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Allianz Global Assistance


Travel Insurance for Canadians

 

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       Destination:     

Single-Trip Medical Plan              Annual Multi-Trip Medical Plan      

 *Total Number of days per trip    (4, 8, 15, 35, 60 or 125 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

Please answer the following medical questions to determine your eligibility

 

1

Have been diagnosed with a terminal illness?

 

 Yes No

2

Have you been diagnosed with stage 3 or 4 cancer, or been diagnosed or received treatment for any cancer (other than basal cell or squamous cell skin cancer or breast cancer treated only with hormone therapy) in the past 3 months?

 

 Yes No

3

Do you require assistance with activities of daily living?

 

 Yes No

4

Have you been prescribed or used home oxygen for a lung/respiratory condition during the previous 12 months?

 

 Yes No

5

Have you had your most recent heart surgery more than 12 years ago or less than 6 months ago ?

 

 Yes No

6

Have a diagnosed unrepaired aneurysm of 4 centimeters or greater, measured in either length or diameter?

 

 Yes  No

7

Have you received or are awaiting a bone marrow or had a major organ transplant?

 

 Yes No

8

Have you been diagnosed with or received treatment for a kidney disease requiring dialysis?

 

 Yes No

9

Have you ever been diagnosed with an auto-immune disorder ?

 

  Yes No

10

Have you ever been diagnosed with congestive heart failure?

 

  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 answer all questions and check Yes or No for each question (for applicants 60 - 89 years of age ).

 

Section 2 - Rate Table Classification

 

1

Have you smoked tobacco or used tobacco products in the last 5 years

 

Yes  No

2 In the 12 months before the date you apply for coverage, have you:
a) been prescribed or taken 7 or more medications excluding aspirin? Yes  No

b) been prescribed or used prednisone for any lung/respiratory condition?

Yes  No
c) used any form of nitroglycerine (spray, patch or pill) for the relief of angina/chest pain? Yes  No

d) been hospitalized (as an inpatient or in the emergency department) for a heart condition?

Yes  No
e) had a stroke or mini-stroke (TIA or transient ischemic attack)?
Yes  No
3

In the last 24 months have you been diagnosed with or received treatment for a blood disorder?

Yes  No
4

Do you have any of the following conditions, or in the last 5 years, have you been diagnosed with or had an investigation, medical consultation , been prescribed medication or received treatment for:

a) Artery or vein disorder?

Yes  No

b) Cancer? (other than basal cell and squamous cell skin cancer or breast cancer treated only with hormone therapy)

Yes  No

c) Diabetes (controlled by oral medication or insulin)?

Yes  No

d) Heart condition? (including pacemaker or defibrillator, even if the procedure was completed more then 5 years ago)

Yes  No

e) Lung/respiratory condition?

Yes  No

f) Stroke (CVA), mini-stroke (TIA)?

Yes  No
5

Do you have any of the following conditions, or in the last 24 months, have you been diagnosed with or had an investigation, medical consultation , been prescribed medication or received treatment for:

a) Neurological disorder?

Yes  No

b) Digestive tract disorder?

Yes  No

c) Internal conditions?

Yes  No

d) High blood pressure treated with 3 or more medications?

Yes  No
6

Was your last medical check-up more than 18 months ago?

Yes  No
7

Do you have any of the following conditions, or in the last 12 months, have you been diagnosed with or had an investigation, medical consultation , been prescribed medication or received treatment for:

a) High blood pressure (hypertension) treated with 1 or 2 prescription medications?

Yes  No

b) Pre-diabetes (glucose intolerance) and diet-controlled diabetes?

Yes  No

c) Muscle, bone and joint disorder?

Yes  No

 

Option to exclude pre-existing conditions from coverage:

(Not available if you answered YES to questions 2 and 3 in Section 2  OR if you answered NO to all questions.)

8

Do you want to exclude all pre-existing medical conditions, regardless of whether or not they are stable?

(Answering YES to this question provides coverage only for new medical conditions that arise during your trip)

Yes  No

 

 

 

Notes

(Please enter your phone number, if you want an insurance broker call you)

 

 

Your E-mail   

 

 


 

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, atherosclerosis, blood clots, carotid artery stenosis, deep vein thrombosis (DVT), peripheral vascular disease (PVD), varicose veins, thrombophlebitis.

 

Auto-immune disorder includes acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV), Grave’s disease, Lou Gehrig’s disease, multiple sclerosis, myasthenia gravis, sarcoidosis any location, scleroderma, systematic lupus erythematosis.

 

Blood Disorder includes anemia (other than vitamin B-12 deficiency anemia),

hematochromatosis, idiopathic thrombocytopenic purpura (ITP), hemophilia, polycythemia vera, Sickle-cell anemia.

 

Cancer includes cancer of the blood, bowel, brain, breast, colorectal, esophagus, lung, ovarian or uterine, prostate, skin, stomach.

 

Digestive tract disorder includes Crohn’s disease, bowel, colon and intestinal disorder, diverticulitis, diverticulosis, esophagus disorder, hernia, stomach disorder, gastroesophaegeal reflux disease (GERD), gastritis, inflammatory bowel disease, irritable bowel syndrome (IBS), ulcer, ulcerative colitis.

 

Heart condition includes angina or chest pain, arrhythmia, arteriosclerosis, atrial fibrillation, congenital heart defect, congestive heart failure, cardiomyopathy, carotid artery occlusion, heart attack (myocardial infarction), heart murmur, irregular heart rate or beat, any other condition relating to the heart or cardiovascular system.

 

Heart surgery includes ablation, angioplasty, heart bypass operation, implanted defibrillator, implanted pacemaker, valve replacement (repair), valvuloplasty.

 

Internal condition includes gallbladder disease, kidney disorder (including kidney stones), liver disease, ovarian or uterine disorder, prostate or urinary disorder, spleen and/or pancreatic disorder.

 

Lung/respiratory condition includes asbestosis, bronchial asthma, bronchiectasis, chronic asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), emphysema, pulmonary embolism, pulmonary fibrosis, sleep apnea (using a CPAP machine), tuberculosis.

 

Major organ means, heart, kidney, liver or lung.

 

Minor ailment means a sickness or injury which ended more than 30 days prior to the effective date and which did not require:

a) treatment for a period longer than 15 consecutive days; or

b) more than one follow-up visit to a physician; or

c) hospitalization, surgery, or referral to a specialist.

 

Medical consultation means any medical services obtained from a licensed medical practitioner for a sickness, injury or medical condition, including but not limited to any or all of: history taking, medical examination, investigative testing, advice or treatment, and during which a diagnosis of the condition need not have been definitively made. This does not include regular medical check-ups where no medical signs or symptoms existed between check-ups or were found during the check-up.

 

Muscle, bone and joint disorder includes degenerative disc disease (DDD), fibromyalgia, herniated disc, osteoporosis, osteopenia, rheumatoid arthritis, sciatica, scoliosis, spinal stenosis, spondylitis/spondylosis.

 

Neurological disorder includes Alzheimer’s disease or dementia, brain injury, brain tumor, cerebral palsy, Creutzfeldt–Jakob disease, Cushing’s syndrome, epilepsy, Guillain-Barré syndrome (GBS), Parkinson’s disease, seizure, trigeminal neuralgia (TN or TGN).

 

Signs or symptoms means any evidence of disease experienced by you or recognized through observation.

 

Terminal applies to a medical condition for which a physician gave a prognosis of eventual death or for which palliative care was received prior to the effective date.

 

Treatment means a medical, therapeutic or diagnostic procedure prescribed, performed or recommended by a physician including, but not limited to, prescribed medication, investigative testing or surgery.

 

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Revised: March 17, 2018