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(12) INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT) 



(19) World Intellectual Property Organization 

International Bureau 

(43) International Publication Date 
13 December 2007 (13.12.2007) 




PCT 



(10) International Publication Number 

WO 2007/141696 A2 



(51) International Patent Classification: 
(21) International Application Number: 



Not Classified (74) Agents: SPOOR & FISHER et al.; P O Box 454, 0001 
Pretoria (ZA). 



(22) International Filing Date: 

(25) Filing Language: 

(26) Publication Language: 

(30) Priority Data: 

2006/04688 



PCT7IB2007/05 1946 (81) 
23 May 2007 (23.05.2007) 
English 
English 



6 June 2006 (06.06.2006) ZA 

(71) Applicant (for all designated States except US): DISCOV- 
ERY HOLDINGS LIMITED [ZA/ZA]; 155 West Street, 
Sandton (ZA). 

(72) Inventors; and 

(75) Inventors/Applicants (for US only): GORE, Adrian 

[ZA/ZA]; 10 7th Street, 2142 Houghton Estate (ZA). 
MAYERS, Herschel, Phillip [ZA/ZA]; 32 Wordsworth 
Avenue, Senderwood, Johannesburg (ZA). RABSON, 
Kenneth, Steven [ZA/ZA]; 5 College Mews, Regina 
Avenue Fairmount Extension, 2192 Johannesburg (ZA). 



Designated States (unless 
kind of national protection 
AT, AU, AZ, BA, BB, BG, 
CN, CO, CR, CU, CZ, DE, 
FI, GB, GD, GE, GH, GM 
IS, JP, KE, KG, KM, KN, 
LS, LT, LU, LY, MA, MD, 
MZ, NA, NG, NI, NO, NZ. 
RU, SC, SD, SE, SG, SK, 
TR, TT, TZ, UA, UG, US, 



otherwise indicated, for every 
available): AE, AG, AL, AM, 
BH, BR, BW, BY, BZ, CA, CH, 
DK, DM, DZ, EC, EE, EG, ES, 
GT, UN. HR, HU, ID, IL, IN, 
KP, KR, KZ, LA, LC, LK, LR, 
MG, MK, MN, MW, MX, MY, 
, OM, PG, PH, PL, PT, RO, RS, 
SL, SM, SV, SY, TJ, TM, TN, 
UZ, VC, VN, ZA, ZM, ZW. 



(84) Designated States (unless otherwise indicated, for every 
kind of regional protection available): ARIPO (BW, GH, 
GM, KE, LS, MW, MZ, NA, SD, SL, SZ, TZ, UG, ZM, 
ZW), Eurasian (AM, AZ, BY, KG, KZ, MD, RU, TJ, TM), 
European (AT, BE, BG, CH, CY, CZ, DE, DK, EE, ES, FI, 
FR, GB, GR, HU, IE, IS, IT, LT, LU, LV, MC, MT, NL, PL, 
PT, RO, SE, SI, SK, TR), OAPI (BF, BJ, CF, CG, CI, CM, 
GA, GN, GQ, GW, ML, MR, NE, SN, TD, TG). 

[ Continued on next page ] 



(54) Title: A SYSTEM AND METHOD OF MANAGING AN INSURANCE SCHEME 



defining a plurality of diseases which 
are covered by the insurance scheme 
so that if an insured life contracts one 
of these diseases they will be paid an 
amount of funds from the insurer 



receiving a request from an insured 
life who has contracted one of the 
defined diseases 



(57) Abstract: A method of managing an insurance scheme includes defining a plu- 
rality of diseases which are covered by the insurance scheme so that if an insured life 
contracts one of these diseases they will be paid an amount of funds from the insurer or 
the insurer will pay or partially pay for treatment of the disease. A request is received 
from an insured life who has contracted one of the defined diseases. The insured life is 
provided with a choice of receiving treatment in the country in which they reside or re- 
ceiving treatment in another country. A selected country is received from the insured life 
and an amount of funds is paid from the insurer to the insured life wherein the amount 
of funds is at least partially determined by the selected country. 



< 

OS 

o 



providing the insured life with a choice 
of receiving treatment in the country in 
which they reside or receiving 
treatment in another country 



receiving a selected country from the 
insured life 



paying an amount of funds from the 
insurer to the insured life wherein the 
amount of funds is at least partially 
determined by the selected country 



WO 2007/141696 A2 



Published: For two-letter codes and other abbreviations, refer to the "Guid- 

— without international search report and to be republished ance Notes on Codes and Abbreviations" appearing at the begin- 
upon receipt of that report ning of each regular issue of the PCT Gazette. 



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-1- 



A SYSTEM AND METHOD OF MANAGING AN INSURANCE SCHEME 



BACKGROUND OF THE INVENTION 

The present application relates to a system and method of managing an 
insurance scheme. 

The present invention may be implemented by a traditional life insurance 
plan operator for its members or may be implemented by another party. 

Conventionally, insurance policies such as life insurance policies operate 
on the basis that an insured person, sometimes referred to as an insured 
life, pays a premium to the life insurer, and the life insurer pays a 
predetermined sum, referred to as the sum assured, to the insured life or 
his/her beneficiary on the occurrence of an insured event. Typical insured 
events are the insured life suffering disability, contracting a dread disease 
or dying. 

Health insurance policies operate where the provider of the medical 
scheme undertakes liability in return for a premium or contribution and 
provides to members who pay such premiums or make such contributions, 
relevant health services and or assistance in defraying expenses incurred 
in connection with rendering such relevant health services. 

In either case, an insured life that contracts a disease or dread disease, for 
example, that needs to be treated will have their costs reimbursed but only 
from a facility in the country within which the insured life resides. 



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However, in some instances, the best treatment for the disease or dread 
disease may not be found in the country within which the insured life 
resides. This treatment will then be inaccessible to the insured life. 

A system and method of addressing this is therefore required. 
SUMMARY OF THE INVENTION 

According to one example embodiment, a method of managing an 
insurance scheme, the method including: 

defining a plurality of diseases which are covered by the insurance 
scheme so that if an insured life contracts one of these diseases 
they will be paid an amount of funds from the insurer or the insurer 
will pay or partially pay for treatment of the disease; 

receiving a request from an insured life who has contracted one of 
the defined diseases; 

providing the insured life with a choice of receiving treatment in the 
country in which they reside or receiving treatment in another 
country; 

receiving a selected country from the insured life; and 

paying an amount of funds from the insurer to the insured life 
wherein the amount of funds is at least partially determined by the 
selected country. 

The plurality of diseases is typically a plurality of severe illness diseases. 

According to another example embodiment there is provided an electronic 
system for managing an insurance scheme, the system including: 



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a rules module to define a plurality of diseases which are covered 
by the insurance scheme so that if an insured life contracts one of 
these diseases they will be paid an amount of funds from the 
insurer; 

a request module to receive a request from an insured life who has 
contracted one of the defined diseases; 

a treatment module to provide the insured life with a choice of 
receiving treatment in the country in which they reside or receiving 
treatment in another country and to receive a selected country from 
the insured life; and 

a payment module to pay an amount of funds from the insurer to the 
insured life wherein the amount of .funds is at least partially 
determined by the selected country. 

A machine-readable medium embodying instructions which, when executed 
by a machine, cause the machine to perform a method including: 

defining a plurality of diseases which are covered by the insurance 
scheme so that if an insured life contracts one of these diseases 
they will be paid an amount of funds from the insurer; 

receiving a request from an insured life who has contracted one of 
the defined diseases; 

providing the insured life with a choice of receiving treatment in the 
country in which they reside or receiving treatment in another 
country; 

receiving a selected country from the insured life; and 



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-4- 

paying an amount of funds from the insurer to the insured life 
wherein the amount of funds is at leas ( t partially determined by the 
selected country. 

BRIEF DESCRIPTION OF THE DRAWINGS 

Figure 1 is a flow chart illustrating the methodology of an example 
embodiment; and 

Figure 2 is a block diagram illustrating an example system to 
implement the methodologies described herein. 

DESCRIPTION OF EMBODIMENTS 

The systems and methodology described herein relate to a system and 
method of managing an insurance scheme such as a life insurance scheme 
or a health insurance scheme. 

Conventional life insurance schemes operate on the basis that an insured 
person, referred to as the insured life, pays premiums on a regular basis to 
the life insurer, specifying a sum assured which is an amount to be paid out 
on the occurrence of an insured event. For example, on the death of the 
insured life, a predetermined death benefit is paid to the nominated 
beneficiaries of the insured life, if the insured life is disabled or suffers a 
dread disease, a different, lesser amount is paid out. 

Health insurance policies operate where the provider of the medical 
scheme undertakes liability in return for a premium or contribution and 
provides to members who pay such premiums, or make such contributions, 
relevant health services and or assistance in defraying expenses incurred 
in connection with rendering such relevant health services. 



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-5- 

The method and system will be described with reference to these kinds of 
schemes but it will be appreciated that the method and system could 
equally be applied to other types of insurance schemes. 

It will also be appreciated that the system and methodology may be 
implemented by any relevant person or organisation. For example, the 
system and methodology may be operated by the organisation which 
operates the life insurance scheme or may be implemented by another 
associated organisation. 

It will be appreciated that with the rapid advance of medical technology as 
well as established recognition of world centers of excellence for specific 
diseases, the best medical treatment for an illness may not be in the 
country in which the insured life is insured. 

The methodology and system below address this. 

For purposes of illustration, the system and methodology will be described 
herein as being operated by the managers of a life insurance scheme. 

Referring to Figure 1 , a plurality of diseases are defined which are covered 
by the insurance scheme so that if an insured life contracts one of these 
diseases they will be paid an amount of funds from the insurer (block 10). 
Alternatively, the insurer will pay or partially pay for treatment of the 
disease. 

A request from an insured life is received who has contracted one of the 
defined diseases (block 12). 

The insured life is provided with a choice of receiving treatment in the 
country in which they reside or receiving treatment in another country 
(block 14). 



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A selected country is received from the insured life (block 16) and an 
amount of funds from the insurer to the insured life wherein the amount of 
funds is at least partially determined by the selected country (block 18). 

For example, if the insured life elects to have all treatment performed in 
their country of residence, for example South Africa, they will receive the 
normal payout under the Severe Illness Benefit of the insurer. This is 
payable as a lump sum based on the severity of the illness. 

If the insured life elects to have all treatment performed overseas they will 
receive a different lump sum. 

In one example this equals 80% of what they would have received under 
the first option, less the amount that would be have been paid by a health 
insurer, plus an amount equal to the actual cost of the treatment at the 
overseas facility less the amount that would be have been paid by a health 
insurer had the treatment been done in South Africa (in Rand terms). 

In addition, members of a health insurance plan will still receive the amount 
that would have been paid had the treatment been done in South Africa. 

The method is best illustrated using an example case study. 

Assume an insured person has a R1 ,000,000 severe illness benefit with a 
life insurer and the insured person requires a kidney transplant. They elect 
for it to be performed in the USA rather than in their home county of South 
Africa. 

The following steps are applied. The cost of the kidney transplant in the 
USA is approximately R710 000, including pre-and post-transplant costs. 

The cost of a kidney transplant in South Africa is approximately R200,000 
including pre and post transplant costs which means that the insured 
person still has a shortfall of R51 0,000. 



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The example method provides additional funding as follows, a kidney 

4 

transplant is a Severity A condition and therefore qualifies for a 100% 
payment under the severe illness benefit. As the client has a R1, 000,000 
severe illness benefit, the Life Insurer will pay R1.31m, calculated as 
follows: 

80% of R1 ,000,000 PLUS 

R710 000 (actual cost of treatment) less R200 000 (amount paid by 
health insurer) 

As the health insurer will in any event typically pay the amount of health 
insurance they normally pay in these kind of situations (R200,000), the total 
payment from both life and health insurers amounts to a total of 
R1 ,51 0,000. 

In addition, the life insurer may arrange discounted costs for the insured life 
through a network of health providers in the country of choice. This has 
been calculated into the above as the discounted cost of the procedure is 
R71 0,000 and the insured life has more than adequate cover to receive 
treatment in the USA. 

Figure 2 illustrates an exemplary system for implementing the above 
methodologies. 

A server 20 includes a number of modules to implement the methodologies 
described above. 

A rules module 22 defines a plurality of diseases which are covered by the 
insurance scheme so that if an insured life contracts one of these diseases 
they will be paid an amount of funds from the insurer. 

A request module 24 receives a request from an insured life who has 
contracted one of the defined diseases. 



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A treatment module 26 provides the insured life with a choice of receiving 
treatment in the country in which they reside or receiving treatment in 
another country and to receive a selected country from the insured life. 

A payment module 28 pays an amount of funds from the insurer to the 
insured life wherein the amount of funds is at least partially determined by 
the selected country. 

The system may include a database 30 for storing information to allow the 
methodologies to be implemented. 

The modules described above may be implemented by a machine-readable 
medium embodying instructions which, when executed by a machine, 
cause the machine to perform any of the methods described above. 

It will be appreciated that embodiments of the present invention are not 
limited to such architecture, and could equally well find application in a 
distributed, or peer-to-peer, architecture system. Thus the modules 
illustrated could be located on one or more servers operated by one or 
more institutions. 



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CLA1MS: 



1. A method of managing an insurance scheme, the method Including: 

defining a plurality of diseases which are covered by the 
insurance scheme so that if an insured life contracts one of 
these diseases they will be paid an amount of funds from the 
insurer or the insurer will pay or partially pay for treatment of 
the disease; 



receiving a request from an insured life who has contracted 
one of the defined diseases; 



providing the insured life with a choice of receiving treatment 
in the country in which they reside or receiving treatment in 
another country; 

receiving a selected country from the insured life; and 



paying an amount of funds from the insurer to the insured 
life wherein the amount of funds is at least partially 
determined by the selected country. 

2. A method according to claim 1 wherein the plurality of diseases is 
typically a plurality of severe illness diseases, 

3. An electronic system for managing an insurance scheme, the 
system including: 

a rules module to define a plurality of diseases which are 
covered by the insurance scheme so that if an insured life 
contracts one of these diseases they will be paid an amount 
of funds from the insurer or the insurer will pay or partially 
pay for treatment of the disease; 



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-10- 

a request module to receive a request from an insured life 
who has contracted one of the defined diseases; 

a treatment module to provide the insured life with a choice 
of receiving treatment in the country in which they reside or 
receiving treatment in another country and to receive a 
selected country from the insured life; and 

a payment module to pay an amount of funds from the 
insurer to the insured life wherein the amount of funds is at 
least partially determined by the selected country. 

4. A machine-readable medium embodying instructions which, when 
executed by a machine, cause the machine to perform a method 
including: 

defining a plurality of diseases which are covered by the 
insurance scheme so that if an insured life contracts one of 
these diseases they will be paid an amount of funds from the 
insurer or the insurer will pay or partially pay for treatment of 
the disease; 

receiving a request from an insured life who has contracted 
one of the defined diseases; 

providing the insured life with a choice of receiving treatment 
in the country in which they reside or receiving treatment in 
another country; 

receiving a selected country from the insured life; and 



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paying an amount of funds from the insurer to the insured 
life wherein the amount of funds is at least partially 
determined by the selected country. 



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1/2 



Fig. 1 



defining a plurality of diseases which 
are covered by the insurance scheme 
so that if an insured life contracts one 
of these diseases they will be paid an 
amount of funds from the insurer 



receiving a request from an insured 
life who has contracted one of the 
defined diseases 



providing the insured life with a choice 
of receiving treatment in the country in 
which they reside or receiving 
treatment in another country 



receiving a selected country from the 
insured life 



paying an amount of funds from the 
insurer to the insured life wherein the 
amount of funds is at least partially 
determined by the selected country 



WO 2007/141696 



PCT/IB2007/051946 



2/2 




Fig. 2