DEPARTMENT OF LABOR AND REGULATION

 

DIVISION OF INSURANCE

 

 

 

 

CLAIMS DENIAL REPORTING FORM FOR

LONG-TERM CARE INSURANCE POLICIES

 

 

Chapter 20:06:21

 

APPENDIX H

 

SEE: § 20:06:21:52

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          Source: 28 SDR 157, effective May 19, 2002; 36 SDR 209, effective July 1, 2010.

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.

 

Indicate the manner of reporting by checking one of the boxes below:

 

□  Per Claimant -- counts each individual who makes one or a series of claim requests.

 

□  Per Transaction -- counts each claim payment request.

 

"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. It does not include a request for payment that is in excess of the applicable contractual limits.

 

Inforce Data

 

	State Data	Nationwide Data
Total Number of Inforce Policies [Certificates] as of December 31

 

Claims & Denial Data

 

			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 Claims 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.