South Carolina Code of Regulations
Chapter 69 - DEPARTMENT OF INSURANCE
69-44 APPENDIX E - Claims Denial Reporting Form
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 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.
|1||Total Number of Long Term Care Claims Reported|
|2||Total Number of Long Term Care Claims Denied/Not Paid|
|3||Number of Claims Not Paid due to Preexisting Condition Exclusion|
|4||Number of Claims Not Paid due to Waiting (Elimination) Period Not Met|
|5||Net Number of Long Term Care Claims Denied for Reporting Purposes (Line 2 Minus Line 3 Minus Line 4)|
|6||Percentage of Long Term Care Claims Denied of Those Reported (Line 5 Divided By Line 1)|
|7||Number of Long Term Care Claim Denied due to:|
Long Term Care Services Not Covered under the Policy2
Provider/Facility Not Qualified under the Policy3
Benefit Eligibility Criteria Not Met4
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.