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    Admed Statement of Attending Physician or Surgeon

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    shemina armorer
    This document is an attending physician statement from a doctor regarding a patient's insurance claim with Maritime Life (Caribbean) Ltd. The doctor is asked to provide medical details about the patient's condition, history, treatments, and whether any of the insurance policy's benefit definitions are met to enable the insurance company to assess the claim. The definitions include requirements for surgical procedures, hospital diagnostic expenses, and accident or emergency services.

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    © All Rights Reserved
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    Admed Statement of Attending Physician or Surgeon

    Uploaded by

    shemina armorer
    21 views2 pages
    This document is an attending physician statement from a doctor regarding a patient's insurance claim with Maritime Life (Caribbean) Ltd. The doctor is asked to provide medical details about the patient's condition, history, treatments, and whether any of the insurance policy's benefit definitions are met to enable the insurance company to assess the claim. The definitions include requirements for surgical procedures, hospital diagnostic expenses, and accident or emergency services.

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    ADmed-Statement-APS-Form

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    This document is an attending physician statement from a doctor regarding a patient's insurance claim with Maritime Life (Caribbean) Ltd. The doctor is asked to provide medical details about the patient's condition, history, treatments, and whether any of the insurance policy's benefit definitions are met to enable the insurance company to assess the claim. The definitions include requirements for surgical procedures, hospital diagnostic expenses, and accident or emergency services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    21 views2 pages

    Admed Statement of Attending Physician or Surgeon

    Uploaded by

    shemina armorer
    This document is an attending physician statement from a doctor regarding a patient's insurance claim with Maritime Life (Caribbean) Ltd. The doctor is asked to provide medical details about the patient's condition, history, treatments, and whether any of the insurance policy's benefit definitions are met to enable the insurance company to assess the claim. The definitions include requirements for surgical procedures, hospital diagnostic expenses, and accident or emergency services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Maritime Life (Caribbean) Ltd.

    P.O. Box 710, Port-of-Spain

    ADmed STATEMENT OF ATTENDING PHYSICIAN OR SURGEON


    (The fee for this statement is the responsibility of the insured)

    Name of Patient: Policy No:


    Date of Birth:
    The above named is insured with MARITIME LIFE (CARIBBEAN) LIMITED against the occurrence of certain contingent events associated with his/her health. We would be
    grateful for your co-operation in the completion of this form to enable us to assess claim and make the prompt settlement.

    THE ISSUE OF THIS FORM IS IN NO WAY AN ADMISSION OF LIABILITY


    A. MEDICAL DETAILS:
    1. Please provide full and exact details of the condition (describe any complications).

    Please give details of any YES answers


    YES NO DETAILS
    2. Was this (a) an Accident?

    (b) an Emergency?

    3. Is there any evidence/history of:

    a) Alcohol Abuse?

    b) Drug Addiction?

    c) Smoking?

    4. Is there any disease or infirmity affecting present


    condition?

    5. a) Please give the details of any tests or investigations recommended by


    you.

    b) Are the tests requested for the purpose of


    obtaining a diagnosis?
    6. Was surgery performed? (If YES, please give name of
    procedure and date)

    7. Is it likely that the patient will have to undergo


    further treatment in connection with this
    illness/injury? (If YES, please give details (including
    laboratory investigations/X-rays/others).

    B. GENERAL
    Are you the usual medical doctor? (If YES, over
    1. what period do your records extend?)

    2. When were you first consulted for this condition?


    3. At that time, how long had the symptoms been present?

    Was the patient informed of the diagnosis? (If YES,


    4. please give date)
    Has the patient previously suffered from the
    5. condition specified above or related illness?
    (If YES, please give details)
    6. Please give the name and address of all consultants, specialists or hospitals to whom your patient has been referred or attended for this condition.
    NAME ADDRESS DATE OF ADMISSION/ DATE OF
    CONSULTATION DISCHARGE

    Revised 1/2010
    C. ADMED BENEFITS
    In order for a claim to be payable at least one of the following definitions must apply:
    SURGICAL BENEFIT:
    The surgical operation must be (a) medically necessary and appropriate, (b) an invasive procedure requiring a surgical incision; and (c) must be performed at
    a hospital.
    HOSPITAL DIAGNOSTICS BENEFIT:

    The expenses were incurred as a result of accident, emergency or for sickness on an approved doctor's recommendation at a hospital in respect of the
    diagnosis of an Injury, condition or disease.
    ACCIDENT & EMERGENCY BENEFIT:
    The expenses incurred at a hospital in respect of accident or emergency services or in respect of ambulance services required as a result of an accident or
    emergency.
    • Under this benefit Accident is defined as:
    Any sudden and unforeseen event occurring during the policy period, resulting in bodily injury, the cause or one of the causes of which is external to the
    victim's own body and occurs beyond the victim's control and for which initial treatment is sought within seven (7) days of the accident.

    • Under this benefit Emergency is defined as:


    The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of
    immediate medical attention could reasonably be expected to result in:
    - placing the patient's health In serious jeopardy;
    - serious Impairment to bodily functions; or
    - serious dysfunction of any body organ or part.

    YES NO
    In your opinion, has one of the definitions stated been satisfied?
     Surgical
     Hospital Diagnostics
     Accident & Emergency

    PRACTICE STAMP:

    DOCTOR'S NAME (PRINTED)

    ADDRESS:

    DATE:
    SIGNATURE

    Revised 1/2010

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