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Quest Travel Insurance

 

Eligibility and Medical Questionnaire

 

 Applicant : Name      Age             Province of residence  

Single-Trip Medical Plan          Annual Multi-Trip Medical Plan      

 Total Number of days per trip     9, 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.

View Medical Definitions

Do you qualify?

Section 1 - Eligibility

Please answer the following medical questions to determine your eligibility

1

In the 36 months prior to application, have you been diagnosed with, treated or ordered by a physician to take medication for  three (3) or more of the following medical conditions?

Heart disease/condition

Liver disease/condition

Lung disease/condition (excluding asthma not requiring prednisone)

Diabetes (requiring medication)

Stroke or mini-stroke (TIA or transient ischemic attack)

 

 Yes No

2

In the 12 months prior to application, have you been diagnosed with, treated or ordered by a physician to take medication for peripheral vascular disease (blocked leg arteries); congestive heart failure; chronic obstructive pulmonary disease (COPD, emphysema)?

 

 Yes No

3

In the 12 months prior to application, have you used or been prescribed home oxygen?

 

 Yes No

4

Do you have a terminal condition or metastatic cancer?

 

 Yes No

5

Did you have heart bypass surgery more than 10 years before application? (Answer “No” to this question if you have had additional bypass surgery and/or placement of a stent less than 10 years prior to application)

 

 Yes No

6

Have you had an organ transplant (excluding cornea or skin graft)?

 

 Yes  No

7

 Do you have a kidney disease requiring dialysis?

 

 Yes  No

8

Do you have an aneurysm larger than four (4) centimetres or greater, measured in either length or diameter?

 

 Yes  No

9

In the 6 months prior to application, have you had a stroke or mini-stroke (TIA or transient ischemic attack)?

  Yes  No

If you must answered YES to any of the medical questions in this Section, you are not eligible to purchase this policy. If all your answers are NO, please complete the questionnaire below.

 

 

What rate category do you qualify for?

Please answer all questions and check Yes or No for each question

 

Section 2 - Rate Table Classification

 

10

In the 5 years prior to application have you been diagnosed with, treated or ordered by a physician to take medication or been hospitalized for any of the following:

a) Heart attack, aneurysm, angioplasty, atrial fibrillation, artery bypass surgery, cardiac surgery, angina, irregular heartbeat, pacemaker, thrombosis, phlebitis, pulmonary edema

  Yes  No

b) Chronic asthma, chronic bronchitis or pneumonia

Yes  No

c) Diabetes (requiring medication)

Yes  No

d) Stroke or mini-stroke (TIA or transient ischemic attack)

Yes  No

e) Carotid artery stenosis (blocked or clogged arteries in the legs or neck)

Yes  No

f) Liver disease/condition

Yes  No

g) Cancer (excluding basal cell skin cancer)

Yes  No

h) Kidney disease that required dialysis, now no longer on dialysis

 

Yes  No
11

In the 24 months prior to application, how many of the following medical conditions have you been diagnosed with, treated for or ordered by a physician to take medication for?

a) Kidney disease

Yes  No

b) Gastrointestinal bleeding

Yes  No

c) Alzheimer’s disease / dementia

Yes  No

d) Pancreatitis

Yes  No

e) Chronic bowel disease

Yes  No

f) Bowel obstruction

 

Yes  No
12

In the 12 months prior to application, have you been diagnosed with or undergone a change in medical treatment (including an alteration in medication dosage or usage) for high blood pressure AND had any of the following conditions?

a) High cholesterol

Yes  No

b) Diabetes (not requiring medication)

Yes  No

c) Gallbladder disease

Yes  No

d) Osteoporosis

Yes  No

e) Arthritis

 

Yes  No
13

Have you ever been treated for a heart disease/condition (excluding congenital heart disease)?

 

Yes  No
14

Was your last regular check-up with a physician more than 24 months ago?

 

Yes  No
15

Have you had a fall that you reported to a physician in the last 6 months?

 

Yes  No
16

In the 12 months prior to application, have you smoked tobacco products?

 

Yes  No
17 Do you need coverage for unstable pre-existing medical condition(s)?
Yes  No

 

IMPORTANT!

If you have any doubt about your medical condition(s) as it relates to the previous questions, you should consult your physician for advice before completing this medical health questionnaire.

If you qualify for the coverage selected but fail to answer truthfully and accurately any question asked at the time of the application, any claim will be subject to an extra deductible of $15,000 USD in addition to any other applicable deductible amount. No future coverage will be provided under this Policy unless you pay any additional premium reflecting true and accurate answers to those questions.

 

 

Notes

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

 

 

Your E-mail   

 

 


 

Definitions

The following definitions are for general information only. Please consult your physician for more detailed information about your medical conditions.

Alteration includes an increase or decrease in medication dosage, usage or a change in medication type, but does not include changes in brand due solely to the availability of your usual brand or due to government regulations regarding reference-based pricing.

Alzheimer’s disease A form of dementia, it is a progressive, degenerative brain disease. It affects memory, thinking, and behavior.

Aneurysm A localized widening (dilatation) of an artery, vein, or the heart. At the area of an aneurysm, there is typically a bulge and the wall is weakened and may rupture.

Angina Chest pain due to coronary artery spasm, a sudden constriction of a coronary artery depriving the heart muscle of blood and oxygen.

Angioplasty Procedure with a balloon-tipped catheter to enlarge a narrowing in a coronary artery. Sometimes a “stent”, or bridge, is inserted to keep the artery open.

Arthritis Inflammation of a joint. When joints are inflamed they can develop stiffness, warmth, swelling, redness and pain.

Atrial fibrillation Abnormal irregular heart rhythm with chaotic generation of electrical signals in the atria of the heart. Sometimes requires anticoagulation (blood thinners such as Coumadin / warfarin).

Bowel obstruction Bowel obstruction is a mechanical blockage of the intestines, preventing the normal transit of products of digestion.

Cancer (except basal cell skin cancer) Any malignant growth or tumor caused by abnormal and uncontrolled cell division; it may spread to other parts of the body through the lymphatic system or the blood stream.

Carotid artery stenosis A narrowing of a carotid artery in the neck.

Chronic asthma Asthma (wheezing and cough) requiring maintenance treatment to achieve part or total control.

Chronic bowel disease Chronic inflammation of the bowels with diarrhea, cramps, and sometimes bleeding.

Chronic bronchitis An inflammation of the main airways in the lungs that continues for a long period or keeps coming back.

Chronic obstructive pulmonary disease (COPD) Lung disease that makes it difficult to breathe, caused by smoking, chronic asthma etc. also called emphysema.

Congenital heart disease A malformation, present at birth, of the heart or the large blood vessels near the heart.

Congestive heart failure Inability of the heart to keep up with the demands on it and, specifically, failure of the heart to pump blood with normal efficiency due to chronic heart disease. Causes fluid in the lungs, shortness of breath, decreased exercise tolerance.

Dementia Significant loss of intellectual abilities such as memory capacity, severe enough to interfere with social or occupational functioning.

Diabetes A chronic condition where the body is unable to produce insulin and properly regulate or maintain sugar (glucose) level in the blood. Includes Type 1 diabetes mellitus, (insulin dependent or juvenile type) and Type 2 diabetes, (adult-onset or non insulin-dependent diabetes mellitus -NIDDM), which is the most common form of diabetes.

Emphysema See chronic obstructive pulmonary disease (COPD).

Gallbladder disease Includes inflammation, infection, stones, or obstruction of the gallbladder—causes right upper abdominal pain.

Gastro intestinal bleeding Refers to any bleeding that starts in the gastrointestinal tract, which extends from the mouth to the large bowel. The amount of bleeding can range from nearly undetectable to acute, massive, and life threatening.

Bleeding may come from any site along the gastrointestinal tract, but is often divided into Upper GI bleeding and Lower GI bleeding.

Heart disease/condition An abnormal condition of the heart, heart disease or cardiopathy.

High blood pressure Also known as hypertension. For example, blood pressure above 140/90 for more than 6 months.

High cholesterol Elevated fat content in blood.

Irregular heartbeat/palpitations Feels like the heart is pounding or racing. You may simply have an unpleasant awareness of your own heartbeat, or may feel skipped or stopped beats. The heart’s rhythm may be normal or abnormal. Palpitations can be felt in your chest, throat, or neck.

Kidney dialysis Medical treatment replaces the function of the kidneys, which normally serve as the body’s natural filtration system.

Kidney disease Any disease or disorder that affects the function of the kidneys.

Liver disease/condition The term “liver disease” applies to many diseases and disorders that cause the liver to function improperly or cease functioning. Abnormal results of liver function tests often suggest liver disease.

Lung disease/condition Any abnormal condition of the lungs, affecting the lungs or associated airways. Most commonly applicable to lung infection such as pneumonia, Chronic Obstructive Pulmonary Disease (COPD), bronchial asthma, etc.

Medication(s) Includes medication that requires a prescription from a physician or other registered medical practitioner and medication purchased over the counter as per the physician’s advice or other registered medical practitioner’s advice, not including aspirin taken for preventative reasons.

Metastatic cancer Cancer that has spread from the place in which it started to other parts of the body.

Osteoporosis Thinning of bone tissue and loss of bone density over time making fractures more likely.

Pancreatitis An inflammation or infection of the pancreas.

Peripheral vascular disease (blocked leg arteries) Also known as Arteriosclerosis of the extremities is a disease of the blood vessels characterized by narrowing and hardening of the arteries that supply the legs and feet. This causes a decrease in blood flow that can cause painful legs and injure nerves and other tissues.

Phlebitis Also known as thrombophlebitis; the swelling (inflammation) of a vein caused by a blood clot.

Pneumonia An infection of the lungs.

Pulmonary edema An abnormal build up of fluid in the lungs, which leads to swelling. Associated with congestive heart failure.

Stroke or mini-stroke (TIA or transient ischemic attack) An interruption of the blood supply to any part of the brain. A stroke is sometimes called a “brain attack”.

Terminal condition A medical condition for which, prior to the commencement date of the covered trip, a physician has given you a terminal prognosis with a life expectancy of 12 months or less.

Tobacco products Not a medical term. Examples are cigarettes, cigars, cigarillos, pipe. Marijuana comes under the class of “drug” or “substance”.

Thrombosis The formation or presence of a blood clot in a blood vessel.

  

Treatment Any reasonable medical, therapeutic or diagnostic measure prescribed by a medical physician or other registered medical practitioner in any form including prescribed medication, reasonable investigative testing, hospitalization, surgery or other prescribed or recommended treatment directly referable to the condition, symptom or problem including referral to a specialist. This includes medication that you take or have been ordered to take by a physician.

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Revised: March 17, 2018