假如投保人在预定期限内的保险费数额为 5千元， 而保费索赔数额为 1万， 如果需要支付的保费索赔数额超出 1万， 则索赔精算模块 103产生报警信息 通知保险管理人员并锁定所述保费数额列表 120进行写保护以防止发生理赔差错 ， 从而避免保险公司带来理赔损失。
[0057]
[0058] 以上仅为本发明的优选实施例， 并非因此限制本发明的专利范围， 凡是利用本 发明说明书及附图内容所作的等效结构或等效流程变换， 或直接或间接运用在 其他相关的技术领域， 均同理包括在本发明的专利保护范围内。
工业实用性
[0059] 本发明所述医疗保险费折扣精算系统及方法采用上述技术方案， 带来的技术效 果为： 能够对需要支付给投保人的保费索赔数额进行差错验证从而精确计算出 投保人的医疗保险费折扣， 投保人从医疗保险计划得到的索赔数额连同激励机 制中投保人的状态等级一起来确定投保人的保险费折扣， 可以减少索赔风险并 避免吸引高危人群来购买保险计划的不利因素， 从而避免了保险公司带来理赔 损失， 提高了保险公司的盈利能力。

Claims

权利要求书
[权利要求 1] 一种医疗保险费折扣精算系统， 运行于云服务器中， 所述云服务器连 接至医疗保险数据库， 其特征在于， 该系统包括： 保险费模块， 用于 从医疗保险数据库中获取投保人在预定期限内的保险费数额， 并将所 述支付的保险费数额添加到保费数额列表中； 风险评估模块， 用于从 医疗保险数据库中获取投保人的健康数据， 并根据投保人的健康数据 建立投保人的理赔风险评估模型； 索赔精算模块， 用于从医疗保险数 据库中获取已支付给投保人的保费索赔数额并存储在所述保费数额列 表中， 根据投保人的理赔风险评估模型预测精算出在预定期限内需要 支付给投保人的保费索赔数额， 对所述需要支付的保费索赔数额进行 差错验证， 当所述需要支付的保费索赔数额没有发生差错吋将所述需 要支付的保费索赔数额添加到所述保费数额列表中； 保费折扣模块 ， 用于根据所述保费数额列表中的保险费数据和保费索赔数额来计算 投保人在预定期限内医疗保险费的折扣数额。
[权利要求 2] 根据权利要求 1所述的医疗保险费折扣精算系统， 其特征在于， 所述 保费折扣模块还用于根据投保人在预定期限内医疗保险费的折扣数额 来计算投保人在续保期限内医疗保险费的折扣数额。
[权利要求 3] 根据权利要求 1所述的医疗保险费折扣精算系统， 其特征在于， 所述 投保人的健康数据包括投保人的生命体征数据、 家族遗传病数据、 既 往病史数据、 个人生活方式指数、 生活环境污染指数、 生活地区传染 病发病率以及交通事故发生率。
[权利要求 4] 根据权利要求 1所述的医疗保险费折扣精算系统， 其特征在于， 所述 索赔精算模块还用于将所述需要支付的保费索赔数额和预定索赔数额 进行比较来验证在预定期限内需要支付给投保人的保费索赔数额， 判 断所述需要支付的保费索赔数额是否发生差错， 当所述需要支付的保 费索赔数额发生差错吋， 锁定所述保费数额列表进行写保护防止发生 差错的保费索赔数额添加到所述保费数额列表并产生报警信息通知保 险管理人员。
[权利要求 5] 根据权利要求 1至 4任一项所述的医疗保险费折扣精算系统， 其特征在 于， 所述保费折扣模块还用于根据预定的激励机制规则确定投保人的 等级数据， 以及根据所述投保人的等级数据以及所述保费数额列表中 的保险费数据和保费索赔数额来计算所述医疗保险费的折扣数额。
[权利要求 6] —种医疗保险折扣精算方法， 应用于云服务器中， 所述云服务器连接 至医疗保险数据库， 其特征在于， 该方法包括步骤： 从医疗保险数据 库中获取投保人在预定期限内的保险费数额， 并将所述支付的保险费 数额添加到保费数额列表中； 从医疗保险数据库中获取投保人的健康 数据， 并根据投保人的健康数据建立投保人的理赔风险评估模型； 从 医疗保险数据库中获取已支付给投保人的保费索赔数额并存储在所述 保费数额列表中； 根据投保人的理赔风险评估模型预测精算出在预定 期限内需要支付给投保人的保费索赔数额； 对所述需要支付的保费索 赔数额进行差错验证； 当所述需要支付的保费索赔数额没有发生差错 吋将所述需要支付的保费索赔数额添加到所述保费数额列表中； 根 据所述保费数额列表中的保险费数据和保费索赔数额来计算投保人在 预定期限内医疗保险费的折扣数额。
[权利要求 7] 根据权利要求 6所述的医疗保险费折扣精算方法， 其特征在于， 该方 法还包括步骤： 根据投保人在预定期限内医疗保险费的折扣数额来计 算投保人在续保期限内医疗保险费的折扣数额。
[权利要求 8] 根据权利要求 6所述的医疗保险费折扣精算方法， 其特征在于， 所述 投保人的健康数据包括投保人的生命体征数据、 家族遗传病数据、 既 往病史数据、 个人生活方式指数、 生活环境污染指数、 生活地区传染 病发病率以及交通事故发生率。
[权利要求 9] 根据权利要求 6所述的医疗保险费折扣精算方法， 其特征在于， 该方 法还包括步骤： 将所述需要支付的保费索赔数额和预定索赔数额进行 比较来验证在预定期限内需要支付给投保人的保费索赔数额； 判断所 述需要支付的保费索赔数额是否发生差错； 当所述需要支付的保费索 赔数额发生差错吋， 锁定所述保费数额列表进行写保护防止发生差错 的保费索赔数额添加到所述保费数额列表并产生报警信息通知保险管 理人员。
[权利要求 10] 根据权利要求 6至 9任一项所述的医疗保险费折扣精算方法， 其特征在 于， 所述根据所述保费数额列表中的保险费数据和保费索赔数额来计 算投保人在预定期限内医疗保险费的折扣数额的步骤还包括步骤： 根 据预定的激励机制规则确定投保人的等级数据； 根据所述投保人的等 级数据以及所述保费数额列表中的保险费数据和保费索赔数额来计算 所述医疗保险费的折扣数额。
PCT/CN2016/105114 2016-03-18 2016-11-08 医疗保险费折扣精算系统及方法 WO2017157030A1 (zh)

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