What the critical illness statement is for
Desjardins uses this statement for critical illness claims under individual, GetWell and group insurance. The insured’s contract lists the covered illnesses and the criteria each must meet, so Desjardins needs detailed clinical information to compare against them. The form has dedicated sections for cancer, heart attack and stroke, and a general section for other covered illnesses. Version 17026A, dated April 2026, is the one Desjardins links from its claims page.
Who completes it
The insured completes Section A: the type of coverage and contract number, name, date of birth, address and phone numbers. The attending physician or the specialist who made the diagnosis completes Sections B, C, D and E.
The insured usually prints the statement, fills in Section A and brings it to the physician who made or follows the diagnosis. In Medulla, you can send Section A to the patient over a secure link. They enter their contract details on the form, and those answers appear on the PDF where you complete the clinical sections, so Desjardins receives one complete statement.
How to fill in Sections B to E
Section B: General information
Give your name and specialty, how long you’ve followed the patient, the critical illness diagnosis, and the dates of first symptoms, first appointment, diagnosis and when the patient was told. List hospitals and physicians consulted, tobacco use, and any hereditary illness in the family with ages. Then record care, treatment and medication for any condition in the past five years.
Section C: Details of diagnosis
Tick the illness and answer its questions. For cancer, give the pathological diagnosis, site, TNM or numeric stage and any recurrence. For a heart attack, answer the questions on cardiac markers, new ECG changes, whether it’s a first infarction and Q waves after a cardiac procedure. For stroke, give the date, whether it’s a first event, any deficits persisting beyond 30 days and whether trauma caused it.
Section D: Symptoms and comments
Describe the symptoms and add anything that helps Desjardins review the claim, such as the treatment plan or how the diagnosis was confirmed.
Section E: Identification of physician
Add your address, licence number, phone and fax, and sign and date the form.
Common reasons it’s delayed
- No pathology report enclosed for a cancer claim.
- A diagnosis date that doesn’t match the pathology or discharge summary.
- Stage left blank, or given without the classification system.
- Stroke claims with no answer about deficits beyond 30 days.
- An incomplete five-year history, which Desjardins then has to request.
Submitting and who pays
The completed form and enclosures go to Desjardins by mail to the address on the form, or are uploaded through its secure site. Desjardins doesn’t pay for the statement, so clinics bill the insured.