1-877-443-0101    Contact us

 

 

Destination Snowbird Plan

Underwritten by Manulife Financial

 

Eligibility and Medical Questionnaire

Who can apply? To be eligible for medical coverage you must:
a) be at least 15 days old and no more than 89 years old; and

b) be a Canadian resident and be covered by the government health insurance plan (GHIP) of your Canadian province/ territory of residence during the entire period of coverage.

 

 Applicant : Name       Age        Province of residence   

Primary 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 8, 15, 30, and 60 days per trip 

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

View Medical Definitions

Do you qualify?

Section 1 - Eligibility Requirements

Please answer the following medical questions to determine your eligibility:

 

a)

Have you been diagnosed with a terminal illness?

 

 Yes    No

b)

During the last 5 years, have you been treated for pancreatic cancer, liver cancer, lung cancer, metastatic cancer or two (2) or more cancers (excluding basal cell and squamous cell skin cancer)?

 

 Yes    No

c)

Had you an organ transplant (heart, lung, liver, kidney) or a bone marrow or stem cell transplant?

 

 Yes    No

d)

Have you  been diagnosed with or received treatment for congestive heart failure or cardiomyopathy in the last 12 months?

 

 Yes    No

e)

In the last 12 months, have you  had a lung condition for which the use of home oxygen has been prescribed or has been prescribed or are taking prednisone for a period of more than 10 consecutive days?

 

 Yes    No

f) 

Have you been diagnosed with or received treatment for Stage 4 or Stage 5 chronic kidney disease or any kidney condition requiring dialysis?

 

 Yes    No

g)

Have you been advised by a physician not to travel?

 

 Yes    No

2.

Prior to your application date, have you had your most recent heart surgery (if any) more than 12 years ago?

Heart surgery includes coronary bypass, coronary angioplasty, valve surgery (repair or replacement), valvuloplasty, implanted pacemaker or implanted defibrillator (excluding battery change).

 Yes    No
3. In the 12 months prior to you application date, have you been:
a)

hospitalized for 24 hours or more for ANY of the following medical conditions

• Artery or Vein disorder

• Heart condition

• Lung condition

• Diabetes (excluding diet controlled

• Stroke (CVA), Transient Ischemic attack (TIA)

• Liver or Pancreas disorder

• Bowel / stomach disorder

• Cancer (excluding basal or squamous cell skin cancer and breast cancer treated only with hormone therapy)

   Yes     No

b)

 diagnosed or treated for 3 or more of the medical conditions listed in question 3-a) above   Yes     No

4.

 On the application date, have you had a diagnosed aneurysm of 4 centimeters or more in either length or diameter, that has not been surgically repaired?

  Yes     No

If you have to answer NO to all questions in Section 1, please continue to Section 2.

If you must answer YES to any of the medical questions in Section 1, you are NOT eligible to purchase this policy. Please call at 1-877-443-0101 discuss other options.

 

 

What Plan Do You Qualify for?

Please answer all questions and check Yes or No for each question (for applicants 55 - 89 years of age ).

Section 2 - Plan Classification

 

1

During the 24 months prior to your application date, have you been diagnosed with, received treatment for, or been prescribed medication (including aspirin) for any of the following medical conditions:
a)  Heart condition? Yes (6pts)     No
b)

 Lung condition (excluding asthma)?

Yes (6pts)     No
c)  Cancer (excluding basal or squamous cell skin cancer and breast cancer treated only with hormone therapy)? Yes (6pts)     No
d)

 Stroke (CVA) or Transient Ischemic Attack (TIA), or mini stroke?

 Yes (6pts)     No
e) Diabetes - treated with insulin?
 Yes (6pts)     No
f)

 Diabetes - treated with oral medication?

 Yes (5pts)     No
g)

Bowel / Stomach disorders ?

 Yes (5pts)     No
h)

Artery or vein disorder ?

 Yes (5pts)     No
i)

 Neurological disorder?

Yes (3pts)     No
j)

 Pancreas disorder?

 Yes (3pts)     No
k)

 Liver disorder?

 Yes (3pts)     No
l)

 Kidney disorder?

 Yes (3pts)    No
m)

 High blood pressure (hypertension)

  
 

i.  treated at any one time with 3 or more medications?

Yes (6pts)    No
 

ii. treated at any one time with 2 medications?

Yes (1pt)     No
n)

 Asthma?

 Yes (2pts)    No
2

 Only answer if you are age 71 or older: During the last 6 months prior to your application, have you had a fall for which you sought medical attention?

 Yes (2pts)     No

3

 Have you used Tobacco products within 24 months prior to your departure date?

 Yes     No

4

 Do you want to apply for the Reduced Stability Option?  

 Yes     No

 

 Total Points: 

 

 

Notes

(Please enter your phone number, if you want an insurance broker call you)

 

 

Your E-mail   

 

        

 

 

Total Points Plan classification Automatic Stability Period Reduced Stability Period Option
0 points Premier Plan

90 days

30 days (20% surcharge )
1 to 5 points Ultra Preferred

180 days (90 days for high blood pressure)

30 days (20% surcharge )
6 to 11 points Super Preferred

365 days (90 days for high blood pressure)

90 days (30% surcharge )

180 days (20% surcharge )
12 to 16 points Elite Preferred

365 days (90 days for high blood pressure)

90 days (30% surcharge )

180 days (20% surcharge )
17  points + Not Eligible  Please call 1-877-443-0101 for other options 

 

 

Definitions

Activities of daily living means any of the following

d) eating;

e) bathing;

f) using the toilet;

g) changing positions (including getting in and out of a bed or chair);

h) dressing.

 

Artery or vein disorder includes aneurysm, peripheral vascular disease (PVD), deep vein thrombosis (DVT),phlebitis, blood clots, venous insufficiency, carotid artery stenosis, atherosclerosis.

It does not include: varicose veins.

 

Bowel/stomach disorder includes ulcer, diverticulitis, irritable bowel syndrome (IBS), gastritis, ulcerative colitis, Crohn’s disease, inflammatory bowel disease, gastrointestinal bleeds, bowel obstruction.

It does NOT include hemorrhoids, gastroesophaegeal reflux disease (GERD) or acid reflux.

It does NOT include the removal of polyps during a colonoscopy if this occurred once in the last 24 months and medical records indicate no further investigations, procedures or treatment are required or recommended.

 

Heart condition includes heart attack (myocardial infarction, arrhythmia, atrial fibrillation, heart murmur, irregular heart rate or beat, chest pain (angina), congestive heart failure, congenital heart defect or any other condition relating to the heart.

 

Heart surgery includes coronary bypass, coronary angioplasty, valve surgery (repair or replacement), valvuloplasty, implanted pacemaker or implanted defibrillator (excluding battery change).

 

Kidney disorder includes chronic kidney disease excluding kidney stones .

 

Liver disorder includes cirrhosis, fatty liver and Hepatitis C.

 

Lung condition includes chronic obstructive pulmonary disease (COPD), asthma, chronic bronchitis, chronic pneumonia, emphysema, tuberculosis, pulmonary fibrosis. It does not include seasonal allergies.

 

Minor ailment describes a sickness or injury during the stability period which ended prior to the effective date and which did not require:

i. treatment for a period longer than 15 consecutive days; or

ii. more than one follow-up visit to a physician; or

iii. hospitalization, surgery, or referral to a specialist; and

iv. which ended at least 30 days prior to the departure date.

A chronic condition or any complication of a chronic condition is not considered a minor condition.

 

Neurological disorder means Alzheimer’s disease or dementia, cerebral palsy, epilepsy, seizures, Parkinson’s disease, Multiple Sclerosis or Lou Gehrig’s disease (ALS).

 

Terminal illness means a medical condition for which, prior to your policy effective date, a physician gave a prognosis of eventual death within 24 months or palliative care was received.

 

Treatment/treated means a medical, therapeutic or diagnostic procedure prescribed, 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. Does not include minor conditions.

 

Stable describes all medical conditions for which:

a) there has been no new treatment; and

b) there has been no alteration in any medication for the condition or in its usage or in its dosage, nor any alteration in treatment prescribed or recommended by a physician; and

c) there has been no signs or symptoms or new diagnosis; and

d) there has been no test results showing deterioration; and

e) there has been no hospitalization; and

 f) there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.

The following are considered stable:

a) Routine (not prescribed by a physician) adjustment of insulin or coumadin provided it was not first prescribed during the stability period.

b) The change from a brand named medication to a generic brand medication provided that the usage or dosage has not changed.

c) a new medication prescribed solely as a result of a drug manufacturer’s discontinuance of the original medication taken.

d) the decrease or elimination of a medication dosage by a physician, provided that it has changed more than 90 days prior to your policy effective date and has not had any effect on the stability of your medical condition for the 90 days prior to your departure/effective date.

 

  Close Window