Fillable Critical Illness Claim Major Burns (RBC Insurance)

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Critical Illness Claim Major Burns (RBC Insurance)

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Critical Illness Claim
Major Burns
Condential Physician’s
Statement
83694 (05/2020)
Page 1 of 2
VPS 107187
PATIENT’S INFORMATION
Name:
Last First Middle
Date of Birth:
(DD/MM/YYYY)
Policy No(s):
Claim No(s):
What We Request and Why
Your patient is applying for benets under a policy issued by RBC Life Insurance Company, and its participating reinsurers, and we will be assessing eligibility for
benets based on your patient’s medical condition. As you can appreciate, the information provided by you is most important in our assessment. We are asking for your
co-operation in providing pertinent information.
We ask that you complete the Physician’s Statement as thoroughly as possible. Please be assured that the information, including the medical records requested, is
required in the adjudication of your patient’s claim and will be treated condentially.
We are requesting copies of your complete le including specialist consultations on your patient and We are prepared to reimburse $50.00 for the costs
associated with preparing the information. If this amount is unreasonable because of the extent of your patient’s le, please have your staff contact our ofce at
416-643-4700 or toll free 1-877-519-9501. Any charge for the completion of the form, however, is the responsibility of the patient.
We would like to thank you in advance for your co-operation.
DIAGNOSIS
1. On what date were you rst consulted for the accident or condition causing Major Burns and, at that time, how long had impairment been present?
2. Has your patient previously suffered from the condition specied above or any related condition? Yes
o
No
o
If “Yes,” please state the dates and situations resulting in prior burns:
3. Please describe the circumstances leading to the occurrence of the burns:
4. What was the exact date of the incident resulting in Major Burns? (DD/MM/YYYY)
5.
Please describe the extent of your patient’s condition as follows:
a) The percentage of the body surface covered by the burns:
b) Which area of the body is affected by the burns (ie limbs, torso, etc):
c) The nature of the burns (ie rst, second and third degree burns):
6. Please provide the names and addresses of other physicians consulted or hospitals attended by your patient for this condition:
Physician/Hospital Address and Telephone Dates seen
(DD/MM/YYYY)
(over)
83694 (05/2020)
Page 2 of 2
VPS 107187
Yes
7.
Please shade in the diagram, showing the areas affected by the burns:
8.
Please give details of any test performed:
9. Please provide details of any surgery performed including dates, hospital, name of surgeon and site of graft:
10. Is there anything in your patient’s habits or personal history that would have increased the risk of accidents or burns? Yes
o
No
o
If “Yes,” please provide details:
11. Are you aware of any liability claim involving a third party?
o
No
o
If “Yes,” please provide details:
12. a) Please provide details of your patient’s past and present tobacco use, including amount per day and date last used:
b) Please provide details on your patient’s past and present use of any smoking cessation products or illicit drugs, including amount per day and date last used:
13. Please provide any other information that would be helpful in the assessment of your patient’s claim:
Our contract requires that a covered illness be diagnosed by a physician who is not related to or in a business relationship with the insured. Are you related to or in a
business relationship with this patient? Yes
o
No
o
SIGNATURE
Signature Date (DD/MM/YYYY) Degree and Specialty
Physician’s Name Primary Care Consultant
Address
(Street / City / Province / Postal Code)
Email Address
Telephone No. Fax No.
Send the completed form and documents to our ofce by email: intake@rbc.com
You can also fax the information to: RBC Life Insurance Company, Life and Health Claims Department, 1-800-714-8861.
If you have any questions, call toll free 1-877-519-9501 or 416-643-4700.
RBC Life Insurance Company, Life and Health Claims Department, P.O. Box 4435, Station A, Toronto ON, M5W 5Y8
www.rbcinsurance.com
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
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Critical Illness Claim Major Burns (RBC Insurance)

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Completed 21 May 2021

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