DISABILITY CLAIM FORM - Beneplan · Nature of request for benefits q Short-Term Disability (please...

GROUP INSURANCE

DISABILITY CLAIM FORMInitial assessment

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Group insurance Disability claim form – Initial assessment

Instructions for: A.Theclaimant 1. Pleasecompleteandsignthe“Claimantstatement”section.

2. Pleaseensurethatthepolicyholdercompletesandsignsthe“Policyholderstatement”section.

3. Pleaseensure thatyourphysiciancompletesandsigns the“Attendingphysicianstatement–Psychologicalconditions” if theprimaryreasonforyourabsencefromworkispsychologicalorthe“Attendingphysicianstatement–Physicalconditions”forallothercondition.Aswell,pleaseprovideyourphysicianwithacopyofyourcompleted“Claimantstatement”sothatthephysicianwillhaveyoursignedauthorizationtoreleaseinformationtoHumaniaAssurance.

4. Pleasenotethatanycostsincurredforthecompletionofthe“Attendingphysicianstatement”areyourresponsibility.

5. Pleaseensurethatalloftheabove-mentionedformsaresubmittedtoHumaniaAssuranceonatimelybasis.Submittingthemtogether will avoid unnecessary delays in the assessment of your claim.Also, please enclose a copy of the first and/or lastunemploymentchequestubandtherecordofemploymentformifapplicable.

Directdeposit 6. PleasecompleteandsignthedirectdepositauthorizationatthebottomofthispageifyouarenotalreadyusingdirectdepositwithHumaniaAssurance.Theformshouldthenbesubmittedwithyourclaiminordertohaveyourbenefitsdepositeddirectlyintoyourbankaccount,shouldyourclaimbeapproved.

B.Thepolicyholder 1. Pleasecompleteandsignthe“Policyholderstatement”section.

2. InordertoavoidunnecessarydelaysintheprocessingofLong-TermDisabilityclaims(withoutShort-TermDisability),weaskthattheseformsbecompletedandsenttoHumaniaAssuranceasfollows:

Forpolicieswithaneliminationperiodof:

- 15weeks,completedformsshouldbesenttousasofthe8thweekofabsence;- 17weeks,completedformsshouldbesenttousasofthe11thweekofabsence;- 26weeks,completedformsshouldbesenttousasofthe20thweekofabsence.

C.Thephysician 1. Pleasecompleteandsigntheappropriate“Attendingphysicianstatement”,dependingonthenatureoftheprimarydiagnosis.

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In order to ensure confidentiality of personal information, Humania Assurance will establish a claim file in which information concerning all of your claims will be kept. Only employees or authorized agents of Humania Assurance responsible for the management of your claim shall have access to the file.

Direct deposit – Authorization

qInitialrequestfordirectdeposit qRequestforbankaccountchange qRequesttoenddirectdeposit

I Insured statement (please print)

Policyandsub-groupno. Certificateno. Insuredsurname Givenname(s)

Telephoneno.(day) Mainresidenceaddress(no.,street) Apt.

City Province Postalcode

Financialinstitutionname Financialinstitutionaddress

II Type of bank account (please print)

qChequing qSavings Pleasecompletethissectionorattachapersonalizedvoidchequetoensurethatweobtainyouraccuratebankinginformation.

Branchno.(5digitnumber) Institutionno.(3–4digitnumber) Accountno.(Allnumbers)

III Authorization

IauthorizeHumaniaAssurancetocreditallmybenefitpaymentstotheaccountmentionedonthisform.Icertifythattheinformationprovidedonthisformisaccurate,andIagreetoinformHumaniaAssuranceofanysubsequentchanges.IacceptthatthisagreementmaybecancelledatanytimebyeitherHumaniaAssurance,myself,inwritingorverbally.

Insuredsignature Date ( Y Y Y Y / M M / D D )

Accountholdersignature(ifotherthanInsured) Date ( Y Y Y Y / M M / D D )

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Forinformation,pleasecontactusat:intheMontrealregionat514485-7236,intheSaint-Hyacintheregionat450773-7236,elsewhereat1800818-7236.Our address is: P.O. Box 10 000 at Saint-Hyacinthe (Quebec) J2S 7C8 • Web site: www.humania.ca

Section A – General information

qMr.qMrs.qMs. Genderq Maleq Female Dateofbirth ( Y Y Y Y / M M / D D ) Policyno. Certificateno.

Surname Givenname(s) Socialinsurancenumber

Address(no.,street)

City Province Postalcode Telephoneno. Languageq Fr.q En.

Nameofemployer(and division if different) Occupation(just prior to last day worked) Originaldateofhire ( Y Y Y Y / M M / D D )Othercurrentemployer qYesqNo Ifyes,pleasename.

Natureofrequestforbenefits q Short-TermDisability(Pleaseencloseacopyoftherecordofemploymentform,ifapplicable) qLong-TermDisability qWaiverofpremiums

Section B – Claim information

WasthereasonyoustoppedworkingduetoqIllness qInjuryawayfromwork qMotorvehicleaccident(notwhileworking) qOccupationalillnessorworkaccident(If the reason was a motor vehicle accident, please submit a police or collision report, except in Quebec.)

If you have suffered an injury, please describe how, when, and where the injury occurred.

Lastdayworked ( Y Y Y Y / M M / D D )

WereyouperformingqYourregulardutiesqModifieddutiesWasthisafullday?qYesqNo Ifno,howmanyhoursdidyouworkonyourlastday?Dateyouwerefirstunabletowork ( Y Y Y Y / M M / D D ) Whendidyoufirstnoticethesesymptoms? ( Y Y Y Y / M M / D D )

Whenwereyoufirsttreatedbyaphysicianforthiscondition? ( Y Y Y Y / M M / D D )

Pleasedescribeallofyoursymptoms,includingfrequencyandseverity.

Haveyoueverhadthesameorsimilarillnessorinjury?qYesqNoIfyes,pleaseprovidethedatesandname(s)ofphysicianswhotreatedyouatthetime.

Pleasedescribethemajordutiesofyouroccupation.

Pleasedescribewhyyouareunabletoperformthedutiesofyouroccupation.

Pleaseindicateifyouare qRight-handedqLeft-handed

Doyouhaveanexpecteddateofreturntowork?qIfyes,pleaseprovidethedate( Y Y Y Y / M M / D D ) qNo

Claimant statementTo be completed by the claimant. All questions must be answered in as much detail as possible.

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Claimant statement (continued)

Section C – Health care professionals information

Pleaselistallofthehealthcareprofessionalsyouhaveconsultedin the last 12 months,startingwiththemostrecent,includingfamilyphysicians,specialists,chiropractors,psychologists,etc.Ifthespaceprovidedbelowisinsufficient,pleaseattachaseparatepageandlisttheadditionalhealthcareprofessionals.

Name Consultedfrom( Y Y Y Y / M M / D D ) to ( Y Y Y Y / M M / D D )

Address(no.,street)

Telephoneno. Faxno. Specialty


Address(no.,street)



Address(no.,street)


Section D – Other income information

Ifyouhaveappliedfor,orarereceivinganyincomefromanyofthefollowingsources,pleasecompletetheappropriatesectionbelowandsubmitacopyofyournoticeofacceptanceorrefusal,ifapplicable.

Source

Claim no., contact name, telephone no. Have you Are you receiving

Monthly applied? payment? Amount Yes No Yes No Pending

Worker’sComp–CSST,WSIB,WCB q q q q q

Crimevictimscompensation(IVAC) q q q q q

CanadaPensionPlan–Disability q q q q q

CanadaPensionPlan– q q q q q Retirement

QuebecPensionPlan(QPP)– q q q q q Disability

QuebecPensionPlan(QPP)– q q q q q RetirementEmploymentInsurance q q q q q

Provincialautoinsurance–SAAQ q q q q q

Otherinsurer q q q q q

Section E – Claimant authorization and declaration

Iauthorizeanyhealthcareprofessional,hospital,clinic,pharmacist,provincialhealthinsuranceplan,rehabilitationagency,insurer,employeroranyotherpersonororganizationinpossessionofinformationconcerningmyselftoreleasetoHumaniaAssurance,allmedical,financialorotherinformationdeemedrelevantintheassessmentofmyclaim.IauthorizeHumaniaAssuranceInc.,toconductallnecessaryinvestigationsrequiredinordertoverifythevalidityofmyclaim.IacceptthatHumaniaAssurance,willusetheinformationprovidedinthisformandanypriorclaimsunderthesameplanforthemanagementofmyclaimandforproductionofstatisticalreports.Icertifythattheinformationcontainedinthisformistrueandcomplete.This authorization is valid for the complete duration of the present claim. A photocopy of this authorization is as valid as the original.

Name(pleaseprint) Signature

Policyno. Date(YYYY/MM/DD)

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Policyholder statementTo be completed by the policyholder. All questions must be answered in as much detail as possible.

Forinformation,pleasecontactusat:intheMontrealregionat514485-7236,intheSaint-Hyacintheregionat450773-7236,elsewhereat1800818-7236.Our address is: P.O. Box 10 000 at Saint-Hyacinthe (Quebec) J2S 7C8 • Web site: www.humania.ca

Section A – Policyholder information

Nameofpolicyholder(Employer/Union/Association) Nameofsubsidiaryordivision(ifdifferent)

Address(no.,street)

City Province Postalcode Telephoneno.

Section B – Claimant information

Surname Givenname(s)

Policyno. Divisionno. Classno. Socialinsurancenumber Certificateno. Permanentemployee?q YesqNo

Natureofrequestforbenefits q Short-TermDisability(pleaseencloseacopyoftherecordofemploymentform,ifapplicable) qLong-TermDisability qWaiverofpremiums

Pleaseprovidethedateonwhichthisclaimantwasfirstcoveredunderthispolicy. ( Y Y Y Y / M M / D D )

Wastheemployeeactivelyatworkwhentheabsencebegan/lossoccured?q YesqNoIfno,pleasecomment.

Whatwastheclaimant’sdateofhire?( Y Y Y Y / M M / D D ) Lastdateofwork?( Y Y Y Y / M M / D D ) Forseenreturntoworkdate?( Y Y Y Y / M M / D D )

Ifalreadybackatwork,whatwasthestartdate?( Y Y Y Y / M M / D D )qPart-timeqFull-timeqTemporaryassignmentqLightdutiesqGradual–Pleaseprovidethereturntoworkprotocol

Whatwastheclaimant’smainreasonfortheabsence?q IllnessqInjuryawayfromworkq Motorvehicleaccident(notwhileworking)qOccupationnalillnessorworkrelatedaccident

Pleaseindicatethehoursofworkinanormalworkweek.

Mon__________Tues___________Wed___________Thur___________Fri___________Sat___________Sun__________(If shift work, please provide work schedule.)

Whatwastheclaimant’sgrossweeklysalaryasofhis/herlastdayofwork?$____________________

Wastheclaimant q Salaried qHourly qOncall

Didtheclaimantreceiveanyincomeduringthedisabilityperiod?q Yes qNoIfyes,pleaseselectoneofthefollowing: q Vacation qMaternityleave q Sickdaysq Employmentinsurance(pleaseencloseacopyoftherecordofemploymentform) qStatutoryholidays q Other_________________

Amount$_______________________ From______________________________to______________________________

Hastheclaimantsubmittedaclaimtothefollowinggovernmentbodies?q WSIB/WCB/CSST qEmploymentinsurance(Pleaseencloseacopyoftherecordofemploymentform) q CPP qQPP(RRQ)q SAAQ–Provincialautomobileinsuranceboard q CrimeVictimCompensationAct

( Y Y Y Y / M M / D D ) ( Y Y Y Y / M M / D D )

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Section C – Occupational information

Whatwastheclaimant’sregularoccupationimmediatelypriortohis/herstoppingwork?

Weretheclaimant’sdutiesmodifiedfromhis/herregularoccupation?q YesqNo

Pleasedescribethisemployee’sregularoccupation(orattachacopyofthejobdescription)aswellasanymodifications.

Thefollowingphysicaldemandsanalysisoftheclaimant’soccupationistobecompletedbyhis/hersupervisor.Intheappropriatecolumn,pleasespecifytheaverageamountoftime(inhours)thefollowingactivitiesareregularlyperformed:

I) atanyonetimewithoutabreak(approximately)and;II) intotalthroughouttheday(approximately)

Physical demands analysis

I II

1. Sitting

2. Standing

3. Driving

4. Bending

5. Climbingupanddownthestairs

6. Lifting 0–10poundsq 10–20poundsq 20–50poundsq 50pounds+q withliftingdevice? Yesq Noq

7. Pushing/Pulling 0–10poundsq 10–20poundsq 20–50poundsq 50pounds+q

Pleasedescribeworkenvironment(i.e.:temperature,noiselevels,chemical/dustexposure,etc.).

Doestheclaimantwearpersonalprotectiveequipment(i.e.:safetyglasses/footwear,respiratoryprotection,earprotection,etc.)?Ifyes,pleasedescribe.

Isthereanycircumstancesorfactsthatwouldcauseyoutoquestionthevalidityoftheclaim?q YesqNoIfyes,pleaseexplain.

Icertifythattheinformationgivenaboveistrueandcomplete. Date ( Y Y Y Y / M M / D D )

Name(pleaseprint) Telephoneno.

Signatureoftheauthorizedperson Jobtitle

Policyholder statement (continued)

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Section A – Information about the patient


Dateofbirth ( Y Y Y Y / M M / D D ) Height Weight

Attending physician statement – physical conditionsIn order for Humania Assurance to properly assess your patient’s claim for Disability Benefits, it is important that you answer the following questions in as much detail as possible. Please note that any costs incurred in the completion of this form are the responsibility of the patient.

Forinformation,pleasecontactusat:intheMontrealregionat514489-8404,intheSaint-Hyacintheregionat450-773-7170,elsewhereat1800773-8404.Our address is: P.O. Box 10 000 at Saint-Hyacinthe (Quebec) J2S 7C8 • Web site: www.humania.ca

Section B – Diagnosis

Whatistheprimarydiagnosis?

Whendidthesymptomsfirstappearordateaccidentoccured? ( Y Y Y Y / M M / D D )

Whatwasthedateofthepatient’sfirstvisitforhis/hercurrentcondition? ( Y Y Y Y / M M / D D )

Whatwasthedateofthepatient’sfirstvisitasregardstothepresentdisabilityperiod? (YYYY/MM/DD)

Accordingtotheanamnesisandyourclinicalexam,isyourpatient’sconditiontheresultofanaccidentaleventq YesqNoPleaseelaborate:

Ifyourpatienthasanorthopaedicand/ormusculo-skeletalcondition,hasanX-ray,MRI,oranyothertestsbeenperformed?q YesqNoIfyes,pleaseattachacopyoftheresultsoftheX-ray,MRI,oranyothertestswhichmayhavebeenperformed.

Isthereasecondarydiagnosisoradditionalcomplicationwhichmightaffectthedurationofthedisability?q YesqNoIfyes,pleaseelaborate.

Pleaseprovideacompletelistofthepatient’ssymptoms(includingseverityandfrequency),identifyingwhichofthesymptomslistedyouhaveobjectivelyobserved.

Whatarethepatient’scurrentlimitations(thingsthathe/shecannot do)?Pleasebespecific.

Whatarethepatient’scurrentrestrictions(thingsthathe/sheshould notdo)?Pleasebespecific.

Pleaseindicatethedatethepatientstoppedworkingorperforminghis/herdailyactivitiesbasedonyourrecommendation. ( Y Y Y Y / M M / D D )

Ifapotentialreturntoworkdateorreturntodailyactivitieshasbeendiscussed,pleaseprovidethedateandindicateifthereturnis ( Y Y Y Y / M M / D D )qPart-timeqFull-timeqTemporaryassignmentqLightdutiesqGradual–Pleaseprovidethereturntoworkprotocol

Hasthepatienteverhadthesameorsimilarcondition?q YesqNoIfyes,pleaseprovidedatesandcompletedescription.

Isthepatient’sconditionduetoinjuryorsicknessarisingoutofhis/heremployment?q YesqNoIfyes,pleaseelaborate.

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Section B – Treatment - (suite)

IsyourpatientqRight-handedqLeft-handed

Isyourpatientcompetenttomanagehis/herownfinancialaffairs?qYesqNo

Ifthepatientwas/ispregnant,pleaseindicatethedateorexpecteddateofdelivery. ( Y Y Y Y / M M / D D )

Section C – Treatment

Frequencyofpatientvisitsq WeeklyqBi-weeklyq MonthlyqOther___________________________________________

Pleasedetailthepatient’spastandpresenttreatment(e.g.: date and type of surgery)aswellasresponsetotreatment.

Hasthepatientbeenhospitalized?q YesqNoIfyes,pleaseprovidethenameofthehospital(s)andthedatesofadmission.

Pleaselistallofthemedicationsthatthepatientiscurrentlytaking,includingdosageanddateprescribed.

Medication

Dosage

Dateprescribed (YYYY/MM/DD)

Ifthispatientwasreferredtoyou,pleaseprovidethenameofthereferringphysician.

Ifyouhavereferredthepatienttoaspecialist(s),pleaseprovidethename(s)ofthespecialist(s)andareaofspecialty.

Haveyoutreatedorhasthepatientconsultedyouduringthelast5 years prior tothelastillness? q Yes qNo

Didthepatient,toyourknowledge,receivetreatmentduringthelast 5 yearsfromanyotherhealthprofessional,orinanyhospitalorinstitution? q Yes qNo

If«Yes»,toeitherquestion,pleasefurnishthefollowing:

Name Address Natureofillnessorinjury Dates

Signature Date ( Y Y Y Y / M M / D D )

Name(pleaseprint) Specialty Licenseno.

Address(no.,street)

Telephoneno. Faxno.

Attending physician statement – physical conditions (continued)

( Y Y Y Y / M M / D D )

( Y Y Y Y / M M / D D )

( Y Y Y Y / M M / D D )

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Section A – Information about the patient


Dateofbirth ( Y Y Y Y / M M / D D ) Height Weight

Section B – Diagnosis

PleaseindicatethediagnosisusingDSM–IVMultiaxialevaluationnomenclatureandcodenumbers.

I

II

III

IV

V

Isthereasecondarydiagnosisoradditionalcomplicationwhichmightaffectthedurationofthedisability?q YesqNoIfyes,pleaseelaborate.

Whendidsymptomsfirstappear? ( Y Y Y Y / M M / D D )

Pleaseprovideacompletelistofyourpatient’ssymptoms(includingseverityandfrequency),identifyingwhichofthesymptomslistedyouhaveobjectivelyobserved.

Whatwasthedateofthepatient’sfirstvisitforhis/hercurrentcondition? ( Y Y Y Y / M M / D D )

Whatwasthedateofthepatient’sfirstvisitduringthepresentdisabilityperiod? ( Y Y Y Y / M M / D D )

Pleasedescribethepatient’sinitialreasonforseekingtreatment.Wasthereaprecipitatingevent?

Isyourpatient’sconditioncauseddirectlyorindirectlybyhis/heremployment?q YesqNoIfyes,pleaseelaborate.

Whatarethepatient’scurrentlimitations(thingsthathe/shecannotdo)?Pleasebespecific.

Whatarethepatient’scurrentrestrictions(thingsthathe/sheshould notdo)?Pleasebespecific.

Isyourpatientcompetenttomanagehis/herownfinancialaffairs?q YesqNo

Pleaseindicatethedatethepatientstoppedworkingorperforminghis/herdailyactivitiesbasedonyourrecommendation. ( Y Y Y Y / M M / D D )

Ifapotentialreturntoworkdateorreturntodailyactivitieshasbeendiscussed,pleaseprovidethedateandindicateifthereturnis ( Y Y Y Y / M M / D D )qPart-timeqFull-timeqTemporaryassignmentqLightdutiesqGradual–Pleaseprovidethereturntoworkprotocol

Attending physician statement – psychological conditionsIn order for Humania Assurance to properly assess your patient’s claim for Disability Benefits, it is important that you answer the following questions in as much detail as possible. Please note that any costs incurred in the completion of this form are the responsibility of the patient.

Forinformation,pleasecontactusat:intheMontrealregionat514489-8404,intheSaint-Hyacintheregionat450-773-7170,elsewhereat1800773-8404.Our address is: P.O. Box 10 000 at Saint-Hyacinthe (Quebec) J2S 7C8 • Web site: www.humania.ca

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Section C – Treatment

Frequencyofpatientvisitsq WeeklyqBi-weeklyq MonthlyqOther___________________________________________Pleasedetailthepatient’spastandpresenttreatment(includingpsychotherapy),responsetotreatment,andcompliance.

Hasthepatientbeenhospitalized?q YesqNoIfyes,pleaseprovidethenameofthehospital(s)andthedatesofadmission.

Pleaselistallofthemedicationsthatthepatientiscurrentlytaking,includingdosageanddateprescribed.

Medication Dosage Dateprescribed

(YYYY/MM/DD)

Haveyoutreatedorhasthepatientconsultedyouduringthelast 5 years priortothelastillness? q Yes qNo

Didthepatient,toyourknowledge,receivetreatmentduringthelast 5 yearsfromanyotherhealthprofessionalorinanyhospitalorinstitution? q Yes qNo

If«Yes»,toeitherquestion,pleasefurnishthefollowing:

Name Address Natureofillnessorinjury Dates

Attending physician statement – psychological conditions (continued)

( Y Y Y Y / M M / D D )

( Y Y Y Y / M M / D D )

Section D – Functional capacities evaluation

Pleaseprovideyouropinionastotheextentofthepatient’simpairmentinperformingthefollowingonasustainedbasis:None: noimpairmentinthisarea. Moderately severe:impairmentsignificantlyaffectsabilitytofunction.Mild:suspectedimpairmentofslightimportancewhichdoesnotaffectfunctionalability. Severe:extremeimpairmentofabilitytofunction.Moderate:impairmentaffectsbutdoesnotprecludeabilitytofunction.

None Mild Moderate Moderately

Severe

severe1. Abilitytorelatetofriendsandfamilymembers q q q q q

2. Abilitytoattendtopersonalcare(bathing,cooking,etc.) q q q q q

3. Abilitytocarryouthouseholdchores q q q q q

4. Abilitytorelatetoco-workersandsupervisors q q q q q

5. Performworkwherecontactwithotherswillbeminimal q q q q q

6. Understand,carryout,andrememberinstructions q q q q q

7. Performtasksinvolvingminimalintellectualeffortorrepetitivetasks q q q q q

8. Performvariedtasks q q q q q

9. Abilitytofollowaregularworkschedule q q q q q

10. Makeindependentjudgements q q q q q

11. Performintellectuallycomplextasksrequiringhigherlevelsofreasoning,math, andlanguageskills

q q q q q

12. Superviseormanageothers q q q q q

Signature Date ( Y Y Y Y / M M / D D )

Name(pleaseprint) Specialty Licenseno.

Address(no.,street)

Telephoneno. Faxno.

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Authorization

I authorize any health care professional, hospital, clinic, pharmacist, provincial health insurance plan, rehabilitation agency, insurer, employer or any other person or organization inpossession of information concerning myself to release to Humania Assurance all medical, financial or other information deemed relevant in the assessment of my claim.

I authorize Humania Assurance to conduct all necessary investigations required in order to verify the validity of my claim. I accept that Humania Assurance will use the informationprovided for this claim and any prior claims under the same plan for the management of my claim and for production or statistical reports.

This authorization is valid for the complete duration of the present claim. A photocopy of this authorization is as valid as the original.

4300-013 - Rév. 04/2013

Name (please print) Signature

Policy no. Date (YYYY/MM/DD)Humania Assurance Inc., 1555 Girouard Street West, P.O. Box 10000, Saint-Hyacinthe, Quebec J2S 7C8

Authorization




4300-013 - Rév. 04/2013



Authorization




4300-013 - Rév. 04/2013



4300-013 293c_04-2013_4300-013.qxd 2013-04-09 09:47 Page 4

To avoid any delay in the assessment of your claim, please complete and sign all the authorizations below, even if you completed the one found on page 3 of this document.

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Notes and Comments

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Notes and Comments

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Notes and Comments

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4300-058 Rév. 04/2013

HUMANIA ASSURANCE INC.

1555 Girouard Street West, P.O. Box 10 000, Saint-Hyacinthe (Quebec) J2S 7C8Montreal region: 514 485-7236Saint-Hyacinthe region: 450 773-7236Other region: 1 800 818-7236Web site : www.humania.ca

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DISABILITY CLAIM FORM - Beneplan · Nature of request for benefits q Short-Term Disability (please...

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Transcript of DISABILITY CLAIM FORM - Beneplan · Nature of request for benefits q Short-Term Disability (please...