| Name | Description | Type | Additional information |
|---|---|---|---|
| IllnessDate | date |
None. |
|
| IsMaternityTreatment | boolean |
None. |
|
| DeliveryDate | date |
None. |
|
| Symptoms | string |
None. |
|
| PhysicianDiagnosis | string |
None. |
|
| PreviousOccurrenceDetails | string |
None. |
|
| TreatmentResultingFrom | TreatmentResultingFrom |
None. |
|
| OtherCoverageDetails | OtherCoverageDetails |
None. |
|
| PhysicianFacilityInformation | PersonalDetails |
None. |