South Carolina Code of Regulations
Chapter 69 - DEPARTMENT OF INSURANCE
69-44 APPENDIX E - Claims Denial Reporting Form

Universal Citation: SC Code Regs 69-44 APPENDIX E

APPENDIX E. Claims Denial Reporting Form

Long Term Care Insurance

For the State of_

For the Reporting Year of_

Company Name: _Due: June 30 annually

Company Address:

Company NAIC Number: _

Contact Person: _Phone Number: _

Line of Business: Individual Group Instructions

The purpose of this form is to report all long term care claim denials under in force long term care insurance policies. "Denied" means a claim that is not paid for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition.

State Data

Nationwide

Data1

1Total Number of Long Term Care Claims Reported
2Total Number of Long Term Care Claims Denied/Not Paid
3Number of Claims Not Paid due to Preexisting Condition Exclusion
4Number of Claims Not Paid due to Waiting (Elimination) Period Not Met

State Data

Nationwide Data1

5Net Number of Long Term Care Claims Denied for Reporting Purposes (Line 2 Minus Line 3 Minus Line 4)
6Percentage of Long Term Care Claims Denied of Those Reported (Line 5 Divided By Line 1)
7Number of Long Term Care Claim Denied due to:
8

Long Term Care Services Not Covered under the Policy2

9

Provider/Facility Not Qualified under the Policy3

10

Benefit Eligibility Criteria Not Met4

11Other

1 . The nationwide data may be viewed as a more representative and credible indicator where the data for claims reported and denied for your state are small in number.

2 . Example-home health care claim filed under a nursing home only policy.

3 . Example-a facility that does not meet the minimum level of care requirements or the licensing requirements as outlined in the policy.

4 . Examples-a benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care.

HISTORY: Added by State Register Volume 13, Issue No. 6, effective 180 days after June 23, 1989. Amended by State Register Volume 34, Issue No. 5, eff May 28, 2010.

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