• Title/Summary/Keyword: claim

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Typology of the medical claims review (의적클레임검토 유형론)

  • Lee, Sin-Hyung
    • The Journal of the Korean life insurance medical association
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    • v.26
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    • pp.41-53
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    • 2007
  • In the course of insurance claim administration, medical experts' opinions are called medical claim reviews. They are classified into two main categories: medical verification and counsel for claim staff. Medical verification compare between product coverage and the insured's physical condition. Medical counsel for claim staff is advice for claim staff when they have a question about medical knowledge to make a claim decision. A common example of medical verification is insurance coding of pituitary apoplexy. Some clinicians have insisted that the ICD coding of pituitary apoplexy is l63 of cerebral infarction, but the exclusion criteria of I code show that neoplasm is coded as C00 to D48. Thus, pituitary apoplexy must be coded as D33. An example of medical counsel for claim staff is interpretation of some medical conditions. It is divided into UCR(usual, customary, and reasonable) assessment, assessment of causality, and so on. Disability evaluation is another subject of medical counsel for claim staff. The final claim decision must be made by claim staff because only the claim staff have the authority of claim decision. Medical claims review is only an expert's opinion.

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CONSTRUCTION PROJECT CLAIM MANAGEMENT

  • M. ASLAM MIRZA
    • International conference on construction engineering and project management
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    • 2007.03a
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    • pp.160-168
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    • 2007
  • Conflicts of interest and independent agenda of the parties brought together for implementation of a construction project often leads to dispute in Contract and claim situations. Construction Industry is notorious for claim that is managed on its arising and there lacks an endeavor to minimize the breeding grounds through efficient planning and alignment to purpose, of all contract-documents. There failure of a concerted effort entails wastage of resources, delayed completion of facilities and stained relationships of parties when collide in mistrust in contract to win over the other. There needs a focus on the claim breeding issue and establish an effective mechanism to deal with disputes in urgency. Claim occurs mostly during the construction phase. But the seeds of claim and nutrients essential for development are contained in the contract documentation and the information supplied or not in pre-contract phase. Opportunity to prevent nutrients for seed of Claim comes to an end once tender-documents are finalized, the contract is awarded and established or not a mechanism for dealing with claim situation. The processes presented here would help in minimizing the breeding grounds and emergence of disputes during progression of works and dealing with eventualities in forceful manners for finding a resolution most effectively in relevant time.

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Claim Management Process of General Contractors in South Korea

  • Seo, Wonkyoung;Kang, Youngcheol
    • International conference on construction engineering and project management
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    • 2020.12a
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    • pp.207-215
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    • 2020
  • The purpose of this study is to investigate the current status of claim management process of general contractors in South Korea. As the claim management becomes more important nowadays, maintaining the process for claim management systematically and consistently becomes more important as well. To improve the claim management process, it is necessary to diagnose the current status of claim management process so companies establish their targets for improvement. This study develops a survey to identify the current status of claim management process that major general contractors in South Korea have. Questions in the survey are classified into four categories including entitlement check, potential claim event check, time bar check, and tasks for substantiation. By conducting a series of statistical analyses with 94 survey data collected from employees working in the general contractor companies in South Korea, this study examines and analyzes their claim management process in terms of the several categories. It is expected that the results contribute to diagnosing how practitioners maintain their claim management, which will help them establish the direction of management enhancement.

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Case Studies on Claim and Arbitration Clauses Using in Trade Contracts (무역계약에서 이용하는 클레임과 중재조항에 관한 사례연구)

  • 김상호
    • Journal of Arbitration Studies
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    • v.12 no.2
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    • pp.115-151
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    • 2003
  • As international trade and commerce increases among the nations in the world, it is inevitable fact that disputes rise as well. As these transactions grow more complex, it becomes increasingly important to resolve disputes and conflicts as quickly, efficiently and formatively as possible. In practical commercial affairs, we call a variety of international commercial troubles ‘trade claims’, Trade claims consist of disputes, controversies, or differences which may arise between the parties, out of, or in relation to, or in connection with their contracts, or for the breach thereof. Trade claim should be instituted promptly, otherwise it may be barred by prescription. Also, the other party will not accept the claim by reason of loss of evidence. In this connection, it should be noted that how long the claim prescription would continue. Trade claim should be settled reasonably and amicably between the parties concerned. And if both parties do not reach an agreement through their negotiation, then the claim shall be settled finally by binding arbitration. For the purpose of managing trade claim and arbitration, the trading parties insert in their contracts claim and arbitration clauses. This paper will examine some judicial precedents concerning claim clauses which are closely connected with a time limit of the claim It will also review some famous precedents rendered by the competent courts in connection with the wording, scope and implied renewal of arbitration clauses.

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Decision of Abnormal Quality Unit Lists from Claim Database

  • Lee, Sang-Hyun;Lee, Sang-Joon;Moon, Kyung-Li;Kim, Byung-Ki
    • Journal of Information Processing Systems
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    • v.4 no.3
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    • pp.113-120
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    • 2008
  • Most enterprises have controlled claim data related to marketing, production, trade and delivery. They can extract the engineering information needed to the reliability of unit from the claim data, and also detect critical and latent reliability problems. Existing method which could detect abnormal quality unit lists in early stage from claim database has three problems: the exclusion of fallacy probability in claim, the false occurrence of claim fallacy alarm caused by not reflecting inventory information and too many excessive considerations of claim change factors. In this paper, we propose a process and methods extracting abnormal quality unit lists to solve three problems of existing method. Proposed one includes data extraction process for reliability measurement, the calculation method of claim fallacy alarm probability, the method for reflecting inventory time in calculating claim reliability and the method for identification of abnormal quality unit lists. This paper also shows that proposed mechanism could be effectively used after analyzing improved effects taken from automotive company's claim data adaptation for two years.

Functional Movement Screen as a Predictor of Occupational Injury Among Denver Firefighters

  • Shore, Erin;Dally, Miranda;Brooks, Shawn;Ostendorf, Danielle;Newman, Madeline;Newman, Lee
    • Safety and Health at Work
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    • v.11 no.3
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    • pp.301-306
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    • 2020
  • Background: The Functional Movement Screen (FMSTM) is a screening tool used to assess an individual's ability to perform fundamental movements that are necessary to do physically active tasks. The purpose of this study was to assess the ability of FMS to predict occupational injury among Denver Fire Department firefighters. Method: FMS tests were administered from 2012 to 2016. Claim status was defined as any claim occurrence vs. no claim and an overexertion vs. no claim/other claim within 1 year of the FMS. To assess associations between FMS score and claim status, FMS scores were dichotomized into ≤ 14 and > 14. Age-adjusted odds ratios were calculated using logistic regression. Sensitivities and specificities of FMS predicting claims at various FMS score cut points, ranging from 10 to 20 were tested. Results: Of 581 firefighters (mean ± SD, age 38 ± 9.8 y) who completed FMS between February 2015 and March 2018, 188 (32.4%) filed a WC claim in the study time frame. Seventy-two of those (38.3%) were categorized as overexertion claims. There was no association between FMS score and claim status [odds ratio (OR) = 1.27, 95% confidence interval (CI): 0.88 - 1.83] and overexertion claim vs. no claim/other claim (OR = 1.33, 95% CI: 0.81 - 2.21). There was no optimal cutoff for FMS in predicting a WC claim. Conclusions: Although the FMS has been predictive of injuries in other populations, among this sample of firefighters, it was not predictive of a future WC claim.

Surplus Process Perturbed by Diffusion and Subject to Two Types of Claim

  • Choi, Seung Kyoung;Won, Hojeong;Lee, Eui Yong
    • Communications for Statistical Applications and Methods
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    • v.22 no.1
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    • pp.95-103
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    • 2015
  • We introduce a surplus process which follows a diffusion process with positive drift and is subject to two types of claim. We assume that type I claim occurs more frequently, however, its size is stochastically smaller than type II claim. We obtain the ruin probability that the level of the surplus becomes negative, and then, decompose the ruin probability into three parts, two ruin probabilities caused by each type of claim and the probability that the level of the surplus becomes negative naturally due to the diffusion process. Finally, we illustrate a numerical example, when the sizes of both types of claim are exponentially distributed, to compare the impacts of two types of claim on the ruin probability of the surplus along with that of the diffusion process.