WO2018149397A1 - Procédé et appareil d'estimation pour réserve de règlement de revendication, support d'informations et dispositif terminal - Google Patents

Procédé et appareil d'estimation pour réserve de règlement de revendication, support d'informations et dispositif terminal Download PDF

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Publication number
WO2018149397A1
WO2018149397A1 PCT/CN2018/076663 CN2018076663W WO2018149397A1 WO 2018149397 A1 WO2018149397 A1 WO 2018149397A1 CN 2018076663 W CN2018076663 W CN 2018076663W WO 2018149397 A1 WO2018149397 A1 WO 2018149397A1
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Prior art keywords
insurance
case
evaluated
policy
amount
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PCT/CN2018/076663
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English (en)
Chinese (zh)
Inventor
戴建云
朱瑾
周鹏
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平安科技（深圳）有限公司
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Publication of WO2018149397A1 publication Critical patent/WO2018149397A1/fr

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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
    • G06Q40/08—Insurance

Definitions

  • 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.
  • 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.
  • a first aspect of the embodiments of the present application provides a method for evaluating a claim reserve, including:
  • 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;
  • 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.
  • 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.
  • 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.
  • FIG. 1 is a flow chart of a first embodiment of a method for evaluating a claim reserve in the present application
  • FIG. 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
  • FIG. 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
  • FIG. 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.
  • 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.
  • a first embodiment of a method for evaluating a claim reserve in the present application includes:
  • 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.
  • 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.
  • the claim insurance type corresponding to the policy of the case to be evaluated may be determined according to the risk information.
  • 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.
  • each type of insurance can be ordered according to the degree of importance: death insurance, critical illness insurance, disability insurance and medical insurance.
  • death insurance critical illness insurance
  • disability insurance disability insurance
  • medical insurance medical insurance
  • the specific steps of determining the claim insurance type of the policy to be evaluated according to the risk information may include:
  • 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;
  • 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;
  • the claim reserve assessment is conducted in accordance with the disability insurance case, and if not, the next step is performed;
  • 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.
  • step 104 determining whether the claims insurance belongs to the medical insurance, if yes, proceed to step 105, if not, proceed to step 108;
  • step 105 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.
  • 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.
  • 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.
  • the amount of the claim can be obtained by the following steps:
  • each month in the past year may be a time period.
  • 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.
  • the total number of historical cases in the month of July last year was B
  • the total amount of historical claims was A
  • the average amount of compensation in July last year was A/B.
  • 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.
  • 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.
  • 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.
  • 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).
  • 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.
  • 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.
  • 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.
  • the claim reserve of the case to be evaluated may be equal to the product of the insurance amount and the preset payout ratio.
  • the preset payout ratio can be calculated by the following steps:
  • each month in the past year may be a time period.
  • 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.
  • 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.
  • 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.
  • 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.
  • the preset payout ratio calculation model may specifically include:
  • the preset payout ratio (B/A)*(D/C-( D/C-F/E)/2);
  • 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.
  • the preset payout ratio of one year may take the average of the preset payout ratios of the plurality of months.
  • the preset payout ratio corresponds to the preset payout ratio.
  • the preset chargeback ratio is 1 - the preset payout ratio, so the preset payout ratio used above may also be used in the system.
  • 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.
  • the estimated proportion of the disability that is estimated to have a disability ratio includes:
  • the preset payout ratio (B1/A)*(D/C+(F/E-D/C)/2);
  • the preset payout ratio (B1/A)*(D/C-( D/C-F/E)/2);
  • the estimated proportion of the disability insurance that is estimated to have no disability ratio includes:
  • the preset payout ratio (B2/A)*(D/C+(F/E-D/C)/2);
  • the preset payout ratio (B2/A)*(D/C-( D/C-F/E)/2);
  • 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.
  • a second embodiment of the method for evaluating claim reserves in the embodiment of the present application includes:
  • 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.
  • step 404 determining whether the claims insurance belongs to the medical insurance, if yes, proceed to step 405, if not, proceed to step 408;
  • Steps 401-409 are the same as steps 101-109. For details, refer to the related description of steps 101-109.
  • 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.
  • 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.
  • the final claim reserve is obtained by adjusting the forecasting claims, making the assessment of the claims reserve more accurate.
  • the audit amount may be directly determined as the claim reserve of the case to be evaluated.
  • 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 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:
  • 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
  • Cnt_new_reck Cnt_old-cnt_old_end+cnt_new-cnt_new_end
  • 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.
  • Fig. 5 is a block diagram showing the first embodiment of an evaluation apparatus for claim settlement in the present application.
  • 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.
  • 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
  • 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.
  • 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
  • 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.
  • 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.
  • evaluation device of the claim reserve may further include:
  • 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.
  • 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.
  • 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.

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Abstract

La présente invention concerne un procédé et un appareil d'estimation pour une réserve de règlement de revendication, un support d'informations lisible par ordinateur et un dispositif terminal, permettant de résoudre les problèmes selon lesquels le résultat d'estimation de la réserve de règlement de revendication est facilement affecté par la norme professionnelle, et l'expérience de travail du personnel d'estimation et l'efficacité d'estimation sont faibles. Le procédé d'estimation consiste : à acquérir un cas à estimer; à acquérir des informations d'accident concernant le cas à estimer; à déterminer, en fonction des informations d'accident, un produit d'assurance de règlement de revendication d'une police d'assurance correspondant au cas à estimer; à déterminer si le produit d'assurance de règlement de revendication est un produit d'assurance de soins de santé; si le produit d'assurance de règlement de revendication est un produit d'assurance de soins de santé, à calculer alors la réserve de règlement de revendication du cas à estimer en fonction de la quantité d'indemnité moyenne et du nombre de produits d'assurance pour la police d'assurance; et si le produit d'assurance de règlement de revendication n'est pas un produit d'assurance de soins de santé, à calculer alors la couverture de la police d'assurance en vertu du produit d'assurance de règlement de revendication, et à calculer la réserve de règlement de revendication du cas à estimer en fonction de la couverture calculée et d'un rapport d'indemnité prédéfini du produit d'assurance de règlement de revendication.
PCT/CN2018/076663 2017-02-16 2018-02-13 Procédé et appareil d'estimation pour réserve de règlement de revendication, support d'informations et dispositif terminal WO2018149397A1 (fr)

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CN201710083376.7A CN107784590A (zh) 2017-02-16 2017-02-16 一种理赔准备金的评估方法和装置
CN201710083376.7 2017-02-16

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