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 eligibility requirements
Applicant : Name
Province of residence
Newfoundland and Labrador
Prince Edward Island
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.
Applicants 60 + years of age have to answer the following questions to determine
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
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)
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
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)
(INCLUDING kidney stones and dialysis)
(INCLUDING asthma and/or seasonal allergies)
Stroke (CVA) and/or mini-stroke (TIA)
4 or more
Has it been longer than 12 months since you last saw a physician or
used any tobacco products in the last 24 months?
Coverage for pre-existing medical conditions
can choose the
period for coverage for
conditions. If you
experience a change to
health or treatment within a stability period before your departure
date, this condition will not be covered.
Stability requirement (age 60 and over)
Stability requirement (age 59 and less)
(If you want an insurance broker call you, please
enter your phone number here)
The following definitions are for
general information only.
Please consult your physician for more detailed
information about your medical conditions.
Bowel obstruction is
a mechanical blockage of the intestines, preventing the
normal transit of products of digestion.
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.
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.
Any abnormal condition of the
heart, heart disease or cardiopathy.
Elevated fat content in blood.
Also known as high blood pressure. For example,
blood pressure above 140/90 for more than 6 months.
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.
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.
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.
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 – 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
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
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.
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.
September 24, 2020