When an employee stops working because of total disability and asks Pacific Life to keep group life coverage in force without premiums, the treating physician completes this three-page statement at the end of the claim package. It covers diagnoses with ICD or DSM codes, objective findings and treatment, maximum medical improvement, detailed physical capacities, and whether the patient is disabled from their own occupation or from any occupation.
The attending physician completes Sections 2 to 5 after the patient's identifying details in Section 1. The employee completes the Employee Statement and the employer completes the Employer Statement, then gives the employee this physician statement.
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Group Life Insurance – Waiver of Premium While Totally Disabled – Attending Physician Statement
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Section 4 asks why the patient cannot perform the job duties, whether they could work within the stated limitations, whether they are totally disabled from their own occupation or any occupation, how many hours and days they could work, and when they might return.
The form asks for objective findings with copies of X-rays, lab tests, EKGs, MRIs, scans and office notes, and the physician checks which ones are enclosed when signing Section 5. The package also asks for hospital records, discharge summaries and lab results documenting the total disability.