RSA Travel Insurance
Emergency Medical Travel Insurance
Eligibility and Medical
Applicant : Name
Worldwide excluding USA
Single-Trip Medical Plan
Annual Multi-Trip Medical Plan
Total Number of days per trip
16, 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.
Are You Eligible?
Section 1 - Eligibility
eligible for this insurance, you must meet the
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;
are NOT travelling against the advice of a physician;
You do NOT have a kidney disease requiring dialysis;
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:
If you have questions,
please call at 416-493-0101 (1-877-443-0101)
Require Customized Medical
Have you ever had a Bone marrow transplant or an
Organ transplant (excluding corneal transplant)?
In the past 5 years have you been
diagnosed with or treated for Congestive heart
failure or Cardiomyopathy?
Are you currently
taking Lasix, Furosemide or a water
pill (excluding a water pill taken for high blood
Which Plan Do You Qualify for?
In the past 2 years, have
your been diagnosed with or treated for any of the following
a) Crohn's disease or
Bowel obstruction or have had Bowel
(including stones), excluding kidney cancer?
Liver disease, excluding
disorder (including stones), excluding gallbladder cancer? Not
applicable if your gallbladder has been removed.
In the past 10 years, have you been
diagnosed with or
treated for a Heart condition or do your currently have
a cardiac stent, shunt, pacemaker and/or defibrillator?
In the past 5 years, have you been
diagnosed with or treated for :
a) Diabetes or
Glucose intolerance (Pre-diabetes)
b) Stroke or Mini-stroke (CVA/TIA)?
c) Peripheral vascular disease
(PVD), Carotid Artery Stenosis or any narrowed or blocked
arteries, excluding coronary artery disease?
d) Lung condition (such
as any prescription for
puffers/inhalers) excluding lung cancer, pulmonary
embolism or a minor ailment?
e) Dementia or
f) Cancer (excluding
basal or squamous cell skin cancer )?
Has it been more than
since your last
regular check-up with a physician?
During the 12 months
prior to your application, have you been
diagnosed with or
High blood pressure
In the past 5 years, have you smoked or used tobacco products?
(Please enter your phone number, if
you want an insurance broker call you)
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.
Metastatic cancer: means a cancer that has
spread from its original site to one or more other area(s) of the body.
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.
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
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
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.
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.
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.
April 10, 2018