What FORM-401E is for
FORM-401E opens a disability insurance claim with Medavie Blue Cross. Medavie uses it to decide whether the patient’s condition keeps them from working and how long recovery is likely to take, and it sets the length of the form by the expected absence. A short absence needs only the diagnosis and treatment pages. A longer one needs investigations, clinical findings, restrictions and limitations, prognosis, and return-to-work goals.
The Canadian life and health insurance industry created a standardized Initial Disability Insurance Medical Statement, and FORM-401E is Medavie’s copy of it. Patients sometimes bring the industry version or another insurer’s form, and the medical content is similar, but the return addresses differ.
Who completes it
The patient completes Section 1: name, phone numbers, address, employer, contract or policy and certificate numbers, date of birth, the date they last worked and expect to return, their current medications with doses, height, weight, and dominant hand. They sign the consent that releases their medical information to the insurer and accepts responsibility for the form fee. The doctor or other medical provider completes Section 2 and signs it.
Patients often bring the form with Section 1 half done, and the medication list rarely matches the chart. In Medulla, you send Section 1 to the patient over a secure link before the visit. They fill it in on the form from any device, and their answers land on the PDF you complete Section 2 on, so you can check their medication list against yours before you sign.
How to fill in Section 2
Diagnosis and cause
Mark whether you’re the family physician, a consulting specialist, or another provider. Give the primary diagnosis and any secondary diagnoses or complications, and the delivery date and type for childbirth. Say whether the condition is due to an occupational illness or injury, a motor vehicle accident, or another accident, with the date. Note other disability forms you’ve completed for the patient, such as for CPP, QPP, or workers’ compensation.
Treatment, response, and hospitalization
Give the date of the first visit for this condition, the first date of work absence, the treatment, how often you see the patient, and the last and next visits. Say whether the patient was treated for the same or a similar condition before and is following the treatment program. Describe the response to treatment, any planned changes, and any hospitalization or surgery with dates.
The four-week stopping point
If the patient has returned to work, or the disability will last less than four weeks, stop after the surgery questions and sign the end of the form. If you expect it to last more than four weeks, complete every page.
Investigations and clinical findings
Attach relevant test results, consultation reports, and clinical notes, leaving out genetic test results. Medavie reads a statement with no results attached as one where no tests were done. List pending tests and future specialist appointments, then describe the symptoms with their history, severity, and frequency, and whether they’ve improved, stayed the same, or retrogressed.
Restrictions and limitations, prognosis, and return to work
Describe the patient’s current cognitive and physical restrictions and limitations, based on your findings. Say whether a licence has been restricted or revoked, whether the patient can manage their own affairs, and what other factors, such as workplace, family, financial, or addiction issues, may affect recovery. Give the prognosis and the return-to-work goals you’ve discussed with the patient.
Common reasons it’s delayed
- A disability longer than four weeks with only the first two pages completed.
- No test results attached, which Medavie reads as no tests done.
- Restrictions and limitations given as a diagnosis instead of what the patient can’t do.
- No prognosis or return-to-work goals.
- Section 1 consent unsigned.
- Missing licence or registration number in the signature block.
Submitting and who pays
Email, fax, or mail the completed statement to the Medavie Blue Cross office for the patient’s province, as listed on the last page: Moncton for New Brunswick and Atlantic Canada, Montreal for Quebec, Etobicoke for Ontario, and Dartmouth for Nova Scotia. The patient is responsible for any fees related to completing the form, so bill the patient directly.