When an over-age dependent cannot support themselves because of a disability, the employee can ask Mutual of Omaha to continue the dependent's group coverage. This four-page request has sections for the employee, employer and attending physician. On page 3 the physician gives a detailed diagnosis with severity, treatment dates, functional capabilities and limitations, and whether the patient is incapable of self-support.
The employee completes page 1 and the employer page 2. The dependent's attending physician completes and signs page 3.
Download the current version from the source each time; forms change without notice.
Request for Continued Coverage for Incapacitated Dependent – Attending Physician
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The attending physician section says any fee for completing the form is the responsibility of the employee. Any charge for completion therefore goes to the employee rather than to Mutual of Omaha.
The physician gives the diagnosis with severity, treatment dates, current functional capabilities and limitations, and answers whether the patient is now incapable of self-support because of a disability. A clinical summary or current supporting documentation is submitted, with IQ results for mental conditions if available.