What the 54-381A is for
The 54-381A opens a disability claim under an iA Financial Group group insurance plan. It covers short-term disability, long-term disability, and waiver of premium, and the type of claim is marked at the top of each statement. iA assesses whether the member can do their job, using the employer’s description of the job’s demands alongside your account of what the member can and can’t do.
When a claim continues past the initial period, iA asks for the Extension of Disability form, the 54-382A, instead. The 54-381A is also separate from the EI sickness certificate and the CPP disability medical report, which go to Service Canada.
Who completes it
The employer or plan administrator completes the Policyholder’s Statement, including the work schedule, earnings, and the physical and mental demands of the job. iA also publishes that statement on its own for plan administrators. The member completes the Member’s Statement, Parts 1 to 8, and signs the confirmation and authorization in Part 8. The member also completes the Member Identification section and signs the Member Authorization at the top of the physician’s statement. The attending physician completes the physical or psychological statement, Parts 1 to 5.
The packet is eleven pages, and iA asks for it back whole, with no pages detached. In practice the member brings the physician’s pages to the visit with the identification section often blank, and the rest of the packet sits at home or with the employer. In Medulla, you send the Member’s Statement and the identification section to the patient over a secure link. They fill in their part on the form from any device, and their answers land on the PDF you complete the physician’s statement on, so the member’s and physician’s pages leave as one document.
How to fill in the physician’s statement
Part 1, Diagnosis
For a physical illness, give the primary and secondary diagnoses, complications, and previous treatment for the same condition. Say whether the disability is related to the risks of the patient’s job, an accident, an illness, a work accident, an occupational illness, a motor vehicle accident, or a pregnancy. Describe the functional limitations at the start of the disability and now, with the date of each, and give height, weight, and handedness. For a psychological illness, give the primary and secondary diagnoses, the symptoms you observed yourself, the severity, contributing problems, the current GAF score and the highest in the last year, and a mental status examination.
Part 2, Limitations and restrictions
The form separates limitations, what the patient can’t do, from restrictions, what the patient shouldn’t do. Keep them apart and tie each to the job. For a cardiac condition, give the American Heart Association functional class and the last blood pressure. Answer whether the patient can manage their affairs, including endorsing cheques.
Part 3, Treatment
List medications with doses. On the psychological statement, record the medication strategies tried: progressive increases, augmentation, combinations, and changes. Note investigations, surgery, other treatment, and hospitalization, and whether the patient sees a psychiatrist, psychologist, social worker, or other provider.
Part 4, Follow-up and prognosis
Give the date of the first consultation for this disability, the start date of the disability, the next consultation, and how often you see the patient. Estimate the duration in weeks or months, or mark undetermined, and say when the patient will be fit to return, part time or full time. If you recommend a gradual return, explain why and fill in the four-week plan with days per week and dates.
Part 5, Identification of the attending physician
Print your name, address, phone, and fax, mark general practitioner, specialist, or other, and sign and date.
Common reasons it’s delayed
- The member identification or authorization at the top of the physician’s statement left unsigned.
- Limitations and restrictions mixed together, or not related to the job.
- A duration of disability left blank instead of an estimate or “undetermined”.
- A gradual return recommended with no reason or no week-by-week plan.
- No test results or specialist reports attached.
- Pages detached from the packet.
Submitting and who pays
The completed packet goes to iA’s Disability Claims office in Montreal for Quebec members, or in Toronto for members in all other provinces, at the addresses printed on the form. The member returns the whole document with copies of any government plan benefit statements. The form states that the member is responsible for any fees charged to complete it, so bill the patient.