Prudential's Waiver of Premium Division sends this two-page form when a group life insured claims waiver of premium because of multiple sclerosis. Based on the latest neurological examination, the attending physician circles one Kurtzke grade for each functional system: pyramidal, cerebellar, brainstem, sensory, bowel and bladder, cerebral and visual, along with the years of diagnosis and first symptoms.
The attending physician or neurologist completes the scoring sections and signs the fraud certification. Prudential identifies the claimant by name and claim number.
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Kurtzke Functional Systems Scores (FSS)
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The physician rates on the basis of the worse function, bowel or bladder, from normal through mild hesitance or urgency, moderate symptoms or rare incontinence, frequent incontinence, near-constant catheterization, loss of bladder function, to loss of bowel and bladder function.
Cerebral or mental function runs from normal and mood alteration only, which does not affect the EDSS score, through mild, moderate and marked decrease in mentation, to dementia or severe chronic brain syndrome, with an unknown option.