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RSA Travel Insurance

Emergency Medical Travel Insurance

 

Eligibility and Medical Questionnaire

 

 Applicant : Name      Age       Destination:     

Single-Trip Medical Plan     Annual Multi-Trip Medical Plan    

Total Number of days per trip      (4, 9, 16, 30  days for Annual Multi-trip plans)

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

  View Definitions

Are You Eligible?

Section 1 - Eligibility

     To be eligible for this insurance, you must meet the following conditions:

1

You are a Canadian resident and be covered by the government health insurance plan (GHIP) of your Canadian province or territory of residence for the entire duration of your trip;

2

You are NOT travelling against the advice of a physician;

3

You have NOT been  diagnosed with a terminal illness or metastatic cancer;

4

You do NOT have a kidney disease requiring dialysis;

5

You have NOT been prescribed or used home oxygen during the 12 months prior to your application date;

 

 Please confirm that you understand and meet the eligibility requirements above:      

 Yes  No

If you have questions, please call at 416-493-0101 (1-877-443-0101)  

 

 

Do You Require Customized Medical Underwriting?

Section 2

1

Have you had Heart bypass surgery more than 12 years ago?

Yes  No

2

Have you had Heart angioplasty (including stent placement) more than 12 years ago?

Yes  No
3

Have you ever had a Bone marrow transplant or an Organ transplant (excluding corneal transplant)?

Yes  No

4

Do you have a surgically unrepaired Aneurysm of 4.0 cm or more ?

Yes  No

5

In the last 5 years, have you been diagnosed with or treated for Congestive heart failure or Cardiomyopathy?

Yes  No

6

Are you currently taking Lasix, Furosemide or a water pill (excluding a water pill taken for high blood pressure only)?

Yes  No

 

Which Plan Do You Qualify for?

Section 3  

1

In the past 10 years, have you been diagnosed with or treated for a Heart condition (including stent placement, pacemaker and/or defibrillator)

Yes   No
2

In the past 5 years, have you been diagnosed with or treated for :

a) Diabetes or Glucose intolerance (Pre-diabetes) ?

Yes  No

b) Stroke or Mini-stroke (CVA/TIA)?

Yes  No

c) Peripheral vascular disease (PVD: narrowing or blockage of any blood vessel), Carotid Artery Stenosis or any narrowed or blocked artery, excluding coronary artery disease ?

Yes  No

d) Lung condition (such as any prescription for puffers/inhalers) excluding lung cancer or a minor ailment?

Yes  No

e)  Dementia or Alzheimer's disease?

Yes  No

f) Cancer (excluding basal or squamous cell skin cancer )?

Yes  No

3

In the past  2 years, have you been diagnosed with or treated for any of the following:

aChronic bowel disease (such as but not limited to Crohn's disease or Ulcerative colitis)?

Yes   No

b) Gastrointestinal bleeding, Bowel obstruction or have had Bowel surgery?

Yes   No

c) Gallbladder disorder (including stones)? Not applicable if your gallbladder has been removed.

Yes   No

d) Kidney disease (including stones), Liver disease or Pancreatitis

Yes   No
4

Has it been more than 24 months since your last regular check-up with a physician?

Yes  No

5

In the past 12 months, have you been diagnosed with or treated for:

a)  High blood pressure

Yes  No

b)  High  cholesterol

Yes  No

 

Do You Use Tobacco Products?

Section 4 
In the last 5 years, have you smoked or used any tobacco products?

Yes  No

 

Notes

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

 

 

Your E-mail   

 

 


 

Definitions

1. Terminal illness: means that you have a medical condition that is cause for a physician to estimate that you have less than 6 months to live or for which palliative care has been received.

2.  Metastatic cancer: means a cancer that has spread from its original site to one or more other area(s) of the body.

3. Treated: means that you have been hospitalized, have been prescribed medication (including prescribed as needed), have taken or are currently taking medication or have undergone a medical or surgical procedure. Note that Aspirin/Entrophen is not considered treatment.

4. Stable: means any medical condition (other than a minor ailment) for which all the following statements are true:

a. There has been no new diagnosis, treatment or prescribed medication.

b. There has been no change in treatment or change in medication, including the amount of medication to be taken, how often it is taken, the type of medication or change in treatment frequency or type.

Exceptions: the routine adjustment of Coumadin, Warfarin, insulin or oral medication to control diabetes (as long as they are not newly prescribed or stopped) and a change from a brand name  medication to a generic brand medication (provided that the dosage is not modified);

c. There have been no new symptoms, more frequent symptoms or more severe symptoms.

d. There have been no test results showing deterioration.

e. There has been no hospitalization or referral to a specialist (made or recommended) and you are not awaiting the results of further investigations for that medical condition.

5. Minor ailment: means any sickness or injury which does not require: the use of medication for a period of greater than 15 days; more than one follow up visit to a physician, hospitalization, surgical intervention or referral to a specialist; and which ends at least 30 consecutive days prior to the departure date of each trip. However, a chronic condition or complications of a chronic condition are not considered a minor ailment.

6. Regular check-up: means any standard or customary medical examination unrelated to any specific medical condition and which is carried out for the purpose of screening, health monitoring or preventive care and may include routine medical tests and investigations.

 

 

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Revised: August 16, 2017