WO2018149397A1

WO2018149397A1 - Estimation method and apparatus for claim settlement reserve, storage medium and terminal device

Info

Publication number: WO2018149397A1
Application number: PCT/CN2018/076663
Authority: WO
Inventors: 戴建云; 朱瑾; 周鹏
Original assignee: 平安科技（深圳）有限公司
Priority date: 2017-02-16
Filing date: 2018-02-13
Publication date: 2018-08-23
Also published as: CN107784590A

Abstract

The present application discloses an estimation method and apparatus for claim settlement reserve, a computer-readable storage medium and a terminal device, for solving the problems that the estimation result of claim settlement reserve is easily affected by the professional standard and working experience of an estimation personnel and an estimation efficiency is low. The estimation method comprises: acquiring a case to be estimated; acquiring accident information about the case to be estimated; determining, according to the accident information, a claim settlement insurance product of an insurance policy corresponding to the case to be estimated; determining whether the claim settlement insurance product is a healthcare insurance product; if the claim settlement insurance product is a healthcare insurance product, then calculating the claim settlement reserve of the case to be estimated according to the average indemnity amount and the number of insurance products for the insurance policy; and if the claim settlement insurance product is not a healthcare insurance product, then calculating the coverage of the insurance policy under the claim settlement insurance product, and calculating the claim settlement reserve of the case to be estimated according to the calculated coverage and a pre-set indemnity ratio of the claim settlement insurance product.

Description

Method for evaluating claim reserve, storage medium, terminal device and device

This application claims the priority of the Chinese Patent Application filed on Feb. 16, 2017, the Chinese Patent Application No. 201710083376.7, entitled "A Method and Apparatus for Evaluating Claims Reserves", the entire contents of which are incorporated by reference. In this application.

Technical field

The present application relates to the field of financial services, and in particular, to a method for evaluating claims reserves, a computer readable storage medium, a terminal device, and a device.

Background technique

At present, insurance companies generally conduct assessments of claims reserves through professional evaluators. This makes the accuracy of the claims reserve assessment often closely related to the professional level of the assessors and the experience of the practitioners. Different assessors may come up with different claims reserve assessment results in the same case, resulting in the accuracy of the assessment of claims reserves being affected. In addition, with the development of the insurance company's business, more and more cases need to be assessed for claims, and it is often difficult to improve the efficiency of the assessment by ensuring the accuracy of the claims reserve assessment. In the face of a large number of cases to be evaluated, the cost of the claims reserve assessment is greatly increased.

technical problem

The application provides an evaluation method for a claim reserve, a computer readable storage medium, a terminal device and a device, which can automatically calculate the claim reserve of the case to be evaluated, and improve the evaluation accuracy and the evaluation efficiency.

Technical solution

A first aspect of the embodiments of the present application provides a method for evaluating a claim reserve, including:

Obtain the case to be evaluated;

Obtaining the insurance information of the case to be evaluated;

Determining, according to the risk information, a claim insurance type corresponding to the policy of the case to be evaluated;

Determining whether the claim insurance type belongs to a medical insurance type;

If the claim insurance type belongs to a medical insurance type, the preset amount of the claim insurance is obtained, and the number of the insurance policy items of the for-assessed case is determined according to the risk information, and the claim is based on the piece of the claim. Calculating the claim reserve for the case to be assessed based on the amount of the policy and the number of the policy insurance;

If the claim insurance type does not belong to the medical insurance category, calculating the insurance amount of the policy under the claim insurance type, and calculating the to-be-evaluated case according to the calculated insurance amount and the preset compensation ratio of the claim insurance type Claims reserve.

A second aspect of the embodiments of the present application provides a computer readable storage medium storing computer readable instructions that are implemented by a processor to implement an embodiment of the present application. The first aspect of the proposed method of assessing the claim reserve.

A third aspect of an embodiment of the present application provides a terminal device including a memory, a processor, and computer readable instructions stored in the memory and executable on the processor, the processor executing the computer The steps of the method for evaluating the claims reserve as set forth in the first aspect of the embodiments of the present application are implemented when the instructions are readable.

A fourth aspect of the embodiments of the present application provides an apparatus for evaluating a claim reserve, including:

a case acquisition module for obtaining a case to be evaluated;

The insurance information obtaining module is configured to obtain the insurance information of the case to be evaluated;

a claim insurance type determining module, configured to determine, according to the risk information, a claim insurance type corresponding to the policy of the case to be evaluated;

a judging module, configured to determine whether the claim insurance type belongs to a medical insurance type;

a first reserve calculation module, configured to acquire a preset amount of the claim for the claim insurance type if the claim type belongs to the medical insurance type, and determine the riskable policy of the case to be evaluated according to the risk information The number of insurance types, the claim reserve for the case to be evaluated is calculated according to the amount of the claim and the number of the policy insurance;

a second reserve calculation module, configured to calculate a policy amount of the policy under the claim insurance type if the claim insurance type does not belong to a medical insurance type, and calculate the insurance amount and the precautionary insurance type according to the calculation Set the compensation ratio to calculate the claim reserve for the case to be evaluated.

Beneficial effect

This application can realize the automatic calculation of the claims reserve of the case to be evaluated, avoiding the evaluation result of the claim reserve from being affected by the professional level and experience of the assessor, improving the accuracy of the assessment; and greatly improving the evaluation efficiency of the claim reserve. In the face of a large number of cases to be assessed, the cost of the claims reserve assessment is reduced.

DRAWINGS

1 is a flow chart of a first embodiment of a method for evaluating a claim reserve in the present application;

2 is a schematic flow chart of a calculation step of an average compensation amount for a method for evaluating a claim reserve in the present application;

3 is a schematic flow chart of a calculation step of a preset payout ratio of a method for evaluating a claim reserve in the present application;

4 is a flow chart of a second embodiment of a method for evaluating claim reserves in the present application;

Fig. 5 is a structural diagram showing a first embodiment of an apparatus for evaluating claim reserves in the present application.

Embodiments of the invention

The present application provides a method and apparatus for evaluating claim reserves, which are used to solve the problem that the evaluation result of the claim reserve is easily influenced by the professional level and experience of the assessor, and the problem of inefficiency is evaluated.

Referring to FIG. 1, a first embodiment of a method for evaluating a claim reserve in the present application includes:

101. Obtain a case to be evaluated;

In this embodiment, first, the case to be evaluated can be obtained. The case to be evaluated may be an insurance product to be evaluated, or may be a claim for evaluation.

102. Obtain the insurance information of the case to be evaluated;

After obtaining the case to be evaluated, the risk information of the case to be evaluated may be obtained. The risk information refers to information for recording the risk situation of the case to be evaluated, which may be entered by the applicant who filed the claim, or may be submitted or entered by the staff of the insurance company.

103. Determine, according to the risk information, a claim insurance type corresponding to the policy of the case to be evaluated;

After obtaining the insurance information of the case to be evaluated, the claim insurance type corresponding to the policy of the case to be evaluated may be determined according to the risk information.

It can be understood that the case to be evaluated can correspond to multiple policies, and there may be multiple types of insurance policies on each policy, such as disability insurance, critical illness insurance, personal injury insurance, medical insurance, and the like. Therefore, a case to be evaluated can determine one, two or more claims insurance based on the risk information.

Generally speaking, under the same policy, each type of insurance can be ordered according to the degree of importance: death insurance, critical illness insurance, disability insurance and medical insurance. When determining the type of claims insurance based on the risk information, it is preferred to choose a type of claims insurance with a higher degree of importance under the policy. For example, if the risk information can match the death insurance, then the critical illness insurance, disability insurance or medical insurance under the same policy will not be selected.

Therefore, the specific steps of determining the claim insurance type of the policy to be evaluated according to the risk information may include:

Determining whether the policy to be evaluated corresponds to the death insurance corresponding to the risk information, and the date of the insurance of the case to be evaluated satisfies the time limit for the death insurance in the policy, and if so, the The claim insurance type is a death insurance, and the claims reserve is evaluated according to the case of personal injury insurance. If not, the next step is performed;

Determining whether the to-be-evaluated case corresponding policy includes a critical illness insurance corresponding to the risk information, and the date of the insurance of the case to be evaluated satisfies the time limit condition for the critical illness insurance in the policy, and if yes, the The claim insurance type is a critical illness insurance, and the claim reserve assessment is carried out according to the case of the critical illness insurance. If not, the next step is performed;

Re-determining whether the to-be-evaluated case corresponding policy includes a disability insurance corresponding to the risk information, and the date of the insurance of the case to be evaluated satisfies the time limit condition for the disability insurance in the policy, and if so, the claim type insurance can be determined For disability insurance, the claim reserve assessment is conducted in accordance with the disability insurance case, and if not, the next step is performed;

Further determining whether the to-be-evaluated case corresponding policy includes a medical insurance corresponding to the risk information, and the date of the insurance of the case to be evaluated satisfies the time limit for the medical insurance in the policy, and if so, the claim insurance can be determined For medical insurance, the claim reserve assessment is carried out according to the case of medical insurance. If not, it can be determined that the corresponding policy is not included in the corresponding policy of the case to be evaluated. Therefore, if the claim is unqualified, the case to be evaluated can be directly determined. The claim reserve is 0.

104, determining whether the claims insurance belongs to the medical insurance, if yes, proceed to step 105, if not, proceed to step 108;

After determining the claims insurance of the policy to be evaluated according to the risk information, it may be determined whether the claim insurance belongs to the medical insurance, and if yes, step 105 is performed; if not, step 108 is performed.

It can be understood that, in this embodiment, since the method for evaluating the claims reserve of the medical insurance type and the non-medical insurance type is different, it is necessary to first determine whether the determined claims insurance type belongs to the medical insurance type or the non-medical insurance type.

The above medical insurance types may be medical insurance, and the above non-medical insurance types may include death insurance, heavy illness insurance and disability insurance.

105. Obtain a predetermined amount of compensation for the claim insurance type;

If the claim insurance type belongs to a medical insurance type, the preset amount of the claim for the claim insurance type may be obtained. Understandably, because the claims for medical insurance need to be based on specific medical expenses, even if the same policy is under the same risk information, the medical expenses that need to be paid are likely to be different. Therefore, it is suitable to use the average amount of compensation to evaluate the claims reserve for medical insurance.

Further, as shown in FIG. 2, the amount of the claim can be obtained by the following steps:

201. Obtain a total number of historical cases of the claim insurance type in the preset first time period;

202. Acquire a total historical payment amount of the claim insurance type in the preset first time period;

203. Calculate, according to the total number of historical cases and the total amount of historical claims, the amount of compensation for the claims insurance.

In the above-mentioned preset first time period, each month in the past year may be a time period. For example, the total number of historical cases and the corresponding historical total amount of medical insurance for each month in the past year can be separately counted. For example, the total number of historical cases in the month of July last year was B, and the total amount of historical claims was A, and the average amount of compensation in July last year was A/B.

In this embodiment, for the data that the compensation amount is too high or too low, the relevant data details may be submitted to the staff for verification, and if the verification is correct, the intervention is not performed; if the verification is incorrect, the abnormality may be manually corrected. The data is used to ensure the accuracy of the claim compensation and the accuracy of the claim reserve assessment.

106. Determine, according to the risk information, the number of insurance policy types of the risky case to be evaluated;

After obtaining the preset amount of the claim for the claim type insurance, the number of the policy insurance items of the case to be evaluated may be determined according to the risk information. It can be seen from the content described in the above step 103 that one case to be evaluated can determine one, two or more types of claims insurance according to the risk information, so that the number of policy types that can be out of danger can also have one, two or more.

107. Calculate a claim reserve for the case to be evaluated according to the amount of the claim and the number of the policy insurance;

After obtaining the average amount of the claim and the number of the insurance policy, the claim reserve of the case to be evaluated may be calculated according to the amount of the claim and the number of the policy insurance. The claim reserve may be equal to the product of the average amount of the claim and the number of the policy insurance.

Further, since the same medical liability is generally only paid once for the same insurance company, and if there are multiple insurance policies in the case to be evaluated that contain the same medical liability, a double counting portion may occur. Therefore, the number of liability claims cnt_liab under each policy insurance type of the case to be evaluated can also be obtained. The different policy types include the quantity cnt_liab_sub of the same liability, assuming that the average amount of compensation in the area is medi_r, and the number of policy insurance items is cnt_pol, then The reserve for each liability for each policy type is medi_r/(cnt_pol*cnt_liab*cnt_liab_sub). Finally, the claim reserve for the case to be evaluated is sum(medi_r/(cnt_pol*cnt_liab*cnt_liab_sub)), and sum is the summation function, that is, the reserve for all liabilities after calculating the reserve for each responsibility. The sum is equal to the claim reserve for the case to be assessed.

108. Calculate a policy amount of the policy under the claim insurance type;

If the claim insurance type is not a medical insurance type, the insurance amount of the policy under the claim insurance type may be calculated. It can be understood that the insured amount of the claim insurance can be calculated according to the agreement of the policy. For example, the type of claims insurance is death insurance, the premium is 10,000 per year. If the insured person dies within 20 years, he can pay 500,000 in one lump sum. The 500,000 is the insured amount of the deceased insurance. The calculation of the specific insurance amount can be found in the contractual agreement of the policy, and will not be repeated here.

109. Calculate a claim reserve for the case to be evaluated according to the calculated insured amount and a preset payout ratio of the claim type insurance.

After calculating the insurance amount of the policy under the claim insurance type, the claim reserve of the case to be evaluated may be calculated according to the calculated insurance amount and the preset payout ratio of the claim insurance type. The preset payout ratio can be calculated or counted according to historical data in advance. It can be understood that the payout ratios of different claims insurance types are generally different, for example, the personal injury insurance, the critical illness insurance, and the disability insurance have respective preset payout ratios.

In this embodiment, if the claim insurance type is a non-medical insurance type, the claim reserve of the case to be evaluated may be equal to the product of the insurance amount and the preset payout ratio.

Further, as shown in FIG. 3, the preset payout ratio can be calculated by the following steps:

301. Obtain a historical total insurance amount of the claim insurance type within a preset time period;

302. Acquire a total historical compensation amount of the claim insurance type in the preset time period;

303. Obtain a total number of application cases of the claim insurance type in the preset time period;

304. Obtain a total number of claims for the claims insurance type in the preset time period;

305. Obtain a total number of insured persons for the policy;

306. Obtain a total number of people who have obtained the insurance policy;

307. Enter a historical total insurance amount, the total amount of the historical claims, the total number of the case applications, the total number of claims, the total number of the insured persons, and the total number of the insured persons into a preset compensation ratio calculation model. , to obtain the preset payout ratio of the claim insurance type.

For the above steps 301-304, in the above preset time period, each month in the past year may be a time period. For example, the historical total amount of insurance for non-medical insurance for each month in the past year, the total amount of the historical claims, the total number of applications for the case, and the total number of claims for the case may be separately counted. Wherein, the above-mentioned historical total insurance amount refers to the total insured amount of the claim insurance case, which is set to A; the above historical total compensation refers to the total payment of the final payment of the claim type under the claim insurance type, and is set as B; the total number of applications for the above-mentioned cases refers to the total number of cases in which claims are applied under the claims insurance, or may be considered as the total number of cases to be assessed, set to C; and the total number of claims in the above cases refers to the application in the case Based on the total number of cases that were finally paid out, set to D.

For the above step 305, the total number of insured persons refers to the total number of insured persons corresponding to the policy to be evaluated in this embodiment, and is set to E.

For the above step 306, the total number of people in the above-mentioned insurance refers to the total number of people who are insured in the case to be evaluated in this embodiment, and is set to F.

For the foregoing step 307, the preset payout ratio calculation model may specifically include:

If F/E>2*D/C is satisfied, the preset payout ratio = (B/A)*(D/C+(F/E-D/C)/2);

If D/C>2F/E is satisfied, the preset payout ratio = (B/A)*(D/C-( D/C-F/E)/2);

If none of the above is satisfied, the preset payout ratio = (B/A)* (D/C).

In this embodiment, for the data whose preset payout ratio is too high or too low, the relevant data details may be submitted to the staff for verification, and if the verification is correct, the intervention is not performed; if the verification is incorrect, the abnormality may be manually corrected. The data is used to ensure that the preset payout ratio is accurate and effective, thereby improving the accuracy of the claims reserve assessment.

In addition, for calculating the preset payout ratio of the claim type in a plurality of months, the preset payout ratio of one year may take the average of the preset payout ratios of the plurality of months.

In this embodiment, the preset payout ratio corresponds to the preset payout ratio. Generally, the preset chargeback ratio is 1 - the preset payout ratio, so the preset payout ratio used above may also be used in the system. Store records in the form of a preset chargeback ratio.

It should be noted that the above steps 301~307 are applicable to the calculation of the preset payout ratio of the death insurance, the critical illness insurance and the disability insurance. Further, when calculating the preset payout ratio of the disability insurance, the historical total compensation B may be specifically subdivided into the historical total compensation B1 including the disability ratio and the historical total compensation B2 not including the disability ratio. The above “contains disability ratio” refers to whether the statistics of the total historical compensation amount takes into account the disability ratio as a factor.

Therefore, similarly, the estimated proportion of the disability that is estimated to have a disability ratio includes:

If F/E>2*D/C is satisfied, the preset payout ratio = (B1/A)*(D/C+(F/E-D/C)/2);

If D/C>2F/E is satisfied, the preset payout ratio = (B1/A)*(D/C-( D/C-F/E)/2);

If none of the above is satisfied, the preset payout ratio = (B1/A)*(D/C).

The estimated proportion of the disability insurance that is estimated to have no disability ratio includes:

If F/E>2*D/C is satisfied, the preset payout ratio = (B2/A)*(D/C+(F/E-D/C)/2);

If D/C>2F/E is satisfied, the preset payout ratio = (B2/A)*(D/C-( D/C-F/E)/2);

If none of the above is satisfied, the preset payout ratio = (B2/A)*(D/C).

In this embodiment, the automatic calculation of the claim reserve for the case to be evaluated can be realized, and the evaluation result of the claim reserve is prevented from being affected by the professional level and experience of the assessor, and the evaluation accuracy is improved; and the claim reserve is greatly improved. The efficiency of the assessment reduces the cost of the claims reserve assessment in the face of a large number of cases to be assessed.

Referring to FIG. 4, a second embodiment of the method for evaluating claim reserves in the embodiment of the present application includes:

401. Obtain a case to be evaluated;

402. Obtain the insurance information of the case to be evaluated;

403. Determine, according to the risk information, a claim insurance type corresponding to the policy of the case to be evaluated;

Before determining the claim insurance type of the policy to be evaluated according to the risk information, the method further includes: determining, according to the risk information, whether the policy corresponding to the case to be evaluated includes a claim insurance type corresponding to the risk information, and The expiration date of the case to be evaluated satisfies the time limit condition of the policy, and if yes, the step of determining the claim type of the policy corresponding to the case to be evaluated according to the risk information, and if not, determining the claim of the case to be evaluated The reserve is 0.

404, determining whether the claims insurance belongs to the medical insurance, if yes, proceed to step 405, if not, proceed to step 408;

405. Acquire a preset amount of the claim for the claim insurance type;

406. Determine, according to the risk information, the number of policy insurance types of the risky case to be evaluated;

407. Calculate a claim reserve for the case to be evaluated according to the amount of the claim and the number of the policy insurance;

408. Calculate a policy amount of the policy under the claim insurance type;

409. Calculate a claim reserve for the case to be evaluated according to the calculated insured amount and a preset payout ratio of the claim insurance type;

Steps 401-409 are the same as steps 101-109. For details, refer to the related description of steps 101-109.

410. Obtain a current claim phase of the case to be evaluated;

After obtaining the case to be evaluated, the current claim phase of the case to be evaluated may be obtained. It can be understood that the current claim phase refers to the current stage of the application for claim settlement of the case to be evaluated, for example, the stage in which the case to be evaluated has been entered into the claim information but the amount of the claim is not paid, and the case to be evaluated has been given. The amount of the audit but not the stage of the payment of the audit amount, and so on.

411. If the current claim phase is a stage in which the claim information has been entered into the claim information but the claim amount is not paid, the predicted claims of the claim insurance type are calculated according to the claim information and the claim calculation rule of the policy. ;

If the current claim phase is a stage in which the claim to be evaluated has entered the claim information but the claim amount is not paid, the predicted claim amount of the claim insurance type may be calculated according to the claim information and the claim calculation rule of the policy.

The above-mentioned "received claim information" means that the claim information has been entered, that is, the claim for the case to be evaluated can be calculated according to the specific claim information; and the above-mentioned "unpaid amount" refers to the fact that although the claim can be calculated, However, the claims paid by the insurance company have not been finalized and reviewed. Therefore, the predicted claims of the claim insurance can be calculated according to the claim calculation rule of the policy. The claim calculation rule is generally pre-agreed in the policy.

412. Compare the claim reserve with the predicted claim, and obtain a comparison result;

413. Adjust the predicted claims according to the comparison result, and determine the adjusted claims to be the claim reserve of the case to be evaluated;

For the above steps 412 and 413, since the calculated claim reserve and the predicted claim are evaluated for the claim reserve of the case to be evaluated, the two can be compared first, and then the comparison result is performed. Adjustments to improve the accuracy of the assessment of claims reserves.

Set the claim reserve to unset_amt and predict the claim to be do_amt. The specific comparison and adjustment steps can be as follows:

If do_amt>2*unset_amt is satisfied, the final adjustment claim margin final_amt=do_amt –(do_amt-unset_amt)/2;

If unset_amt >2*do_amt is satisfied, the final adjustment claim margin final_amt=do_amt +( unset_amt- do_amt)/2;

If none of the above conditions are met, the final settlement of the claims reserve final_amt=do_amt.

The final claim reserve is obtained by adjusting the forecasting claims, making the assessment of the claims reserve more accurate.

414. If the current claim phase is a stage in which the audit amount of the case to be evaluated has been given but the payment of the audit amount is not initiated, determine that the audit amount is a claim reserve of the case to be evaluated.

If the current claim phase is a stage in which the audit amount of the case to be evaluated has been given but the payment amount of the audit amount is not initiated, the audit amount may be directly determined as the claim reserve of the case to be evaluated.

It can be understood that, in the case that the audit amount has been given, the claim amount (equal to the audit amount) of the case to be evaluated has been determined, and only the payment of the claim amount is still not paid at this stage, so the audit amount can be directly determined. The claim reserve for the case to be assessed.

Further, in the embodiment, after the claim reserve for the case to be evaluated is determined or calculated, the accuracy of the claims reserve of each product may be verified. The accuracy check can be performed in three dimensions, namely the total evaluation amount, the evaluation amount of each product category, and the total throughput of the evaluation case. The steps to verify the accuracy of the three dimensions are briefly described below:

Total assessment:

First, obtain the following data from the database: the monthly evaluation case amount allCnt, the total evaluation amount of the month allAmt, the last month evaluation case amount allCntOld, the last month total evaluation amount allAmtOld, the last month evaluation case amount allCntLast, last year's total evaluation amount allAmtLast, last year The monthly assessment case amount allCntOldLast and last year's total evaluation amount of allAmtOldLast.

Then, based on the obtained data, it is determined whether there is a surge in the total evaluation amount, and if so, verification is performed on the specific surge data, which specifically includes:

If (allAmtall-allAmtOld)> set the growth threshold * (allAmtallLast-allAmtOldLast), then it is judged whether allCnt-allCntOld is greater than the case growth threshold * (allCntLast-allCntOldLast), if it is greater, then analyze the link of the surge case. If the analysis finds that there is a suspicious increase in a certain area of a certain link, it needs to be verified in the relevant area. If it is found that there is a problem, it is necessary to adjust the relevant processing, and then re-verify after the adjustment is completed. Among them, in the analysis process, you can grab the reserve for the policy type of the case with a large amount of preparation (the specific amount of data captured is controlled by the larger case amount and the larger reserve value), and then the test results in a large value. The calculation process factor. In the whole verification process, if the amount of insurance coverage is involved, it needs to be transferred to the insurance company responsible for underwriting to make adjustments, and then re-calibration after adjustment; if it involves the issue of addition and reduction, it is necessary to transfer the insurance company responsible for the preservation. The adjustment process is carried out, and the adjustment is performed again after the adjustment; if the acceptance of the claim is involved, the person in charge of the claim of the insurance company needs to be adjusted and processed, and the adjustment is performed again after the adjustment.

In addition, if you take a case where the reserve is evaluated multiple times, and the growth value of the current month is greater than the set growth threshold, you need to analyze the factors that caused the change, and then analyze the “nuclear insurance, security, claims” The reason is that after the analysis, the relevant processing is performed, and the verification is performed again.

On the other hand, according to the obtained data, it is also possible to determine whether there is a sudden drop in the total evaluation amount, and if so, to verify the data of the specific sudden drop, specifically including:

If (allAmtall-allAmtOld) < set growth threshold * (allAmtallLast-allAmtOldLast), then it is judged whether allCnt-allCntOld is less than the case growth threshold * (allCntLast-allCntOldLast), if less than, then analyze the link in the case of the sudden drop If the analysis finds that there is a suspicious sudden drop in a certain area, it needs to be verified by the relevant area. If it is found that there is a problem, it is necessary to adjust the relevant processing, and then re-verify after the adjustment is completed.

In addition, if you take a case where the reserve is evaluated multiple times, and the reduction value of the current month is greater than the set reduction threshold, you need to analyze the factors that caused the change, and then analyze the “nuclear insurance, security, claims” The reason is that after the analysis, the relevant processing is performed, and the verification is performed again.

The evaluation of each product category:

According to different product categories, calculate the amount of evaluation cases and the value of claims reserves for this month, the amount of evaluation cases and the value of claims reserves in the previous month. After comparison, the major categories of products with large differences are extracted and analyzed. Which product categories are mutated, in which institutions are mutated, whether certain policies are concentrated, etc., and then the analysis result data is sent to designated locations in designated regions and/or headquarters for verification. If verification is found to require adjustment, adjustments are made. Re-check after completion.

Assess the total throughput of the case:

First, obtain the following data from the database: last month to evaluate the case amount cnt_old, last month to evaluate the case closed cnt_old_end, the current month intake cnt_new, the current month intake and evaluate cnt_new_reck, the current month closing amount cnt_new_end. Then the obtained data is put into the following equation for verification:

Cnt_new_reck= Cnt_old-cnt_old_end+cnt_new-cnt_new_end

In general, the equation should be identical. If the equation is found to be unsuccessful, the difference detail data is extracted and submitted to each region for analysis.

In addition, you can also check the details of the case, including the following:

If the case is evaluated at the same time of the previous month and the current month, and the case process has not changed, but the evaluation amount of the current month is inconsistent with the evaluation amount of the previous month, the detailed data should be selected and submitted to each region for analysis and processing;

If the case is evaluated last month and the case process has not changed, but the assessment for the current month is carried out, the detailed data should be selected and submitted to each region for analysis and processing;

If the case is evaluated at the same time of the previous month and the month, and the case process has not changed, but the evaluation product category of the current month is inconsistent with the evaluation product category of the previous month, the detailed data needs to be selected and submitted to each region for analysis and processing.

Fig. 5 is a block diagram showing the first embodiment of an evaluation apparatus for claim settlement in the present application.

In this embodiment, an evaluation device for claim settlement includes:

a case obtaining module 501, configured to obtain a case to be evaluated;

The risk information obtaining module 502 is configured to obtain the risk information of the case to be evaluated;

The claim insurance type determining module 503 is configured to determine, according to the risk information, a claim insurance type corresponding to the policy of the case to be evaluated;

The determining module 504 is configured to determine whether the claim insurance type belongs to a medical insurance type;

The first reserve calculation module 505 is configured to: if the claim insurance belongs to the medical insurance, acquire the preset amount of the claim for the claim insurance, and determine, according to the insurance information, the risk of the case to be evaluated. The number of insurance policy types, the claim reserve for the case to be evaluated is calculated according to the average amount of the claim and the number of the policy insurance;

a second reserve calculation module 506, configured to calculate a policy amount of the policy under the claim insurance type if the claim insurance type does not belong to a medical insurance type, and calculate the insurance amount and the claim insurance type according to the calculation The claim compensation ratio is calculated by the preset payout ratio.

Further, the preset payout ratio can be calculated by the following modules:

The historical total insurance amount acquisition module is configured to obtain the historical total insurance amount of the claim insurance type within the preset time period;

a historical compensation total acquisition module, configured to obtain a historical total payment amount of the claim insurance type in the preset time period;

a total number of cases for obtaining a case application module, configured to obtain a total number of case applications for the claims insurance type in the preset time period;

a case payment total item obtaining module, configured to obtain a total number of case claims for the claim insurance type in the preset time period;

Insured total number acquisition module for obtaining the total number of insured persons for the policy;

The total number of people in the insurance acquisition module is used to obtain the total number of persons who have taken out the insurance policy;

The input module is configured to input the historical total amount of the insurance, the total amount of the historical claims, the total number of the case applications, the total number of the claims, the total number of the insured persons, and the total number of the insured persons into a preset payment The proportional calculation model obtains the preset payout ratio of the claim insurance type.

Further, the evaluation device of the claim reserve may further include:

a claim phase acquisition module, configured to obtain a current claim phase of the case to be evaluated;

a predictive claims calculation module, configured to calculate, according to the claim information and the claim calculation rule of the policy, if the current claim phase is a stage in which the claim information has been entered but the amount of the claim is not paid Predicted claims for claims insurance;

a comparison module, configured to compare the claim reserve with the predicted claims to obtain a comparison result;

And an adjustment module, configured to adjust the predicted claims according to the comparison result, and determine the adjusted claims to be the claim reserve of the case to be evaluated.

Further, the evaluation device of the claim reserve may further include:

a first determining module, configured to determine that the audit amount is the case to be evaluated if the current claim phase is a stage in which the audit amount of the case to be evaluated has been given but the payment amount of the audit amount is not initiated Claims reserve.

Further, the evaluation device of the claim reserve may further include:

a condition judging module, configured to determine, according to the risk information, whether the policy to be evaluated corresponds to a claim insurance policy corresponding to the risk information, and the date of the insurance of the case to be evaluated satisfies the time limit of the policy;

a triggering module, configured to trigger the claim insurance type determining module if the determination result of the condition determining module 519 is YES;

The second determining module is configured to determine, if the determination result of the condition determining module 519 is negative, that the claim reserve of the case to be evaluated is 0.

A person skilled in the art can clearly understand that the specific working processes of the system, the device and the unit described above can refer to the corresponding processes in the foregoing method embodiments, and details are not described herein again.

The embodiment of the present application further provides a computer readable storage medium storing computer readable instructions, which are executed by a processor to implement any one as shown in FIG. 1 or FIG. The steps of the method of evaluating the claims reserve.

The embodiment of the present application further provides a terminal device, including a memory, a processor, and computer readable instructions stored in the memory and executable on the processor, when the processor executes the computer readable instruction The steps of the evaluation method of any claim reserve as shown in FIG. 1 or FIG. 4 are implemented.

Claims

A method for evaluating a claim reserve, characterized in that it comprises:

Obtain the case to be evaluated;

Obtaining the insurance information of the case to be evaluated;

Determining, according to the risk information, a claim insurance type corresponding to the policy of the case to be evaluated;

Determining whether the claim insurance type belongs to a medical insurance type;

If the claim insurance type belongs to a medical insurance type, the preset amount of the claim insurance is obtained, and the number of the insurance policy items of the for-assessed case is determined according to the risk information, and the claim is based on the piece of the claim. Calculating the claim reserve for the case to be assessed based on the amount of the policy and the number of the policy insurance;

If the claim insurance type does not belong to the medical insurance category, calculating the insurance amount of the policy under the claim insurance type, and calculating the to-be-evaluated case according to the calculated insurance amount and the preset compensation ratio of the claim insurance type Claims reserve.
The method for evaluating a claim reserve according to claim 1, wherein the predetermined payout ratio is calculated by the following steps:

Obtaining the historical total amount of insurance coverage of the claims insurance within the preset time period;

Obtaining a total historical compensation amount of the claim insurance type in the preset time period;

Obtaining a total number of case applications for the claims insurance type in the preset time period;

Obtaining a total number of claims for the claim insurance type in the preset time period;

Obtaining the total number of insured persons for the policy;

Obtain the total number of people who have taken out the policy;

Entering the historical total insurance amount, the total amount of the historical claims, the total number of the case applications, the total number of claims, the total number of insured persons, and the total number of the insurance persons into a preset compensation ratio calculation model, The default payout ratio of the claim insurance type.
The method for evaluating a claim reserve according to claim 1, wherein after obtaining the case to be evaluated, the method further comprises:

Obtaining the current claim phase of the case to be evaluated;

After calculating the claim reserve of the case to be evaluated, the method for evaluating the claim reserve further includes:

If the current claim phase is a stage in which the claim to be evaluated has entered the claim information but the claim amount is not paid, the predicted claim amount of the claim insurance type is calculated according to the claim information and the claim calculation rule of the policy;

Comparing the claim reserve with the predicted claims to obtain a comparison result;

The predicted claims are adjusted according to the comparison result, and the adjusted claims are determined as the claim reserve of the case to be evaluated.
The method for evaluating a claim reserve according to claim 3, wherein the method for evaluating the claim reserve further comprises:

If the current claim phase is a stage in which the audit amount of the case to be evaluated has been given but the payment of the audit amount is not initiated, it is determined that the audit amount is the claim reserve of the case to be evaluated.
The method for evaluating a claim reserve according to any one of claims 1 to 4, further comprising: before determining the claim insurance type of the policy to be evaluated according to the risk information, further comprising:

Determining, according to the risk information, whether the policy to be evaluated corresponds to a claim insurance policy corresponding to the risk information, and the date of the insurance of the case to be evaluated satisfies the time limit of the policy;

If yes, performing a step of determining, according to the risk information, a claim insurance type corresponding to the policy to be evaluated;

If not, it is determined that the claim reserve of the case to be evaluated is zero.
A computer readable storage medium storing computer readable instructions, wherein the computer readable instructions, when executed by a processor, implement the following steps:

Obtain the case to be evaluated;

Obtaining the insurance information of the case to be evaluated;

Determining, according to the risk information, a claim insurance type corresponding to the policy of the case to be evaluated;

Determining whether the claim insurance type belongs to a medical insurance type;

If the claim insurance type belongs to a medical insurance type, the preset amount of the claim insurance is obtained, and the number of the insurance policy items of the for-assessed case is determined according to the risk information, and the claim is based on the piece of the claim. Calculating the claim reserve for the case to be assessed based on the amount of the policy and the number of the policy insurance;

If the claim insurance type does not belong to the medical insurance category, calculating the insurance amount of the policy under the claim insurance type, and calculating the to-be-evaluated case according to the calculated insurance amount and the preset compensation ratio of the claim insurance type Claims reserve.
The computer readable storage medium according to claim 6, wherein the predetermined payout ratio is calculated by the following steps:

Obtaining the historical total amount of insurance coverage of the claims insurance within the preset time period;

Obtaining a total historical compensation amount of the claim insurance type in the preset time period;

Obtaining a total number of case applications for the claims insurance type in the preset time period;

Obtaining a total number of claims for the claim insurance type in the preset time period;

Obtaining the total number of insured persons for the policy;

Obtain the total number of people who have taken out the policy;

Entering the historical total insurance amount, the total amount of the historical claims, the total number of the case applications, the total number of claims, the total number of insured persons, and the total number of the insurance persons into a preset compensation ratio calculation model, The default payout ratio of the claim insurance type.
The computer readable storage medium according to claim 6, wherein after obtaining the case to be evaluated, the method further comprises:

Obtaining the current claim phase of the case to be evaluated;

After calculating the claim reserve of the case to be evaluated, the method for evaluating the claim reserve further includes:

If the current claim phase is a stage in which the claim to be evaluated has entered the claim information but the claim amount is not paid, the predicted claim amount of the claim insurance type is calculated according to the claim information and the claim calculation rule of the policy;

Comparing the claim reserve with the predicted claims to obtain a comparison result;

The predicted claims are adjusted according to the comparison result, and the adjusted claims are determined as the claim reserve of the case to be evaluated.
The computer readable storage medium of claim 8 wherein the step of implementing the computer readable instructions by the processor further comprises:

If the current claim phase is a stage in which the audit amount of the case to be evaluated has been given but the payment of the audit amount is not initiated, it is determined that the audit amount is the claim reserve of the case to be evaluated.
The computer readable storage medium according to any one of claims 6 to 9, wherein before determining the claims insurance policy of the policy to be evaluated according to the risk information, the method further comprises:

Determining, according to the risk information, whether the policy to be evaluated corresponds to a claim insurance policy corresponding to the risk information, and the date of the insurance of the case to be evaluated satisfies the time limit of the policy;

If yes, performing a step of determining, according to the risk information, a claim insurance type corresponding to the policy to be evaluated;

If not, it is determined that the claim reserve of the case to be evaluated is zero.
A terminal device comprising a memory, a processor, and computer readable instructions stored in the memory and operable on the processor, wherein the processor executes the computer readable instructions as follows step:

Obtain the case to be evaluated;

Obtaining the insurance information of the case to be evaluated;

Determining, according to the risk information, a claim insurance type corresponding to the policy of the case to be evaluated;

Determining whether the claim insurance type belongs to a medical insurance type;

If the claim insurance type belongs to a medical insurance type, the preset amount of the claim insurance is obtained, and the number of the insurance policy items of the for-assessed case is determined according to the risk information, and the claim is based on the piece of the claim. Calculating the claim reserve for the case to be assessed based on the amount of the policy and the number of the policy insurance;

If the claim insurance type does not belong to the medical insurance category, calculating the insurance amount of the policy under the claim insurance type, and calculating the to-be-evaluated case according to the calculated insurance amount and the preset compensation ratio of the claim insurance type Claims reserve.
The terminal device according to claim 11, wherein the preset payout ratio is calculated by the following steps:

Obtaining the historical total amount of insurance coverage of the claims insurance within the preset time period;

Obtaining a total historical compensation amount of the claim insurance type in the preset time period;

Obtaining a total number of case applications for the claims insurance type in the preset time period;

Obtaining a total number of claims for the claim insurance type in the preset time period;

Obtaining the total number of insured persons for the policy;

Obtain the total number of people who have taken out the policy;

Entering the historical total insurance amount, the total amount of the historical claims, the total number of the case applications, the total number of claims, the total number of insured persons, and the total number of the insurance persons into a preset compensation ratio calculation model, The default payout ratio of the claim insurance type.
The terminal device according to claim 11, wherein after obtaining the case to be evaluated, the method further comprises:

Obtaining the current claim phase of the case to be evaluated;

After calculating the claim reserve of the case to be evaluated, the method for evaluating the claim reserve further includes:

If the current claim phase is a stage in which the claim to be evaluated has entered the claim information but the claim amount is not paid, the predicted claim amount of the claim insurance type is calculated according to the claim information and the claim calculation rule of the policy;

Comparing the claim reserve with the predicted claims to obtain a comparison result;

The predicted claims are adjusted according to the comparison result, and the adjusted claims are determined as the claim reserve of the case to be evaluated.
The terminal device according to claim 13, wherein the step of implementing the computer readable instructions by the processor further comprises:

If the current claim phase is a stage in which the audit amount of the case to be evaluated has been given but the payment of the audit amount is not initiated, it is determined that the audit amount is the claim reserve of the case to be evaluated.
The terminal device according to any one of claims 11 to 14, wherein before determining the claims insurance for the policy to be evaluated according to the risk information, the method further comprises:

Determining, according to the risk information, whether the policy to be evaluated corresponds to a claim insurance policy corresponding to the risk information, and the date of the insurance of the case to be evaluated satisfies the time limit of the policy;

If yes, performing a step of determining, according to the risk information, a claim insurance type corresponding to the policy to be evaluated;

If not, it is determined that the claim reserve of the case to be evaluated is zero.
An apparatus for evaluating claims reserves, comprising:

a case acquisition module for obtaining a case to be evaluated;

The insurance information obtaining module is configured to obtain the insurance information of the case to be evaluated;

a claim insurance type determining module, configured to determine, according to the risk information, a claim insurance type corresponding to the policy of the case to be evaluated;

a judging module, configured to determine whether the claim insurance type belongs to a medical insurance type;

a first reserve calculation module, configured to acquire a preset amount of the claim for the claim insurance type if the claim type belongs to the medical insurance type, and determine the riskable policy of the case to be evaluated according to the risk information The number of insurance types, the claim reserve for the case to be evaluated is calculated according to the amount of the claim and the number of the policy insurance;

a second reserve calculation module, configured to calculate a policy amount of the policy under the claim insurance type if the claim insurance type does not belong to a medical insurance type, and calculate the insurance amount and the precautionary insurance type according to the calculation Set the compensation ratio to calculate the claim reserve for the case to be evaluated.
The apparatus for evaluating claim reserves according to claim 16, wherein the preset payout ratio is calculated by the following module:

The historical total insurance amount acquisition module is configured to obtain the historical total insurance amount of the claim insurance type within the preset time period;

a historical compensation total acquisition module, configured to obtain a historical total payment amount of the claim insurance type in the preset time period;

a total number of cases for obtaining a case application module, configured to obtain a total number of case applications for the claims insurance type in the preset time period;

a case payment total item obtaining module, configured to obtain a total number of case claims for the claim insurance type in the preset time period;

Insured total number acquisition module for obtaining the total number of insured persons for the policy;

The total number of people in the insurance acquisition module is used to obtain the total number of persons who have taken out the insurance policy;

The input module is configured to input the historical total amount of the insurance, the total amount of the historical claims, the total number of the case applications, the total number of the claims, the total number of the insured persons, and the total number of the insured persons into a preset payment The proportional calculation model obtains the preset payout ratio of the claim insurance type.
The apparatus for evaluating claims reserves according to claim 16, wherein the apparatus for evaluating claims reserves further comprises:

a claim phase acquisition module, configured to obtain a current claim phase of the case to be evaluated;

a predictive claims calculation module, configured to calculate, according to the claim information and the claim calculation rule of the policy, if the current claim phase is a stage in which the claim information has been entered but the amount of the claim is not paid Predicted claims for claims insurance;

a comparison module, configured to compare the claim reserve with the predicted claims to obtain a comparison result;

And an adjustment module, configured to adjust the predicted claims according to the comparison result, and determine the adjusted claims to be the claim reserve of the case to be evaluated.
The apparatus for evaluating claims reserves according to claim 18, wherein the apparatus for evaluating claims reserves further comprises:

a first determining module, configured to determine that the audit amount is the case to be evaluated if the current claim phase is a stage in which the audit amount of the case to be evaluated has been given but the payment amount of the audit amount is not initiated Claims reserve.
The apparatus for evaluating the claim reserve according to any one of claims 16 to 19, wherein the claim reserve evaluation apparatus further comprises:

a condition judging module, configured to determine, according to the risk information, whether the policy to be evaluated corresponds to a claim insurance policy corresponding to the risk information, and the date of the insurance of the case to be evaluated satisfies the time limit of the policy;

a triggering module, configured to trigger the claim insurance type determining module if the determination result of the condition determining module is YES;

The second determining module is configured to determine, if the determination result of the condition determining module is negative, that the claim reserve of the case to be evaluated is 0.