Desjardins Insurance uses this three-page statement for the medical part of a critical illness claim under individual, GetWell or group insurance. Because benefits depend on the illness meeting the contract's specific criteria, it asks for detailed diagnosis dates, five years of treatment history, tobacco use and hereditary family history, plus condition-specific details for cancer, heart attack, stroke or another illness.
The insured's attending physician, or the specialist who diagnosed the critical illness, completes Sections B to E, including identification with licence number and signature. The insured completes Section A, indicating whether the coverage is individual, GetWell or group insurance.
Download the current version from the source each time; forms change without notice.
Critical illness claim – Attending physician's statement
Déclaration du médecin traitant pour une maladie grave
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Sections B, C, D and E must be completed by the insured's attending physician or by the specialist who diagnosed the critical illness. The insured completes only Section A. Section E asks for the physician's address, licence number, telephone and fax numbers, signature and date.
Each condition in Section C names its records: for cancer, the complete medical file including the pathology report for the biopsy that led to the diagnosis; for heart attack, test, bloodwork and ECG results and the hospital discharge summary; for stroke or another illness, test results and the discharge summary.
The insured. A notice at the top of the form states that fees charged for the statement are to be paid by the insured. Desjardins asks for the information as soon as possible so it can review the claim, with the additional documents requested enclosed with the form.