Wisconsin Administrative Code
Office of the Commissioner of Insurance
Chapter Ins 3 - Casualty Insurance
Appendix 9
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 |
|
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: |
|
8 |
Long-Term Care Services Not Covered under the Policy2 |
|
9 |
Provider/Facility Not Qualified under the Policy3 |
|
10 |
Benefit Eligibility Criteria Not Met4 |
|
11 |
Other |
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.
