Integrated group insurance information processing and reporting system based upon an enterprise-wide data structure

We claim:

1. An enterprise-wide integrated computer system for storing, processing and reporting information regarding a plurality of group insurance accounts comprising:

a central processing unit;

a memory;

means for storing data concerning each group insurance account in a single relational data base, the relational data base having a structure comprising a plurality of tables in third normal form, each table concerning a specific data subject and wherein the tables are grouped into a plurality of subject categories, each category corresponding to an operating objective of the enterprise on which data is collected;

means for managing the relational data base;

a plurality of applications workstation sub-systems including sales, underwriting administration and actuarial sub-systems;

the sales sub-system comprising means for processing sales data including means for communicating with the central processing unit, memory and data storage means and means for accessing defined subject categories on the single relational database and for capturing, modifying and processing data contained in tables of a defined subject category which are necessary for the sales sub-system functions;

the underwriting sub-system comprising means for processing underwriting data including means for communicating with the central processing unit, memory and data storage means and means for accessing defined subject categories on the single relational database and for capturing, modifying and processing data contained in tables of a defined subject category which are necessary for the underwriting sub-system functions;

the administration sub-system comprising means for processing administration data including means for communicating with the central processing unit, memory and data storage means and means for accessing defined subject categories on the single relational database and for capturing, modifying and processing data contained in tables of a defined subject category which are necessary for the administration sub-system functions;

the actuarial sub-system comprising means for processing actuarial data including means for communicating with the central processing unit, memory and data storage means and means for accessing defined subject categories on the single relational database and for capturing, modifying and processing data contained in tables of a defined subject category which are necessary for the actuarial sub-system functions;

means for controlling the access of an operator to each of the workstation sub-systems;

a plurality of workstations each workstation comprising means for inputting data, means for displaying data, and means for selecting, accessing and interacting with the memory means and each of the applications workstation sub-systems; and

a printing means.

2. The enterprise-wide integrated system of claim 1 wherein the tables of at least one subject category are clustered and stored in a separate physical location on the means for storing data.

3. An enterprise-wide integrated computer system for storing, processing and reporting information regarding a plurality of group insurance accounts comprising:

a central processing unit;

a memory;

means for storing data concerning each group insurance account, including data on policyholders, coverage rate, participant restrictions, premiums, commissions, clients, claims, products, producers, competitors cases, payments, bills, provisions, obligation conditions, exposure fees, income, schedules, and reinsurance in a single relational data base;

means for managing the relational data base including means for creating tables to contain the data stored on the data base and means for modifying, storing, retrieving and manipulating the data;

the relational data base having a structure comprising a plurality of third normal form tables, grouped in a plurality of subject categories including a Case subject category, a Claims subject category, a Client subject category, a Competitor subject category, a Coverage subject category and a Producer subject category;

a plurality of applications workstation sub-systems including sales, underwriting, administration and actuarial sub-systems;

the sales sub-system comprising means for processing sales data comprising means for tracking the history of each account, means for generating reports on the case history of each account, means for producing policyholder, coverage, rate and participant data, means for generating sales proposals outlining the coverage, rates and restrictions for an account, means for communicating with the central processing unit and memory, and means for modifying and accessing sales data in the single relational data base;

the underwriting sub-system comprising means for processing underwriting data comprising case tracking means for tracking and logging tasks associated with each account after, sale, notification means for generating reports for notifying personnel of tasks to be performed, rate means for calculating rates and generating manual sales based on case and census information, means for generating field bulletins comprising information specified from the underwriting data processing means, means for communicating with the central processing unit and memory, and means for modifying and accessing underwriting data stored in the single relational data base;

the administration sub-system comprising means for processing administration data comprising case management means for maintaining and updating information on each account once the account has issued, means for creating, storing and maintaining records on individual account participants concerning coverage, benefit levels and status, means for generating certificates of insurance and participant identification cards, means for producing printed standard contracts outlining policy provisions, conditions and obligations and other provisions, means for producing printed individual participant certificates outlining selected coverage and conditions, means for generating bills at specified intervals for each account or account participant, means for recording and validating payment of bills, means for reconciling payments received for premiums, fees or income with client data, means for processing premium payments to each account and coverage type, commission processing means for calculating commissions due on each account, taxes, minimum payments and issuing advances on earned commissions, means for storing and providing premium and claim information for accounting and tax purposes, means for communicating with the central processing unit and memory, and means for accessing and modifying the administration data stored on the single relational data base;

the actuarial sub-system comprising means for processing actuarial data comprising means for accessing premium, claim and exposure information at a plurality of levels, means for maintaining and reporting the requirements of any reinsurance agreements for an account, and financial reporting means for storing and providing premium and claim information, means for communicating with the central processing unit and memory, and means for accessing and modifying actuarial data stored on the memory means single relational data base;

security means for controlling the access by an operator of the system to each of the workstation sub-systems;

a plurality of workstations each workstation comprising means for inputting data, means for displaying data, and means for selecting, accessing and interacting with each of the stored program controlled data processing means; and

a printing means.

4. A computerized enterprise-wide integrated group insurance information processing and reporting system, comprising in combination, data entry means, data display means, a central processing unit, a memory, data storage means for storing data in a relational data base, a plurality of applications programs, and a relational data base management systems program, the data base being a single relational data base having a data structure comprising a plurality of third normal form relational tables:

the tables being organized into a plurality of subject categories, each subject category corresponding to an operating objective of the enterprise, the subject categories comprising;

a) a Case subject category comprising tables that contain data on the case description, activity history, coverage available, policy level, participants, coverage in-force, billing, producers and commissions;

b) a Claim subject category comprising tables that contain data concerning the requests from a participant for reimbursement for an incurred procedure or loss;

c) a Client subject category comprising tables that contain data describing the client, client locations, and the insured person;

d) a Competitor subject category comprising tables that contain data on competitor coverage rates;

e) a Coverage subject category comprising tables that contain data concerning rules and options of the insurance products marketed by the enterprise, coverage, services, and funding methods; and

f) a Producer subject category comprising tables containing data on the persons or firms who sell or administer products or services on behalf of the enterprise and commission schedules:

each subject category being acceptable to at least one of the applications programs.

5. The system of claim 4, wherein one or more of the subject categories are stored as a clusters in separate physical locations in the means for storing data.

6. A method of constructing an enterprise wide integrated computer system for storing, processing and reporting information regarding a plurality of group insurance accounts comprising,

providing a computer system which in combination includes, a central processing unit, a memory, means for storing data, a plurality of workstations and printing means,

providing a relational database management system means for managing a relational database and for creating tables to contain data stored on a single relational database and means for modifying, storing and retrieving and manipulating the database,

providing a single relational database having a data structure comprising a plurality of third normal form relational tables,

the tables being organized into a plurality of subject categories, each subject category corresponding to an operating objective of the enterprise, the subject categories comprising:

a) a Case subject category comprising tables that contain data on the case description, activity history, coverage available, policy level, participants, coverage in force, billing, producers and commissions;

b) a Claim category comprising tables that contain data concerning the request from a participant for reimbursement for an incurred procedure or loss;

c) a Client subject category comprising tables that contain data describing the client, client locations, and the insured person;

d) a competitor subject category comprising tables that contain data on competitor coverage rates;

e) a Coverage subject category comprising tables that contain data concerning rules and options of the insurance products marketed by the enterprise, coverage, services and funding methods; and

f) a Producer subject category comprising tables containing data on the persons or firms who sell or administer products or services on behalf of the enterprise and commission schedules; storing the single relational database on the means for storing data of the computer system;

providing a plurality of workstation application sub-systems including sales, underwriting, administration and actuarial sub-systems, each sub-system comprising a plurality of application program modules, each sub-system application program module comprising means for processing, modifying, storing and manipulating data on the single relational database;

providing security means for controlling the access by an operator of the system to each of the work station application sub-systems, the security means also comprising means for restricting the access of the operator of a specific sub-system application program module to tables on the single relational database which contain data related to the application program module.

7. The method of claim 6 wherein the tables of each of the Claim, Client, Competitor, Coverage, and Producer subject categories are clustered and stored in separate physical locations in the means for storing data.

Description Submit all comments and votes

BACKGROUND OF THE INVENTION

This invention relates to enterprise-wide data structures for relational data bases and their use in constructing enterprise-wide integrated information processing and reporting system. The invention also provides, in a specific embodiment an information storage, processing and reporting system which integrates the sales, underwriting, administration, claims and actuarial functions that support and service the sale and administration of group insurance products.

The traditional approach of developing data bases and processing systems has been to develop an individual single application data base and data processing system for each of the business functions. Such a traditional approach to data base design has been used to date in the group insurance industry.

For example, the sale and support of group insurance products such as group health care insurance, and the administration of the group insurance program involve a large amount of information processing and reporting. The major types of group insurance products are Life; Accidental Death and Dismemberment; Long Term Disability,; Medical; Dental; and Weekly Disability. The volume of data that must be stored and processed includes the specific parameters of each group insurance plan for each policy holder (e.g., employer) in addition to data on different member groups of that policy holder, and individual group members covered by the plan and their eligible benefits. The scope of coverage for each of the individuals covered under a given plan may also vary. Due to the complexity of the products and the large amount of data, the administration of such group insurance programs presently entails the use of many complex data processing and management processes and systems.

In general, the data bases and processing systems currently in use to administer such group insurance plans are actually aggregations of unconnected individual systems each of which has a limited function. The amount of data shared or exchanged among the components of existing systems is minimal. These current systems are usually old and were designed and installed to support and service an earlier generation of insurance products that did not require processing of the amount of information associated with the insurance products offered today. The organization of these existing systems makes it very difficult and expensive to modify and integrate them.

For example, the sales of group insurance policies would be processed on a sales data processing system and the claims from existing policies would be processed separately on a claims data processing system. Each of these different data processing systems would also be developed based on its own data structures which were often not compatible. Due to the different data structures the various systems must be individually interfaced with each other. This has proven to be expensive and inefficient. In addition, since these current systems were developed as discrete systems, they also have redundant support requirements and are fraught with inconsistencies and operational inefficiencies. For these reasons, the current systems are incapable of efficiently supporting, or being modified to support, the new product development, administration and regulatory reporting requirements of the insurance industry today.

Accordingly, it is an object of this invention to provide a fully integrated information storage, processing and reporting system which will function as a single respository for sales, underwriting, actuarial and management information, for an enterprise and as a single source for processing and reporting it. The invention achieves this objective by developing the system based on a single data structure model for a relational data base which is compatible with and accessible to all of the applications programs of the enterprise-wide system. The system will provide automated sales support, e.g., tracking and reporting proposals; integrated underwriting tools; improved administration systems (e.g., billing), issuance of certificates, etc.; elimination of redundant data capture; and integrated actuarial tools. The system will improve operations by providing work management tools such as integrated case tracking and status reporting, and by providing on-line reference material, such as underwriting guidelines and legislative bulletins.

SUMMARY OF THE INVENTION

The invention provides a method of constructing, and a system comprising, an integrated information processing and reporting system for a specific enterprise, which system contains a single relational data base established at the onset, and encompassing all of the data requirements of the enterprise.

The key to the integrated system is its single enterprise-wide relational data base. Various application program modules also stored in the integrated system can accept and process data contained in one or more of the separate tables of the single relational data base. This unique data structure composed of relational tables, established at the outset in a single relational data base allows the system to operate more efficiently while at the same time allowing for the implementation of security measures which restrict the access of certain system users to particular data.

The data structure is developed by rigorously analyzing the business and data requirements of the entire enterprise. During the first stage of the development, the entities about which data is to be gathered are identified and a data item that distinguishes a unique occurrence of each entity is selected to serve as a primary key.

The relationships between entities are also identified, and documented in the table format and entered into entity-to-entity relationship tables in the computer storage means memory. The tables of the data base are in the format of rows and columns. Since the data base is relational, each of its tables will have a column that is the same as a column of at least one other table.

The attributes that describe each entity are determined and normalized. After normalization, the attributes are documented in the entity relationship tables and data concerning each attribute is entered into the relational data base in the storage means.

A data dictionary which defines the entities and attributes and includes an index of the tables is then compiled and entered into the storage means to complete the relational data base. After the tables have been constructed a first level graphic model depicting all of the entities and their relationships is produced.

The operational relationship between each of the entities is then determined for each entity-to-entity relationship and categorized so as to a form first level entity-relationship model.

The entities and relationships are then analyzed so as to produce a second level model. This entails grouping the entities into subject categories which correspond to the business objectives and use of the business data in the enterprise's business. The grouped entity-relationship tables or subject categories may then stored as clusters of tables in separate physical locations in the storage means.

Access to specific data or tables may then be limited to users of specific application programs. This allows the system to operate more efficiently since, by limiting the access of each application program only to the appropriate data cluster, the entire relational data base does not have to be searched while running that program. The limited access also offers advantages in security by limiting the access of certain users to the data base or portions thereof.

In a specific embodiment of the invention an enterprise-wide data structure and relational data base for an integrated group insurance information storage, processing and reporting system was constructed. The overall system comprises in combination, storage means for storing group insurance account data in the enterprise-wide data structure format, memory means, and a central processing unit. The system also contains a plurality of stored program-controlled application workstation sub-systems. By using the data structure of the invention the access of certain workstation subsystems to the data base can be restricted to certain subject category. Each application workstation sub-system concerns one of the following general functions: sales, underwriting, administration or actuarial. Each of the workstation sub-systems comprises a combination of specific stored program modules which are capable of inputting and processing data onto the single relational data base. The memory, data storage workstation sub-systems and the stored program modules are accessible from an integrated computer workstation.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 shows the subject categories data structure of an automated integrated group insurance information storage, processing and reporting system.

FIG. 2 shows a portion of the entity-relationship model of the Case subject category of the data structure of a group insurance information storage, processing and reporting system.

FIG. 3 shows a portion of the entity-relationship model of the Case subject category of the data structure of a group insurance information storage, processing and reporting system.

FIG. 4 shows a portion of the entity-relationship model of the Case subject category of the data structure of a group insurance information storage, processing and reporting system.

FIG. 5 shows the entity-relationship model of the Claims subject category of the data structure of a group insurance information storage, processing and reporting system.

FIG. 6 shows the entity-relationship model of the Client subject category of the data structure of a group insurance information storage, processing and reporting system.

FIG. 7 shows the entity-relationship model of the Competitor subject category of the data structure of a group insurance information storage, processing and reporting system.

FIG. 8 shows the entity-relationship model of the Coverage subject category of the data structure of a group insurance information storage, processing and reporting system.

FIG. 9 shows the entity-relationship model of the Producer subject category of the data structure of a group insurance information storage, processing and reporting system.

FIG. 10 shows a sample of the table format into which the data is entered into the system relational data base.

FIG. 11 shows the basic functional applications programs of the automated integrated group insurance information storage processing and reporting system.

FIG. 12 shows an embodiment of the functional access architecture of an integrated group insurance information storage, processing and reporting system.

FIG. 13 shows the workstation architecture of an integrated workstation used in one embodiment of the invention.

DETAILED DESCRIPTION OF THE INVENTION

The integrated group insurance information reporting and processing system disclosed herein comprises a single enterprise-wide relational data base developed on a rigorously defined data structure model which is a representation of the data of the group insurance business as depicted by subjects, business entities and their relationships. The Group Administration Data Model documents the data which is required to support the various group insurance functions.

This single relational data base is composed of third normal form data tables as defined in, E. F. Codd, "Extending the Database Relational Model to Capture More Meaning" ACM Transactions on Database Systems, Vol. 4 Nov. 4, December 1979 pp. 397-434. The model was developed using an extended relational analysis approach to constructing relational data bases, such as the approach developed by Relational Systems Corporation Birmington, Mich. 48010 entitled ERA, Extended Relational Analysis, Version S.I. This approach uses a rigorous methodology to identify the business objects about which data is captured, ("entities"), and their business relationship. The aim of the approach is to construct third normal form relational data base model as as also described in E. F. Codd, "Further Normalization of the Data Base Relational Model", Data Base Systems, Randall Rustin, ed. 1972, pp 65-98. Prentice-Hall, Inc., Englewood Cliffs, N.J.

The basic premise of the methodology is to capture the business meaning of the data in a structure which will inherently support all usage in the present and contemplated in the future. As aspects of Group Administration business change, additions or changes may be introduced into the model so that it reflects an up-to-date depiction of the business data requirements. The data model comprises the organization of data based on the concepts of subjects, entities and their relationships.

A subject is an operating objective of the business enterprise on which data is collected and processed during the course of business. Each enterprise will have different subject categories. These subjects can only be determined by rigorously analyzing the business of the enterprise and determining which data categories are essential to the operation of that business. The subjects of the group insurance business which are the operating objectives of a specific embodiment of this invention are depicted in FIG. 1 and are more fully described below.

An entity as used in this data structure model is an object, e.g. a person, place or thing about which data is captured during the course of business.

A relationship is an association between entities which reflects a business rule or the behavior patterns of business entities.

In developing the data model each data element must be accurately identified and distinguished from all others. One set of commonly used data terminologies must also be used. This ensures that a consistent format and values are used to represent occurrences of data throughout the system.

To develop the data model the entity relationships of the subject objectives are determined and described by entity-relationship clauses.

An entity-relationship clause should have the following general format: Each Entity-A "may be" or "must be" in some relationship with, "one or more" or "one and only one" Entity-B(s). "Each"--means a single occurrence of Entity-A (one record/row in the sample of Table-A) (see FIG. 10). "May be"--means Entity-A may exist with or without a relationship to Entity-B. "Must be"--means in order for an occurrence of Entity-A to be valid, a relationship between Entity-A and Entity-B must exist.

The following are examples and descriptions of some entity relationship clauses:

(a) Each Client may be the owner of one or more Policies. Each Policy must be owned by one and only one Client.

The first sentence recognizes that one may not actually sell a policy to a client but that one wishes to still capture client information. The second sentence notes that the identification of a policy owner is required but there cannot be more than one owner.

(b) Each Participant may be responsible for one or more Dependents. Each Dependent must be insured under one and only one Participant.

The first sentence recognizes that a participant may never have any dependents. The second sentence states a business rule that a dependent must be tied to a participant. This also implies that if an individual is coincidently insured under two participants we must recognize this individual twice as two separate dependents.

(c) Each Policy/Bill must be associated by one and only one Policy to one and only one Bill. Each Policy may be associated to one or more Policy/Bills. Each Bill must be associated to one or more Policy/Bills.

The first sentence is a compound relationship clause to reflect a many-to-many association between Policy and Bill entities. A single occurrence of the association entity Policy/Bill maps the relationship of one Bill to one Policy. (Reading multiple rows of the Policy/Bill table will indicate all the bills for a specific Policy or all the policies for a specific bill). The second sentence recognizes that a policy may exist without a bill. The third sentence reflects that if a bill exists it must be mapped to at least one, but maybe more policies.

Once all of the entities of the enterprise are identified, each entity must be analyzed to determine whether it is within the scope of the system being developed. A table of the format depicted in FIG 10 is then constructed for each verified entity. The data is then entered into the system using the table generated by a relational data base management system program ("RDBMS"). In a specific embodiment of the invention the Table format and the Tables of the relational data base are generated by using the ORACLE Relational Data Base Management System. To implement this system a software package such as the Relational Data Base Management System ("RDBMS") produced by Oracle Corporation of Belmont, Calif. is used. Any other RDBMS may also be used in the invention. Example of such RDBMS programs are CYBASE.TM. of Cybase Corp., INGRES.TM. of Ingres Corp. and DB2 of IBM Corp.

In developing the data base for the integrated group insurance system of the invention, the following entities where identified and verified to be within the scope of the system. A table of the format depicted in FIG. 10 was provided for each of these entities.

Case Subject--Entities

APPLICANT: The participant (employee/member) or dependent who is requesting coverage under a specific case as a late entrant. This entity identifies are associated with a late entry application for group coverage. There may be several dependents in addition to one participant on a single application, and over time, any of the dependents or the participant may have submitted more than one application.

APPLICANT ACTIVITY: A historical record of every Group Medical Underwriting activity performed per applicant. This entity tracks by application ID insured person ID, activity code, and activity date the activities done to medically underwrite an individual. There may be numerous activities per applicant the information recorded per activity includes handled date, follow-up date, response received date, activity cost, and remarks.

APPLICATION: A late (non-enrollment period) request for coverage(s) from an eligible individual for personal insurance or dependent insurance. Information in this entity includes reference to the policy the application is written under and dated indicating when and by whom the application was processed. The actual coverages requested per applicant will be contained in the Selected Coverage entity.

BILL: A request for payment of contractual amounts due for services and/or insurance. This entity identifies the billee (the client and/or covered person) and includes a system assigned bill number. The detail bill amounts and coverages billed are not in this entity (see BILL DETAIL entity).

BILL DETAIL: Specific payments due per coverage category or coverage within a single bill. For each bill, several costs of different coverages may be due; this entity identifies all items payable and associates them with a single bill.

CASE: The association of all components of a plan of insurance for a client. This is the "cornerstone" entity of the Case Subject, providing the system assigned case ID number and identifying the associated client and sales office. Also included are various activity processing dates and information used to characterize the case. Each case is unique to a single client, but over time a client may have more than one case.

CASE COMMENTS: Narrative text recording remarks from processors assigned to the case. This entity stores multiple lines of text as needed per case.

CASE/COVERAGE: The coverages included on a specific case. This entity identifies which coverages are provided per the terms of a case and further identifies the policy each coverage is written under.

CASE/COVERAGE/FUNDING CONDITION: Identification of the conditions per funding method that the client has agreed to per coverage on the case. According to the Funding Conditions entity, for certain Funding Methods on a case the client must agree to certain conditions required by the Group Insurer. This entity specifies which of those conditions (per Funding Method per Coverage) are included on the case.

CASE/COVERAGE/FUNDING CONDITION OPTION: The specific amounts agreed to by the client for each condition specified per applicable Funding Method. Having determined the conditions to be in-force per each Funding Method on the case, the client must agree to one of the optional values of the conditions as offered by the Group Insurer in the Condition Option entity. This entity contains those chosen condition values for the case. Example: Attachment Point for Medical ASL=$500,000 (as opposed to an alternate choice of $1,000,000).

CASE/FUNDING/SERVICE: The specification of services to be provided on the case per each Funding Method that pertains to the case. This entity identifies which Services the client desires on the case in terms of each Funding Method utilized on the case.

CASE/PRODUCER: Identification of all producers responsible for a case (present and past) and all cases per each producer. This entity accounts for the fact that a producer may be associated with many cases and a case may be the responsibility of several producers, whether concurrently or over time. The entity identifies by key each case and producer and also provides an effective date for the association.

CASE/PRODUCER/COVERAGE: Information associating each producer involved in a case with each coverage provided by the case. The entity identifies per coverage which producers share in each coverage in terms of compensation and service responsibility. This entity specifically references which commission schedule applies per producer and coverage. This entity specifically references which commission schedule applies per producer and coverage.

CASE RATING HISTORY A historical record of each occasion that a case was rated or rerated during the proposal process. Included in this entity per case and rating date are the current rating system key, important processing dates, and identification of the home office underwriter who processed the case.

CASE REPRESENTATIVE: Identification of all sales and service representatives associated with each case. This entity records the fact that sales office representatives (sales and service) may work on many cases and each case may be the responsibility of more than one representative.

CASE STATUS HISTORY: A historical record of all status changes for a case as it is processed during the Pre-Sale function. This entity tracks each status code and date of status per case and records the sales office processor who entered the information.

CLASS COVERAGE SCHEDULE: The definition of each category of employees/members per coverage for the purpose of providing and differentiating benefits within a specific case. For each coverage on a case the policyholder established one or more classes of participants according to such criteria as salary, position, years of experience, grade level, etc. This entity records these definitions and thereby identifies which coverages an enrollee/applicant may select according to the characteristics of each enrollee/applicant. A class code is relevant only in terms of a specific coverage; in other words, class "1" Medical and class "1" Life may not be the same category definition.

CLASS/COVERAGE/FUNDING METHOD: The identification of the Funding Method per each class, coverage, policy, and client location. This entity established which funding methods per coverage on the case are located on which policies and is the level at which coverage rates can be determined and established.

CLASS PROVISION OPTION SCHEDULE: The allowable values per class provision from which the participant may select his or her own benefit levels per each offered coverage. This entity contains the value(s) per provision that the policyholder has chosen to make available to the participants according to coverage and class; each provision may have a single, required value (a mandatory default for all participants and dependents) or may allow for multiple options from which the applicant may choose his or her desired benefit. Example; the deductible on Comprehensive Dental is a flat $50 for all employees provided that coverage, but for AD&D coverage, the participant may select 1.times.Salary, 3.times.Salary, or 5.times.Salary as a benefit amount.

CLASS PROVISION SCHEDULE: Identification of the eligibility requirements and benefits associated with class and related coverage. This entity identifies which provisions are allowed per coverage and class for a specific case; these provisions may be mandatory (required default) or optional (applicant may select his or her desired provisions) according to the Group Insurer's rules and the negotiated rules governing the case.

PARTICIPANT/POLICY: Identification of all participants per policy under which they are covered. The entity simply associates all participant keys with all related policy keys.

POLICY: Information identifying and describing the legal contract between a client and the Enterprise that specifies which coverages and services are provided for what price(s). The Policy entity contains the system assigned policy ID, Enterprise assigned policy number, data regarding Funding Method (only one per policy), policy dates, and elements used to characterize the policy and associate it with other entities. A case may include several policies, but a policy applies to only one case.

POLICY BILL: Identification of the specific policy for which a bill has been generated for the collection of monies due. This entity reflects the fact that more than one bill may be required to collect money under a single policy (i.e., multiple coverages grouped under one policy but bill separately), and a bill may also represent money due on more than one policy.

SELECTED COVERAGE: Specific coverage chosen by an enrollee/applicant (employee/member or dependent) according to the terms of the Class Coverage Schedule offered by a case. This entity records per insured (participant or dependent) each coverage selected by that person. Specific benefits and benefit values selected by the enrollee/applicant are dependent upon this entity but are not components of this entity (see Selected Provision and Selected Provision Option entities).

SELECTED PROVISION: The specific benefits chosen by an enrollee/applicant per each coverage selected. Having specified the coverages desired, a new enrollee or applicant next selects from the Class Provision Schedule the types of benefits desired within each coverage (where a choice is available, otherwise the same benefit applies to each insured person for the same coverage and class). This entity records each provision chosen by the enrollee/applicant per each coverage.

SELECTED PROVISION OPTION: The specific values chosen by the insured from the options offered on a case for each provision per each coverage. This entity contains the specific values for an insured person for each benefit on a coverage according to the insured person's selection from the Class Provision Option Schedule. Example; the enrollee/applicant selects 3.times.Salary for an AD&D benefit and chooses $250 for a Medical deductible.

Case Subject--Minor Tables

APPLICATION ACTIVITY CODE: Provides codes and descriptions for each Group Medical Underwriting activity.

APPLICATION LETTER CODE: Provides codes and descriptions for each letter used in Group Medical Underwriting and contains all variable data requirements per letter.

CASE CORRESPONDENT CONTACT: This refers to the person or department designated as the primary recipient for all business correspondence regarding one or more cases. The contact may be a person or department within the policyholder's or producer's organization.

CASE INFORMATION REQUEST REASON CODES: Provides codes and descriptions for the reasons extra information may be requested by an underwriter while processing a case.

CASE FUND REASON CODES: Provides codes and descriptions for each reason that a coverage may be duplicated on a case but funded by a different funding method.

CASE STATUS CODES: Provides codes and descriptions of each type of status that a case may be in during pre-sale and immediate post-sale processing.

CASE TERMINATED REASON CODES: Provides codes and descriptions of each reason that a case may be terminated (declined by the Enterprise not taken by the client, or cancelled after the case had been sold).

Claim Subject--Entities

CLAIM: A request from a participant for reimbursement for an incurred procedure or loss. This entity captures information about a unique claim that identifies the claimant, policy and key claim dates.

CLAIM BENEFIT: A set of payable insurance amounts per claim filed due to the claimant and identified by benefit codes. For each claim, one or more benefits may be requested by the claimant; this entity specifies those liabilities.

Claim Subject--Entities--Minor Tables

BENEFIT CODES: Provides codes and description for each type of benefit (an amount payable per contractual obligations specified in an insurance policy). Examples include:

______________________________________ 008 Major Medical Reimbursement 022 Medicare Supplement 042 Basic Term life Rated Payment ______________________________________

Client Subject

CLIENT: The external organization (company, association, or trust) to whom the Enterprise may (or may not) sell insurance and/or insurance services. This entity identifies and describes (name, address, industry type) existing and potential policyholders. Usual clients are Employers, Unions, Associations, and Trustees, where a Trustee is defined as several client companies associated together for the purpose of obtaining group insurance. The entity is the focal point of the Client subject and is identified by a system assigned key.

CLIENT LOCATION: A specific client physical/geographic place where participants are located. Examples of Client Location include Divisions, Plant, and Subsidiary; each location is dependent on a specific client. The entity contains location name and address information.

INSURED: A person (employee/member or dependent) with one or more in-force coverages provided under a Group Insurance plan. This entity provides descriptive information about individuals who have selected coverages made available to them as participants (or dependents of participants) in a Group Insurance plan. The information includes name, address, social security number, client (policyholder) identification, and any personal data required for underwriting purpose (age, sex, etc).

INSURED ROLE: The identification of an insured person's role on a specific case. This entity associates a role type with an Insured ID to record whether an insured plays the role of a participant, spouse, or child of the participant within a case. This entity allows for the fact that the same person may be insured on a single case both as a participant and as a dependent.

INSURED TYPE ROLE: The description of each role an individual may play on any case. This entity identifies and describes role types, such as participant, spouse, or child, that characterize an insured person on a case

INSURED DEPENDENT ASSOCIATION: The identification of all familial