Aflac Group critical illness coverage, issued by Continental American Insurance Company, pays when a covered illness such as cancer, heart attack, stroke, a major organ transplant or end-stage renal failure is diagnosed. This two-page statement records how and when the diagnosis was made and which evidence supports it. Aflac asks the physician who first diagnosed the condition to complete it, and the employee files it with the critical illness claim.
The physician who first diagnosed the condition completes both pages and signs the certification. The employee completes the Insured's Statement on the separate Group Critical Illness Claims form and signs a HIPAA authorization.
Enter the patient's first and last name and date of birth, then when signs or symptoms first appeared and whether the patient ever received medical advice or treatment for this or a similar condition, with the date if yes. Give the diagnosis including complications. Answer the history questions with dates; a claim filed in the first year of coverage also needs the employee's Pre-Existing Investigation Statement.
Give the date of diagnosis, defined as the date the pathological specimens were obtained, and mark whether the cancer or carcinoma in situ was diagnosed pathologically or clinically. For a pathological diagnosis, attach the pathology report. For a clinical diagnosis, state why a pathological diagnosis was not obtained and attach the medical evidence that supports the cancer diagnosis. Aflac's claim instructions ask for the pathology report for skin cancer as well.
Answer yes or no to each criterion the condition must meet: new and serial EKG findings consistent with infarction, cardiac enzymes elevated above generally accepted normal levels using a CPK-MB measurement, diagnostic studies confirming infarction and occlusion of one or more coronary arteries, and chest pain consistent with infarction. Attach the EKGs, lab report and study reports. The date of diagnosis is the date the patient met all of the criteria.
For bypass surgery, confirm whether the patient had open heart surgery with bypass grafts to correct narrowing or blockage of one or more coronary arteries, name the condition that made it necessary and give the date the patient was first treated for its signs or symptoms. For a transplant, confirm surgery to receive a human heart, liver, lung, kidney, pancreas or bone marrow and give the first treatment date. Both require a copy of the operative report.
Confirm whether the patient had a stroke, meaning apoplexy from rupture or acute occlusion of a cerebral artery. The form excludes transient ischemic attacks, vertebrobasilar ischemia, head injury and chronic cerebrovascular insufficiency. The date of diagnosis is the date the stroke occurred based on documented neurological deficits and neuroimaging studies. Aflac's claim instructions ask for the discharge summary, initial MRI or CT reports and proof of permanent neurological damage.
Answer whether the patient has end-stage renal failure presenting as chronic, irreversible failure of both kidneys, and whether it requires regular dialysis at least weekly or results in kidney transplantation. Give the cause of the renal disease, the date the patient was first treated for its signs or symptoms and the date of diagnosis, defined as the date a physician recommended starting dialysis. Aflac's instructions name the End Stage Renal Disease Medical Evidence Report as the preferred proof.
Page 2 asks whether the patient is unable to perform job duties, with dates, which duties, and restrictions quantified in hours, weight and similar measures. For retired or unemployed patients, list the activities of daily living they cannot perform and the date a person of like age, gender and good health would resume normal activities. Record hospital or skilled nursing confinement with dates, whether the patient is ambulatory, bed confined or house confined, expected partial and full duty dates, and other treating physicians.
Print your name, degree and telephone number, give your address and medical ID number, then sign and date. The signature certifies that the information is based on reasonable medical probability and is true and correct to the best of your knowledge and belief. The form reminds the signer that it is unlawful to include facts known to be false or to leave out relevant facts, and points to the state fraud notices.
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Aflac Group Critical Illness Claim Form – Attending Physician's Statement
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Sources for this guide
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Aflac Group's claim page says the Attending Physician's Statement is to be completed by the physician who first diagnosed the condition. The physician prints a name, degree and medical ID number, then signs a certification that the information is based on reasonable medical probability and is true and correct to the best of their knowledge.
The form asks whether the cancer or carcinoma in situ was diagnosed pathologically or clinically. For a pathological diagnosis, attach the pathology report and give the date the specimen was obtained. For a clinical diagnosis, explain why a pathological diagnosis was not obtained and attach medical evidence that supports the diagnosis of cancer.
The myocardial infarction section asks whether the patient met all listed criteria: new and serial EKG findings consistent with infarction, cardiac enzymes elevated above normal with a CPK-MB measurement, diagnostic studies confirming infarction and coronary occlusion, and consistent chest pain. Attach the EKGs, lab report and study reports, and give the date all criteria were met.
Yes. Page 2 asks whether the patient is unable to perform job duties, with dates, which duties, and restrictions quantified in hours or weight. For retired or unemployed patients, it asks which activities of daily living they cannot perform and when a person of like age, gender and good health would resume normal activities.