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Group Medical Services (GMS)

TravelStar® Travel Insurance

Eligibility and Medical Questionnaire

 Applicant :  Name         Age         Province of residence  

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

        * For Annual Multi-trip plans, please choose 15 or 30 days per trip

 * * If you are topping-up your existing policy, please provide details (total trip duration & number of days covered under your existing policy) in section Notes below .

 

Eligibility Requirements

All applicants  for travel medical insurance are subject to this Eligibility section.

Section 1 - Do you qualify?
 You are NOT eligible, if you are not a Canadian resident with valid provincial health coverage for the entire duration of your trip.

1

Are you awaiting tests or medical treatment for a heart condition?

 Yes No

2

Do you have a surgically untreated vascular aneurysm?

 Yes No

3

Have you ever been diagnosed Congestive Heart Failure (CHF)?

 Yes No

4

Do you have an Implantable Cardioverter Defibrillator (ICD)?

 Yes No

5

In the last 12 months,

were you diagnosed; received NEW treatment (e.g. consultation, tests or prescription drugs); or had a change in your medical treatment (e.g. a stop, start or dosage change to a prescription drug, other than a dosage change of Coumadin or Warfarin) for  any of the following heart and vascular conditions:

5a) Heart Transplant?

 Yes No

5b) Atrial Flutter?

 Yes No

5c) Atrial/Ventricular Fibrillation?

 Yes No

5d) Peripheral Vascular Disease?

 Yes No

5e) Stroke/TIA?

 Yes No

5f) Blood Clots?

 Yes No

6

Do you have diabetes that is treated with insulin

AND

take prescription medication for a heart condition (excluding medication ONLY to treat high cholesterol or high blood pressure)?

 Yes  No

7

Do you use home oxygen or take an oral steroid to treat a lung condition?

(Oral steroids are steroids that are swallowed to treat a lung condition. They do not include steroids that are inhaled)

  Yes No

8

Are you currently being treated for cancer, excluding breast or prostate cancer treated exclusively with hormone therapy?

  Yes No

9

In the last 12 months, were you diagnosed; received NEW treatment (e.g. consultation, tests or prescription drugs); or had a change in your medical treatment (e.g. a stop, start or dosage change to a prescription drug) for  any of the following conditions:

9a)  Liver Failure?

 Yes No

9b)  Gastrointestinal Bleed?

 Yes No

9c)  AIDs?

 Yes No

9d) Terminal Illness?

 Yes No

10

In the last 12 months, have you had any of the following procedures:

10a)  Valve Surgery or Replacement?

 Yes No

10b)  Kidney Dialysis?

 Yes No 

10c)  Organ, Stem Cell or Bone Marrow Transplant?

 Yes No 

11

If you are 70 years of age or older, do you require assistance from another person(s) with activities of daily living (ADL)?

Activities such as, personal hygiene and grooming; dressing and undressing; self-feeding; functional transfers (getting into and out of bed or a wheelchair, getting onto or off of the toilet, etc.); and bowel and bladder management.

  Yes  No

12

Are you 80 years of age or older at the time of application and purchasing a Multi-Trip Annual Emergency Medical Plan?

 Yes  No

 If you must answer YES to any of the medical questions in Section 1, you are not eligible to purchase this policy.

Please continue to Section 2, if you have to answer NO to all questions in Section 1.
 

 

What rate category do you qualify for

Please complete this Questionnaire, if you are 60 years of age or older

 

Section 2 

Have you ever suffered from, been diagnosed with, received treatment for, or been prescribed medication for any of the following medical conditions or undergone any of the following medical procedures?

1

 

Heart/Cardiovascular Disease or Condition (excluding hypertension and high cholesterol):

1a)  Heart Attack

Yes  No

1b)  Valve Replacement or Valve Surgery

 Yes  No 

1c)  Atrial Flutter

 Yes  No 

1d)  Atrial/Venticulr Fibrillation

 Yes  No 

1e)  Other Heart Condition not listed above (including, Angina, Irregular

      Heartbeat, Heart Surgery, Coronary Angioplasty, Stenting, Bypass, etc.)

 Yes  No 

2

 

Vascular Conditions:

 2a) Stroke/TIA

Yes  No

2b) Blood Clots

 Yes  No

2c) Aneurysm

 Yes  No 

2d) Peripheral Vascular Disease

 Yes  No 

2e) Carotid Stenosis

 Yes  No 

3

Chronic Lung Disease (e.g. Chronic Obstructive Pulmonary Disease (COPD); Emphysema;  Persistent Asthma)

Persistent asthma is when treatment is required on a daily basis to manage the condition and does not include occasional or temporary respiratory treatment.

 Yes  No

4

Bone Marrow or Organ Transplant

 Yes   No
5 

HIV or AIDs 

 Yes  No 
6 

Terminal Illness 

 Yes  No 
7

Cancer (Excluding Basal Cell Carcinoma)

 Yes  No 

 

 

Section 3

In the past two (2) years have you been diagnosed with, received treatment for or been prescribed medication for any of the following medical conditions?

1 

Cancer (Excluding Basal Cell Carcinoma)

 Yes   No
2 

Pancreatitis

 Yes   No
3

Chronic Kidney Disease

 Yes   No
4

Liver Disease

 Yes   No
5

Gastrointestinal Disorders (e.g. ulcers, GI bleed, bowel obstruction, Crohn's disease, colitis, diverticular disease, etc. Does not include GERD or hiatus hernia)

 Yes   No
6

Multiple Sclerosis (M.S.)

Yes   No
7 

Lou Gehrig's Disease

 Yes   No 
8 

Parkinson's Disease

 Yes   No 
9 

Dementia or Alzheimer's

 Yes   No 
10 

Epilepsy, Seizures or Syncope 

 Yes   No
11 

Hospitalized as a result of a fall 

 Yes   No
12

Diabetes (including diabetes managed by diet and exercise)

 Yes  No 

 

 

Section 4

1

Has it been more than 30 months since your last check-up with a physician?

Yes     No

2

In the past 24 months, have you used any tobacco products?

Yes    No

 

 

 

Notes

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

 

 

        Please confirm you are not a Robot or AI:

Your E-mail   

 

 

 

Definitions

Alteration: includes any newly prescribed medication, change in medication type or the increase, decrease or discontinuation of a medication and the adjustment (stop and start) in an anticoagulation medication dosage due to surgery within ten (10) days prior to your effective date, except:

a. a dosage adjustment for an anti-hypertensive or cholesterol lowering medication;

b. a change from a brand name medication to a generic brand medication of the same dosage;

c. if you are taking Coumadin/Warfarin for anticoagulation therapy and are required to have your blood levels tested on a regular basis (INR) and your medical condition remains unchanged, yet you are adjusting the dosage of your anticoagulation medication to ensure your INR is maintained within therapeutic range as directed by your physician(s); or

d. if you are taking insulin or oral anti-diabetic medication for diabetes and are required to have your blood levels tested on a regular basis and your medical condition remains unchanged, yet you are adjusting the dosage of your medication to ensure your blood glucose level is maintained within therapeutic range as directed by your physician(s).

 

Medical treatment: any medical, therapeutic or diagnostic measure prescribed or recommended by a physician in any form, including: prescription drugs; investigative testing; in-hospital care; surgery; or other prescribed or recommended action directly referable to the applicable condition, symptom or problem.

 

Stable: a medical condition is stable if, during the period of time specified in the policy, you:

a. have not received new medical treatment;

b. have not been prescribed a new prescription medication;

c. have not had a change in medical treatment;

d. have not had an alteration in a prescribed medication;

e. have not experienced a deterioration in your condition;

f. have not experienced new, more frequent or more severe;

g. have not had or required medical consultation to investigate symptoms that remain undiagnosed; h. have not required in-hospital care or a referral to a specialist, including initial follow-up visits, tests or investigations related to the medical condition and pending results; and/or

i. do not anticipate further medical treatment after departure from your province of residence.