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Destination: Travel Health Plans

Underwritten by CUMIS General Insurance Company

 

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 insured for benefits under a Canadian government health insurance plan during the entire period of coverage

 

 Applicant :  Name            Age (on the application date)    

Destination:     

Single-Trip Medical Plan                 Annual Multi-Trip Medical Plan        

Total Number of days per trip     (8, 15, 30, and 60 days for Annual Multi-trip plans)

  * 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:

 

1

Have you been diagnosed with a terminal illness?

 

 Yes No

2

Have you been diagnosed with acquired immune deficiency syndrome (AIDS) or human immune deficiency virus (HIV)?

 

 Yes No

3

Did you receive  treatment for pancreatic cancer, liver cancer or any type of cancer that has metastasized?

 

 Yes No

4

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

 Yes No

5

Have you been diagnosed with or received treatment for congestive heart failure or cardiomyopathy in the last 24 months?

 Yes No

6

Have you had a lung condition for which the use of home oxygen has been prescribed in the last 24 months?

 Yes  No

7

Have you been diagnosed with or treated for kidney or renal failure, required kidney dialysis, or had a physician recommend kidney dialysis in the last 24 months?

 Yes No

8

Do you require assistance with activities of daily living?

 

 Yes No

9

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

10

In the 12 months prior to your 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 10 a) above?

  Yes  No
c)

prescribed a total of 6 or more separate and distinct prescription medications (excluding aspirin and prescriptions for minor conditions) for all of the medical conditions combined as listed in Question 10 a) above?

  Yes   No

11

On your 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 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 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)  Diabetes (excluding controlled by diet)? Yes (6pts)    No
d)

 Stroke (CVA) or Transient  Ischemic Attack (TIA)?

Yes (6pts)    No
e)  Bowel / Stomach disorder (excluding Diverticulitis)?
Yes (6pts)    No
f)

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

Yes (6pts)    No
g)

 Artery or vein disorder?

Yes (5pts)    No
h)

 Diverticulitis?

Yes (4pts)    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 1 or 2 medication(s) only ?

Yes (1pts)    No
n)

 Asthma

Yes (2pts)    No
o)

 Diet  controlled diabetes?

Yes (1pts)    No
2

 Prior to your application date, has it been more than 24 months since you have undergone a medical check-up?

Yes (2pts)    No
3

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

Yes          No
4  Do you need Reduced Stability Period Option? Yes        No

 

 

Notes

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

 

 

Your E-mail   

 

 

 

Total Points Plan classification Automatic Stability Period Reduced Stability Period Option
0 to 1 points Premier Plan

90 days

30 days (20% surcharge )

2 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).

 

Insurer means CUMIS General Insurance Company, a member of The Co-operators group of companies.

 

Lung/respiratory 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 conditions are not considered stable:

a) any lung condition for which in the last 365 days you were prescribed or are taking prednisone for a period of more than 10 consecutive days;

b) any heart condition for which in the last 12 months you have used nitroglycerin.

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.

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Revised: October 17, 2017