Destination: Travel Health Plans
Underwritten by CUMIS
General Insurance Company
Eligibility and Medical
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;
b) be insured for benefits under a Canadian government
health insurance plan
during the entire period of coverage
Applicant : Name
Worldwide excluding USA
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.
Do you qualify?
Section 1 - Eligibility Requirements
Please answer the
following medical questions to determine your eligibility:
Have you been
diagnosed with a terminal illness?
Have you been diagnosed with acquired immune deficiency syndrome (AIDS)
or human immune deficiency virus (HIV)?
Did you receive treatment for pancreatic cancer, liver cancer or any type of cancer
that has metastasized?
Have you had an organ transplant (heart,
lung, liver, kidney) or a bone marrow or stem cell transplant?
Have you been diagnosed with or received
treatment for congestive heart
failure or cardiomyopathy in the last 24 months?
had a lung condition
for which the use of home
oxygen has been prescribed in the last 24 months?
Have you been diagnosed with or
for kidney or renal failure,
required kidney dialysis, or had a physician recommend kidney dialysis in the last 24
Do you require assistance
with activities of daily living?
your application date, you had your most recent
heart surgery (if any) more than 12 years
Heart surgery includes coronary
bypass, coronary angioplasty, valve surgery (repair or
implanted pacemaker or implanted defibrillator (excluding
hospitalized for 24 hours or more for ANY
of the following medical conditions
• Artery or Vein
• Lung condition
• Diabetes (excluding diet controlled
• Stroke (CVA), Transient Ischemic attack
• Liver or Pancreas disorder
• Bowel / stomach
• Cancer (excluding basal or squamous
cell skin cancer and breast cancer treated only with hormone
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?
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
condition (excluding asthma)?
Stroke (CVA) or
Transient Ischemic Attack TIA)?
(excluding basal cell or squamous cell skin cancer or breast cancer treated
only with hormone therapy)?
Artery or vein disorder?
blood pressure hypertension)
i. treated at any one time with 3 or more
ii. treated at any one time with 1or 2 medication(s)?
Diet controlled diabetes?
Prior to your
application date, has it been more than 24 months since you
have undergone a medical check-up?
Have you used Tobacco
products within 24 months prior to your departure date?
Do you want to apply
for the Reduced Stability Option?
(Please enter your phone number, if
you want an insurance broker call you)
(20% surcharge )
(90 days for high blood pressure)
(90 days for high blood pressure)
(30% surcharge )
(20% surcharge )
of daily living means any of the following
f) using the toilet;
g) changing positions (including getting in and out of a
bed or chair);
or vein disorder
includes aneurysm, peripheral vascular disease (PVD),
deep vein thrombosis (DVT),phlebitis,
blood clots, venous insufficiency, carotid artery stenosis,
It does not include:
includes ulcer, diverticulitis, irritable bowel
syndrome (IBS), gastritis, ulcerative colitis, Crohn’s disease,
inflammatory bowel disease, gastrointestinal bleeds.
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
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.
condition includes chronic obstructive pulmonary disease
(COPD), asthma, chronic bronchitis, chronic pneumonia, emphysema,
tuberculosis, pulmonary fibrosis. It does not include seasonal allergies.
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
ii. more than one follow-up visit to a physician; or
iii. hospitalization, surgery, or referral to a
iv. which ended at least 30 days prior to the departure
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.
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
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;
d) there has been no test results showing deterioration;
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.
April 03, 2018