Travel Insurance

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T.I.C. Travel Insurance Coordinators

Travel Insurance

 

Eligibility and Medical Questionnaire

 

 Applicant : Name      Age       Destination:   

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

* For multi-trip plans, you can choose from 8, 15, 35, 60 and 105 day annual plans.

 

Do you qualify?

Section 1 - Eligibility

Please answer the following medical questions to determine your eligibility

 

1

Have been diagnosed with a terminal illness?

 

 Yes No

2

Have you been diagnosed with or has had an episode of congestive heart failure?

 

 Yes No

3

Do you have Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV)?

 

 Yes No

4

Do you have Alzheimer's disease or any other type of dementia?

 

 Yes No

5

Have you received any type of treatment for pancreatic cancer, liver cancer or any type of cancer that has metastasized?

 

 Yes No

6

Have you been prescribed or used home oxygen treatment in the last 12 months?

 

 Yes  No

7

Have you had a major organ transplant (heart, kidney, liver, lung)

 

 Yes No

8

Have you received kidney dialysis treatment in the last 12 months

 

 Yes No

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

 

What rate category do you qualify for?

Please answer all questions and check Yes or No for each question (for applicants 60 years of age and over).

 

Section 2 - Offer of insurance

 

1

In the last 24 months have you been diagnosed with, or needed a medical consultation, investigation, or treatment for 2 or more of the following conditions:
• cardiovascular/heart condition;
• cerebrovascular condition;
• diabetes (excluding controlled with diet only);
• cancer (excluding skin cancer, basal or squamous);
• emphysema or COPD?

 

Yes  No

 

 

Section 3 - Rate classification

 

1

In the last 24 months have you had, been diagnosed with, or needed a medical consultation, investigation, or treatment for any one of the following conditions:
• a cardiovascular/heart condition;
• a ccerebrovascular condition;
• a respiratory/lung condition;
• a blood disorder;
• diabetes treated with insulin;
• cancer (excluding skin cancer (basal or squamous)?

 

  Yes    No

 

 

Section 4 - Rate classification

 

1

In the last 24 months have you had, been diagnosed with, or needed a medical consultation, investigation, or treatment for any one of the following conditions:
• a gastrointestinal condition;
• an internal condition;
• diabetes treated with oral medication?

 

Yes     No

2

In the last 24 months, have you had, been diagnosed with, or needed a medical consultation, investigation, or treatment for any one of the following conditions:
• a musculoskeletal disorder or osteoporosis;
• high blood pressure (hypertension) treated with 3 or more medications?

 

Yes     No

 

 

Definitions

Blood disorder means any condition of the blood including anemia (other than vitamin B-12 deficiency anemia), purpura, Hemophilia, polycythemia, Sickle-cell anemia, hematochromatosis.

Cardiovascular condition means myocardial infarction, heart attack, arrhythmia, atrial fibrillation, heart murmur, chest pain or angina, arteriosclerosis, carotid artery occlusion, congestive heart failure, cardiac by-pass or any other kind of cardiac surgery, angioplasty or stent, use of pacemaker or defibrillator, congenital heart defect or any other condition relating to the heart or cardiovascular system.

Cerebrovascular condition means cerebrovascular accident (CVA), stroke, transient ischemic attack (TIA), mini-stroke or aneurysm, Parkinson's disease, seizures or epilepsy.

Gastrointestinal disorder means any stomach or bowel disorder, ulcer, diverticulitis, diverticulosis, ulcerative colitis, Crohn's disease, hiatus hernia or irritable bowel syndrome (excluding acid reflux, gastro-esophageal reflux disease

Internal condition means liver disease, gall bladder disease, kidney disorder (including kidney stones), spleen or pancreatic disorder, prostate or urinary disorder, ovarian or uterine disorder, aneurysm, peripheral vascular disease or artery or vein disorder (including blood clots, carotid artery stenosis and deep vein thrombosis).

Medical consultation means any medical services obtained from a licensed medical practitioner for an ailment, sickness or medical condition, including but not limited to any or all of: history taking, medical examination, investigative testing, advice or treatment, and for which a diagnosis of the condition need not have been definitively made. This does not include regular medical check-ups where no medical signs or symptoms existed or were found during the check-up.

Respiratory condition means chronic obstructive pulmonary disease (COPD), bronchial asthma, chronic bronchitis, emphysema, or any other respiratory condition requiring the use of corticosteroids.

Treatment means a medical, therapeutic or diagnostic procedure prescribed, performed or recommended by a physician including, but not limited to, prescribed medication, investigative testing or surgery.

 

Notes

 

 

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                May 14, 2012