【作者】 李丽；

【导师】 陈滔；

【作者基本信息】 西南财经大学 ， 工商管理（MBA）（专业学位）， 2021， 硕士

【摘要】 随着我国保险行业的高速发展以及公众健康意识的不断增强,商业健康保险得到了快速的发展,各家保险公司在商业健康保险领域的竞争也越来越激烈。在保险市场产品严重同质化的情况下,传统健康保险的比产品、比费用时代已经结束,竞争的焦点已悄然转变为创新的科技应用、管理能力和服务能力。近年来,以数据为核心的互联网、大数据、人工智能、人脸识别、云计算、区块链等信息技术逐渐应用到各个行业和领域,保险行业在产品定价、精准营销、智能客服等方面与前沿科技的融合愈发深入和成熟,而作为保险公司传统两大核心业务之一的理赔,却没有与科技更好地融合创新,健康保险理赔业务仍存在业务流程繁琐、理赔时效低等服务效率和服务品质问题,以及医疗费用控制能力差、风险管理水平低等管理问题。因此,探讨商业健康险理赔管理与新型科技的融合创新,有助于改善健康险理赔现状,促进健康险理赔的长远健康发展。理赔管理能力对保险公司的长远发展具有重大的影响,本文以G寿险公司为例,通过梳理G寿险公司理赔管理的现状,找出现阶段健康险理赔管理存在的问题,分析问题存在的原因,利用流程再造理论、ASME方法、ESEIA方法和保险经营理论等,对理赔核心业务系统进行再造,结合大数据、人工智能、人脸识别、可穿戴设备、云计算、区块链等数字科学技术,构建涵盖理赔直付、健康管理和反欺诈为一体的理赔管理系统,提出对内构建理赔管理系统的具体方案,对外积极加强与其它保险公司、外部机构的合作,积极寻求政策法规支持,共同建立医疗数据共享平台和信息共享机制,以解决业务流程繁琐、效率低、时效长、风险控制水平低、服务单一等问题,提高G寿险公司费用控制能力、风险控制水平和客户服务能力,降低理赔成本,满足客户多元化差异化的需求,推动商业健康险的变革转型,实现保险公司和客户双赢的局面。但同时也要注意数字科技应用面临的一些挑战,高度重视科技应用中出现的新风险,保护个人信息安全,积极培养新型理赔管理复合人才,助力商业健康险的转型升级。目前,G寿险公司正处于战略转型的关键时期,公司内部正在积极研究提升健康险理赔服务质量的方法、途径,同时也采取了一系列措施来简化健康险理赔业务流程,提高健康险理赔的质量和效率,拓展健康险理赔服务范围。因此研究健康险理赔管理系统的重构具有现实意义,也可为其他寿险公司的理赔管理提供可借鉴性和实务性的指导。更多还原

【Abstract】 With the rapid development of China’s insurance industry and the continuous enhancement of public health awareness,commercial health insurance has developed rapidly,and the competition among insurance companies in the field of commercial health insurance has become more and more fierce.In the case of serious homogeneity of products in the insurance market,the era of traditional products and expenses has come to an end,and the focus of competition has quietly turned into innovative technologies,management capabilities and service ability.In recent years,internet,big data,artificial intelligence,face recognition,cloud computing,blockchain,and other information technologies have been gradually applied to various industries and fields,and the insurance industry is determined in its products price,precision marketing,intelligent customer service and other aspects of the integration of cutting-edge technology more in-depth and mature.But as one of the two traditional core businesses of insurance companies,claims settlement has not been better integrated with science and technology innovation.There are still problems,such as complicated business process,low service efficiency and service quality,poor medical cost control ability and low risk management level.So,talking about quotient industry health insurance claims management and new technology integration innovation,help to improve the health insurance claims status quo,promote health insurance claims into the long-term health development.Claims management ability for the long-term development of the insurance company has a significant impact,taking life insurance company G as an example,through carding life insurance G claims management present situation,find out the problems existing in the current health insurance claims management,analysis the reasons of the existence of problems,and using the theory of process re-engineering,ASME method,ESEIA method and the theory of insurance business,to claim the core business system,combined with large data,artificial intelligence,face recognition,wearable devices,cloud computing,chain blocks,such as digital science and technology,build claim straight pay,health management and fraud as one of the claims management system.This paper put forward the concrete scheme of internal construction claims management system and calls forstrengthening cooperation with other insurance companies and external agencies,actively seeking support from policies and regulations,and jointly establishing a medical data which can share platform and information so as to solve business process trivial,low efficiency,time consumption,low level of risk control,service single and other problems,improve the cost control ability,risk control level and customer service ability of life insurance company G,reduce the cost of claim settlement,meet the diversified needs of the customers,promote the reform and transformation of commercial health insurance to achieve a win-win situation for insurance company and customers.It also points out that we should pay attention to the challenges faced by the application of digital technology,attach great importance to new risks in the application of science and technology,protect personal information security,actively cultivate new claims management complex talents,and help the transformation and upgrading of commercial health insurance.Currently,life insurance company G is in a critical period of strategic transformation,inside the company are actively research methods and ways to improve the quality of health insurance claims service.At the same time,the company has taken a series of measures to simplify the claims business process,improve the quality and efficiency of health claims.Therefore,it is of practical significance to study the restructuring of health insurance claims management system,and it can also provide reference and practical guidance for other life insurance companies’ claims management.更多还原