Ill. Admin. Code tit. 50, § 2012.EXHIBIT I
| For the State of Illinois 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 format 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 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 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 Example - a benefit trigger not met, certification by a licensed health care practitioner not provided, no plan of care.
(Source: Amended at 32 Ill. Reg. 7600, effective May 5, 2008)