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Manulife Financial

Out of Province Travel Insurance for Canadians

 

Eligibility and Medical Questionnaire

Applicants 55 year of age or older must answer the following questions to determine eligibility and rate category. Medical questions help the company to determine your eligibility and premium rate. If you are uncertain of your answers to any of the medical questions, please consult your doctor before completing the application for insurance.

Applicant :  Name      Age  

Single-Trip Medical Plan     Annual Multi-Trip Medical Plan     Total Number of days per trip*  

* For multi-trip plans, you can choose from 4,10,18 and 30 day annual plans.

 

Do you qualify?

Section 1 - Eligibility

Please answer the following medical questions to determine your eligibility

 

1

Have you been advised by a physician not to travel at this time?

 

 Yes No

2

Do you require kidney dialysis?

 

 Yes No

3

Have you ever had a bone marrow or organ transplant (excluding corneal transplant)?

 

 Yes No

4

Have you had a heart bypass, angioplasty or heart valve surgery more than ten (10) years ago?

 

 Yes No

5

In the last five (5) years, have you been diagnosed with and/or had treatment for metastatic cancer?

 

 Yes No

6

In the last six (6) months, have you received chemotherapy and/or radiotherapy and/or other treatment, other than routine follow-up, for cancer (except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?

 

 Yes  No

7

In the last twelve (12) months, have you been prescribed or taken Prednisone or oxygen, or been hospitalized (as an inpatient or in the emergency department) for a lung condition?

 

 Yes No

8

In the last two (2) years, have you:
a) been prescribed or taken Lasix or Furosemide for any reason?
b) had congestive heart failure?
 

 Yes No

9

In the last twelve (12) months, have you been hospitalized (as an inpatient or in the emergency department) for a heart condition?

 

 Yes No

10

In the last four (4) months, have you been prescribed or taken six (6) or more prescription medications? Do not count the following medications: hormone replacement therapy (thyroid or menopausal); drugs used for osteoporosis, or traveller’s diarrhea; or any form of immunization.
Do not count topical medications that go in your ears or eyes or on your scalp or skin except: any form of nitroglycerine or any drug(s) for angina.

 

 Yes No

11

In the last three (3) years, have you been diagnosed with and/or had treatment for and/or been hospitalized (as an in-patient or seen in the emergency department) and/or been prescribed or taken medication for any two (2) of the following (if you only have one (1) of the following conditions, answer NO)?
• Heart condition
• Lung condition (medication includes any puffer(s)/inhaler(s) (except a single unrepeated prescription used for a single episode)
• Diabetes (treated with medication and/or insulin)
• Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack) (including use of aspirin/Entrophen for this condition)
• Peripheral vascular disease (blocked or narrowed arteries)?
• Alzheimer’s disease, or any other form of Dementia

 

 Yes No

If you answered is YES to any of the medical questions in this Section, you are not eligible to purchase this policy.

 

If you are unable to meet the Eligibility Requirements as stated in Section 1, you may be eligible for Manulife’s Individual Medical Underwriting Plan. Call 416-493-0101 for more information. 

 

 

What rate category do you qualify for?

IF YOU ARE UNCERTAIN OF YOUR ANSWERS TO ANY OF THE MEDICAL QUESTIONS, PLEASE CONSULT YOUR DOCTOR BEFORE COMPLETING THIS QUESTIONNAIRE

 

Section 2 - Rate Category Qualification Part 1

Please answer the following medical questions to determine the rate category you qualify for.

The rate category determines the pre-existing medical condition exclusion that applies to your coverage and the rate category you qualify for.

 

1

In the last five (5) years, have you been diagnosed with and/or had treatment and/or been hospitalized (as an in-patient or seen in the emergency department) and/or been prescribed or taken medication for any of the following?
• Heart condition
• Stroke/CVA (cerebrovascular accident) or mini-stroke/TIA (transient ischemic attack)(including use of aspirin/Entrophen for this condition)
• Aneurysm
• Peripheral vascular disease (blocked or narrowed arteries)
• Diabetes (if treated with medication and/or insulin)
• Lung condition (medication includes any puffer(s)/inhaler(s) except a single unrepeated prescription used for a single episode)
• Cirrhosis of the liver
• Alzheimer’s disease, any other form of Dementia, or Parkinson’s disease

 

Yes        No

2

In the last five (5) years, have you smoked or used any tobacco products and been prescribed or used any puffer(s)/inhaler(s)?

 

Yes        No

3

In the last six (6) months, have you received advice or treatment for a medical emergency more than once in the emergency room of a hospital?

 

Yes        No

4

In the last three (3) months, have you been prescribed or taken a total of three (3) or more medications for high blood pressure (hypertension) and/or a heart condition?

 

 Yes  No

 

 

Section 3 - Rate Category Qualification Part 2

Please continue to answer part-2 of medical questions to determine the rate category you qualify for.

The rate category determines the pre-existing medical condition exclusion that applies to your coverage and the rate category you qualify for.

1

In the last two (2) years, have you been diagnosed with or received treatment for and/or been hospitalized (as an in-patient or seen in the emergency department) and/or been prescribed or taken medication for any of the the following conditions?

 
1a

• Bowel obstruction or surgery

 

  Yes No

1b

• Diverticular disorder requiring prescription medication or surgery

 

Yes        No

1c

• Gastrointestinal bleeding

 

Yes        No

1d

• Bleeding or perforated ulcer(s)

 

Yes        No

1e

• Chronic bowel disorder

 

Yes        No

1f

• Liver disorder

 

Yes        No

1g

• Pancreatic disorder

 

 Yes No

1h

• Kidney disorder (including stones)

 

Yes        No

1i

• Gallbladder disorder (including stones. If gallbladder has been removed, answer NO).

 

Yes        No

 

 

Section 4 - Rate Category Qualification Part 3

Please continue to answer part-3 of medical questions to determine the rate category you qualify for.

1

In the last two (2) years, have you been diagnosed with, and/or been hospitalized (as an inpatient or seen in the emergency department), and/or received treatment, and/or been prescribed medication by a Hematologist or an Internist for a blood disorder?

 

Yes        No

2

In the last twelve (12) months, have you been prescribed or used a puffer/inhaler?

 

Yes        No

3

In the last twelve (12) months, have you been diagnosed with or received treatment for cancer (other than routine follow-up except basal cell and squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?

 

Yes        No

4

Are you over 65, and have you had a fall that you reported to a physician in the last six (6) months?

 

Yes        No

 

 

Section 5 - Rate Category Qualification Part 4

Please continue to answer part-4 of medical questions to determine the rate category you qualify for.

1

In the last two (2) years, have you smoked or used any tobacco products?

 

Yes        No

 

Notes

 

 

Your E-mail   

 

                                          Revised: May 10, 2012                                                       May 10, 2012