LIVING ASSURANCE / EPCC CLAIM DOCTOR S STATEMENT
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1 LIVING ASSURANCE / EPCC CLAIM DOCTOR S STATEMENT DOCTOR S STATEMENT FOR: STROKE * Please delete where appropriate For Official Use _ G E L S Name of Life Assured: NRIC/ Passport No.: of Birth (dd/mm/yyyy): Gender: M / F * 1. Are you the Life Assured s usual medical doctor? YES / NO* If YES, since what date? 2. (a) when Life Assured first consulted you for Stroke: (b) Please state symptoms presented and date symptoms first appeared. Symptoms Presented at First Consultation Symptoms First Started (D/M/Y) What is the source of this information? Patient / Referring Doctor / Others* If Others, please specify: (c) Please provide full and exact diagnosis of the Life Assured s condition. (d) when illness / condition was FIRST diagnosed: (e) Diagnosis was first made by (name of doctor): (f) when Life Assured first became aware of the illness: The Great Eastern Life Assurance Company Limited (Reg. No G) CCLMDOCLAP
2 3. (a) Describe the initial episode Nature of episode: : (iii) Duration of acute symptoms: (iv) Is the Life Assured able to return to normal duties? If YES, please state when: YES / NO* If NO, please state the Life Assured s latest physical and mental limitations (with date of latest assessment) Neurological Limits (b) Was there any neurological deficit 6 weeks after the date of diagnosis of Life Assured s stroke? YES / NO* If YES, please describe the neurological deficit. (c) Is this neurological damage likely to be permanent? YES / NO* If YES, please provide details. (d) Has there been an infarction of brain tissue, haemorrhage or embolisation from an extracranial sourcce? YES / NO* If YES, please state which of the above.
3 (e) Are the investigation or findings consistent with the diagnosis of a new stroke? YES / NO* If YES, please provide details. (f) Please provide names and addresses of any hospital or clinic to which the Life Assured was referred, together with the names of the consultants attended. This section is applicable to intracranial aneurysm or arterio-venous malformation condition only. 4. (a) Was an arteriogram carried out? YES / NO* If YES, please provide the following: of arteriogram: A copy of the report. (b) Was surgery carried out to correct intracranial aneurysm or arterio-venous malformation? YES / NO* If YES, please provide the following: of surgery: Was surgery done via craniotomy? YES / NO* If NO, please state the type of surgery performed. This section is applicable to hydrocephalus condition only. 5. (a) of first diagnosis of hydrocephalus: (b) Please state the symptoms presented.
4 (c) How was this diagnosis established? Please include a copy of diagnostic investigation report. (d) Was the Life Assured s condition of hydrocephalus congenital in nature? YES / NO* If NO, please indicate the cause of the hydrocephalus. (e) Was there any intracranial pressure giving rise to neurological deficits as a result of the hydrocephalus? YES / NO* If YES, please indicate the neurological deficits. (f) Is there surgical insertion of a shunt? YES / NO* If YES, please state the date of shunt insertion. (g) Was there any other method that could have been used to treat the Life Assured s hydrocephalus? YES / NO* If YES, please state the alternative treatment options. Why was this treatment method not selected? 6. (a) Did Life Assured suffer from narrowing of the carotid artery? YES / NO* If NO, please proceed to Question 7. If YES, please provide the following: Was an arteriography carried out? YES / NO* If YES, please provide a copy of report. Please state the percentage of narrowing of the carotid artery.
5 (iii) Was Endarterectomy carried out to correct the carotid artery? YES / NO* If YES, please state the date of surgery. If NO, please state the types of treatment provided. 7. (a) Has the Life Assured previously suffered from all the conditions described above or any related illnesses, e.g hypertension, transient ischaemic attack, angina, other cardiovascular disease, etc? YES / NO* If YES, please state: Illness of First Diagnosis (D/M/Y) Name and Address of Attending Doctor (b) Is there anything in the Life Assured s personal medical history which would have increased the risk of a Stroke? YES / NO* If YES, please give full details including the date of diagnosis, name and address of attending doctor and source of information. (c) Is there anything in the Life Assured s family history which would have increased the risk of a Stroke? YES /NO* If YES, please give full details including the relationship, nature of illness, date of diagnosis and source of information. (d) Please give details of the Life Assured s habits in relation to cigarette smoking, including the duration of smoking habits, number of cigarettes smoked per day and source of information.
6 (e) Please give details of the Life Assured s habits in relation to alcohol consumption including the amount of alcohol consumption per day and source of information. (f) Is the Life Assured suffering or has suffered from any other significant illnesses? YES / NO* If YES, please state illness, date of first diagnosis and name and address of attending doctor. 8. (a) Please describe the Life Assured s mental and cognitive abiliites. (b) Is the Life Assured mentally incapacitated in accordance to the Mental Capacity Act (Chapter 177A of Singapore)? YES / NO* 9. (a) Did the Life Assured consult any other doctor for this illness of its symptoms BEFORE he/she consulted you? YES / NO* If YES, please give name(s) and address(es) of the doctor(s) whom he/she consulted. Name of Doctor Name of Clinic / Hospital and Address (b) Please provide the names and addresses of any hospital or clinic to which the Life Assured was referred, together with the names of the consultants attended.
7 10. Please state and attach copies of all hospital, radiological, CT scanning reports, MRI and supply details of laboratory or any other tests done. 11. Please provide us with any other additional information that will enable the Company to assess this claim. Signature & Official Stamp of Doctor
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