What the 2115 is for
The 2115 is Equitable Life’s medical statement for a disability benefits claim. Equitable uses it to decide whether the insured can’t work because of illness or injury, and how long that is likely to last. The form also lets Equitable use it for other benefits it chooses to assess, so the same statement can support more than one claim on the policy.
Equitable doesn’t decide on the diagnosis alone. It reads the physical and mental limitations you describe, whether the patient is following treatment, and your answer on whether the disability prevents the regular occupation and any other occupation. The standardized industry Initial Disability Insurance Medical Statement covers similar ground, which is why patients sometimes bring the wrong one.
Who completes it
The owner or insured completes Part 1, the patient authorization, with their name, policy number, date of birth, address, phone, and email, and signs and dates the release of information to the insurer. The attending physician completes Part 2, sections 1 to 10, and signs at the end with their name, specialty, address, and phone number.
Patients usually receive the 2115 from Equitable or their advisor, sign Part 1 at home, and drop the form at the clinic, where it waits in a pile until you write in Part 2 by hand. If Part 1 comes back unsigned, the whole form goes back to the patient. In Medulla, you send Part 1 to the patient over a secure link before or after the visit. They fill it in on the form from any device, and their answers land on the same PDF you complete Part 2 on, so Equitable gets one complete statement.
How to fill in Part 2
History
Give the date symptoms first appeared or the accident happened, and the date the patient stopped work because of this condition. Say whether the condition arose from the patient’s employment, whether they’ve had the same or a similar condition before, and whether it’s chronic. For a chronic condition the form asks what precipitated the absence, which is often the question an adjuster follows up on. List the other treating physicians and providers.
Diagnosis
Enter the primary diagnosis and any additional conditions or complications that might lengthen the absence. Separate the subjective symptoms the patient reports from the objective signs you found, and attach the investigations that support them. A claim built only on reported symptoms is the weakest kind.
Physical and mental or nervous impairment
Describe the physical limitations that affect work in concrete terms: how much the patient can lift or carry, and how long they can walk, stand, or bend. For a mental health condition, describe how it affects the ability to work, say whether there’s been a psychiatric referral, and answer whether the patient is competent to endorse cheques and direct the use of the proceeds.
Cardiac
Complete this only for a cardiac condition. Give the American Heart Association functional class, from class 1 (no limitation) to class 4 (complete limitation), and the blood pressure from the last visit. Attach stress test or angiogram results.
Treatment and progress
Give the dates of the first and latest visits, how often you see the patient, and the treatment, including surgery, physiotherapy, and medications. Say whether the patient is following the recommended program, and comment if they aren’t. Then mark whether the patient has recovered, improved, not improved, or retrogressed.
Prognosis and rehabilitation
The prognosis grid asks two questions for the regular occupation and for any other occupation: does the disability prevent the patient from working, and when do you expect them to recover enough to work, from 1 to 3 months to never. Answer both columns, since a “yes” for the regular job and a blank for other work leaves half the question unanswered. Then say whether the patient is a candidate for medical rehabilitation, vocational counselling, or trial employment.
Common reasons it’s delayed
- Part 1 not signed, so Equitable can’t use the medical information.
- Symptoms described with no objective findings or attached results.
- Limitations given as a diagnosis instead of what the patient can’t do at work.
- Only one column of the prognosis grid answered.
- No date the patient stopped work, or no expected recovery period.
- Missing physician name, specialty, or signature.
Submitting and who pays
The form carries Equitable’s Waterloo head office address and phone numbers, and the completed statement goes back to Equitable with the claim. It warns that Equitable can’t guarantee the privacy of email and gives a phone number for other ways to submit. It doesn’t set a fee, so bill the patient as an uninsured service on the terms you agree with them.