What the group critical illness claim is for
Group critical illness coverage pays a benefit when the insured or a covered dependant is diagnosed with one of the conditions the policy lists. On this RBC form, administered by Allstate Insurance Company of Canada, the list includes invasive cancer, carcinoma in situ, heart attack, stroke, coronary artery bypass surgery, kidney failure, multiple sclerosis, ALS, Alzheimer’s disease, Parkinson’s disease, and others. Each condition comes with the proof it needs, and the claim is assessed on that proof.
Critical illness is often confused with disability insurance. Disability claims turn on whether the patient can work. A critical illness claim turns on the diagnosis meeting the policy definition, and work capacity comes in only through the optional waiver of premium questions.
Who completes it
The insured completes the Insured and Patient Information, including the patient’s details when the claim is for a dependant, checks the illness being claimed, and signs the authorization. An optional section assigns benefits to a provider. The attending physician completes the Attending Physician’s Statement on page 3, including the waiver of premium questions when they apply, and signs the physician verification.
Patients usually download the form, complete the first two pages at home, and bring page 3 to the clinic with the pathology report still to be found. In Medulla, you send the claimant pages to the patient over a secure link. They fill them in on the form from any device, and their answers land on the PDF you complete the Attending Physician’s Statement on, so the illness they’ve checked and the diagnosis you give arrive on one form.
How to fill in the Attending Physician’s Statement
Diagnosis and history
Give the diagnosis, when symptoms first appeared or the accident happened, and when the patient first consulted you for it. Say whether the patient has had the same or a similar condition before, with when and a description, and describe other diseases or infirmities affecting the present condition. Match the diagnosis to the policy’s wording for the illness the patient has checked, such as invasive cancer versus carcinoma in situ.
Procedures and hospitalization
Describe any surgical or obstetrical procedure in full. For bypass or aortic surgery, the claim needs the medical record or billing proof of the procedure. If the patient was hospitalized, give the hospital and the dates admitted and discharged.
Attach the diagnostic proof
The form asks for the results of the tissue specimen, cultures, titers, or other studies that first diagnosed the illness. For cancer that’s the pathology report. For a heart attack it’s the ECG and the cardiac marker results. For a stroke it’s documentation of a permanent neurological deficit. Some conditions need a specialist’s documentation, such as a neurologist or psychiatrist for Alzheimer’s disease and an ophthalmologist for blindness.
Waiver of premium
Answer these only when the patient claims waiver of premium. Say whether the patient can do their job and for which dates, which duties they can’t perform, and their restrictions and limitations, quantified in hours or weight. For a retired or unemployed patient, give the activities of daily living they can’t do. Then give the last examination date, visit frequency, whether the patient is ambulatory or confined, and when you expect partial and full duties to resume.
Common reasons it’s delayed
- No pathology or diagnostic report attached for the illness claimed.
- A diagnosis that doesn’t match the illness the patient checked.
- Waiver of premium questions answered without quantified restrictions.
- Missing dates for symptom onset or first consultation.
- An unsigned physician verification.
Submitting and who pays
The insured sends the completed claim to Allstate Benefits’ Group Claims Department in Ottawa by fax, by email as a scan, or by mail, using the details on the first page, with the certificate number on the form. The form doesn’t mention a physician fee, so bill the patient as an uninsured service on the terms you agree.