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True Senior Guard Travel Insurance
Medical Questionnaire

 

Eligibility

You must meet the following eligibility requirements on the departure date of each trip in order to be eligible for coverage  

You are eligible for coverage if:
1. You are a Canadian resident  covered by a provincial health insurance plan for the entire trip length,
2. You are not traveling against a physician's advice, or
3. You know of no reason to seek consultation during the trip, or
4. You have not been diagnosed with a terminal condition with a life expectancy of 6 months or less.

I confirm that I understand and meet the eligibility requirements above : YES      NO

 

 

Applicant : Name       Age         Province of residence   

 Destination:    State (for USA only): 

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

* For Annual Multi-trip plans, you can choose 4, 16, 31, 61 days per trip

**  If you are topping-up your existing policy, please provide the details in section Notes below.

 

 

Rate Qualification Questions:

View Medical Definitions

Applicants 60 +: If you have any doubt about your medical condition (s) as it relates to the following questions, you should consult your physician for advice before completing this medical health questionnaire.

Question 1

At the time of application, how many medications in total do you take or been ordered to take by a physician to treat one or more of the following conditions:

  • Lung conditions (EXCLUDING asthma and/or seasonal allergies)

  • Diabetes

  • Heart conditions/disease (Do not include aspirin, high blood pressure and cholesterol medication)

  • Stroke and/or transient ischemic attack (mini-stroke, TIA) (do not include aspirin)

3 or more medications  

2 medications

1 medication

None  

 

 

Question 2

At the time of application, are you being treated, taking or have been prescribed medication for any of the following (including Aspirin or Entrophen):

AIDS or HIV

Bowel Obstruction or Bowel Surgery

Cancer (excluding basal cell/squamous cell skin cancer)

Cholesterol medication
Crohn’s disease Dementia and/or Alzheimer’s
Diabetes (treated with oral medications or insulin) Fibromyalgia
Gastrointestinal Bleeding High Blood Pressure (HBP)
Heart condition(s)/disease (INCLUDING aspirin)

Kidney disease

   (INCLUDING kidney stones and dialysis)
Liver disease

Lung condition(s)/disease

  (INCLUDING asthma and/or seasonal allergies)
Pancreatic disease Parkinson’s disease
Seizures Spleen disease

Stroke (CVA) and/or mini-stroke (TIA)

   (INCLUDING aspirin)

 Ulcerative Colitis

4 or more medical conditions

3 medical conditions 2 medical conditions 1 medical condition

None 

 

 

Question 3

Has it been longer than 12 months since you last saw a physician or nurse practitioner?

YES        

   NO    

 

 

Question 4

Have you used any tobacco products in the last 24 months? 

YES       

   NO      

 

 

Coverage for pre-existing medical conditions

You can choose the stability period for coverage for pre-existing medical conditions. If you experience a change to your health or treatment within a stability period before your departure date, this condition will not be covered.

Stability requirement (age 60 and over)

 365 days 180 days 90 days 7 days

Stability requirement (age 59 and less)

 45 days 7 days    

 

 

Notes

(If you want an insurance broker call you, please enter your phone number here)

 

 

Your E-mail    

 

 

 

Definitions

The following definitions are for general information only.

Please consult your physician for more detailed information about your medical conditions.

Bowel Obstruction

Bowel obstruction is a mechanical blockage of the intestines, preventing the normal transit of products of digestion.

Cancer

Any malignant growth or tumor caused by abnormal and uncontrolled cell division; it may spread to other parts of the body through the lymphatic system or the blood stream.

Diabetes

A chronic condition where the body is unable to produce insulin and properly regulate or maintain sugar (glucose) level in the blood. Includes Type 1 diabetes mellitus, (insulin dependent or juvenile type) and Type 2 diabetes, (adult-onset or noninsulin-dependent diabetes mellitus -NIDDM), which is the most common form of diabetes.

Heart Conditions/Disease

Any abnormal condition of the heart, heart disease or cardiopathy.

Hypertension

Also known as high blood pressure. For example, blood pressure above 140/90 for more than 6 months.

Lung Conditions/Disease

Any abnormal condition of the lungs, affecting the lungs or associated airways. Most commonly applicable to lung infection such as pneumonia, Chronic Obstructive Pulmonary Disease (COPD), asthma, etc.

Medical Condition

Any condition of the body or mind that causes discomfort, dysfunction, or distress to the person affected. Sometimes the term is used broadly to include injuries, disabilities, syndromes, symptoms, deviant behaviours, and atypical variations of structure and function of the human body.

Medication

Includes medication that requires a prescription from a physician or other registered medical practitioner and medication purchased over the counter as per the physician′s advice or other registered medical practitioner′s advice.

Medical Treatment

Means examination and treatment by a Legally Qualified Physician for a condition which first manifested itself, worsened or became acute or had symptoms which would have prompted reasonable person to seek diagnosis, care or treatment.

Minor ailment

Minor Ailment – a condition that does not require the following:

a) Hospitalization or surgical intervention.

b) Referral to a specialist

c) Treatment for a period greater than 32 days

d) More than one follow up visit

e) Treatment ending at least 30 days prior to Departure Date

Pre-existing condition

A medical or dental condition for which treatment has been received or taken or symptoms have appeared prior to the Policy Effective Date and includes a medically recognized complication or recurrence of a medical condition

Stable

A medical condition (other than minor ailment) for which all the following statements are true:

1. Has been no new diagnosis, Treatment or prescribed medication.

2. No test results showing a deterioration in Your condition.

3. No Hospitalization, referral to a specialist (made or recommended) or You are not awaiting test or Treatment.

4. No change in Your medical Treatment and/or change in dosage of a medication

(The following is not considered a change:  the routine adjustment to Coumadin, Warfarin or insulin to maintain optimal levels  and change from a brand name to a generic with the same dosage this condition will remain stable.)

5. Stability period:

a. Stability is calculated at the departure date of your trip. For individuals 59 years or less, it can be 45 days with the option to reduce it to 7 days.

b. Stability is calculated at the departure date of your trip. For individuals 60 years or older, it can be 365 days with the option to reduce to 180 days, 90 days, 7 days.

Treat/Treatment

A medical, therapeutic or diagnostic procedure ordered performed or recommended by a Physician, including but not limited to prescription medication, surgery or investigative testing that results in a diagnosis of a specific medical condition. Treatment Does not include Minor Ailment.

 

 

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Revised: October 14, 2021