47287_caamed0913e_july31_layout

47287_CAAMED0913E_July31_Layout 13-07-31 7:45 AM Page 1 CAA Travel
Medical Questionnaire
Insurance
SECTION 3 – Complete this SECTION ONLY if you were instructed to do so in SECTION 2
SECTION 6 – Complete this SECTION ONLY if you were instructed to do so in
Effective September 1st, 2013
SECTION 5
Name:_______________________________________________________________________________ 8. In the last 5 years , have you been diagnosed with and/or had medical treatment* and/or been in hospital
(including emergency department) and/or been prescribed or taken medication for ANY of the follo wing
18. Has it been more than 18 months since your last regular check-up* with a physician or
Date of Birth: __________________________ Membership Number: ________________________ 19. Do you have diabetes that is ONLY treated by diet? .
Please see reverse side for DEFINITIONS and TERMS*.Comments written on the Medical
20. Have you ever had a heart condition* or stroke/CVA (Cerebrovascular Accident) or a
Questionnaire, other than those specifical y requested, will void the Medical Questionnaire.
9. In the last 6 months, have you received advice or medical treatment* for a medical emergency* more
mini-stroke/TIA (Transient Ischemic Attack)? .
SECTION 1 – Must be completed
than once in the emergency room of a hospital? .
21. In the last 3 months, have you had high blood pressure (hypertension) for which you ha ve
10. In the last 3 months, have you been prescribed or taken a total of 3 or more medications for high
been prescribed or taken 2 medications? .
1. Have you had a heart bypass, angioplasty or heart valve surgery before 2005? .
blood pressure (hypertension) and/or a heart condition*?.
22. In the last 12 months have you been prescribed or taken or have you refilled more
2. In the last 6 months, have you received chemotherapy and/or radiotherapy and/or
11. In the last 5 years, have you smoked /used any tobacco products and, during the last 12 months,
than 2 prescriptions for the treatment of pain? .
received medical treatment* for cancer, (other than routine fol ow-up), EXCEPT basal cell
have you been prescribed or taken ANY puffer(s)/inhaler(s)?.
and squamous cel skin cancer and breast cancer treated only with hormonal therapy? .
3. In the last 2 years, have you:
NO to ALL Questions in SECTION 6, you qualify for PLAN A+. Please stop here and go to
a) been prescribed or taken Lasix or Furosemide for any reason? . . . . . . . . . . . . . . . .
NO to ALL Questions listed in SECTION 3, please go to SECTION 4.
YES to ANY Question in SECTION 3, you qualify for PLAN C. Please stop here and go to SECTION 7.
YES to ANY Question in SECTION 6, you qualify for PLAN A. Please stop here and go to
4. In the last 12 months, have you been prescribed or taken Prednisone for a lung condition*
or been in hospital (including emergency department) for a lung condition*? .
5. In the last 12 months, have you been in hospital (including emergency department)
SECTION 4 – Complete this SECTION ONLY if you were instructed to do so in SECTION 3
SECTION 7 – Agreement, Understanding and Authorization
12. In the last 2 years, have you been diagnosed with and/or received medical treatment* and/or been in hospital
Please read the fol owing important statements careful y. Once you have read and understood the
(including emergency department) and/or been prescribed or taken medication for:
statements, p lease i nitial t he P LAN you qu alify f or a nd s ign b elow t o c omplete t his M edical
NO to ALL Questions listed in SECTION 1, please go to SECTION 2.
Questionnaire.
YES to ANY Question in SECTION 1, please consult your CAA professional for alternative
• I personally completed this Medical Questionnaire and all informa tion disc losed on it is true and accura te. options that may be available, as you are not eligible to purchase this insurance.
I fully understand that if any of my answers are untrue or incorrect, then any coverage offered will be null and void. • I confirm I have read and understood the Instructions to Applicant, Eligibility, Definitions and Terms sections
SECTION 2 – Complete this SECTION ONLY if you were instructed to do so in
on the reverse side of this Medical Questionnaire Form, prior to completing my Medical Questionnaire.
SECTION 1
• I understand CAA Insurance Compan y (Ontario), its a gents, third party administra tors or its legal prescription medication or surgery .
• Kidney disorder (including stones) .
representatives may investiga te an y c laim. I authorize an y hospital, physician, other medical ser vice 6. In the last 4 months , how many prescription medications have you been prescribed or taken, including
• Gall bladder disorder (including stones) .
provider, or any other organization or person that has any records or knowledge of me and my health to any oral, inhaled, or injected medica tions, as well as an y medications applied to the skin tha t contain (If gal bladder has been removed, answer NO).
release to third party administrators, CAA and/or CAA Insurance Company (Ontario) and its reinsurers any • Bleeding or perforated ulcer(s) .
any form of nitroglycerine or any drug(s) for angina? Do not count the following medications: hormonal
such information for the purpose of this a pplication and contract and any subsequent claim.
replacement therapy (thyroid or menopausal); drugs used for osteoporosis, or traveller’s diarrhea; or any INITIAL ONE PLAN ONLY
form of immunization. Do not count topical medications that go in your ears or eyes or on your scalp or skin
EXCEPT: any form of nitroglycerine or any drug(s) for angina as noted above. Have you:
PLAN A+ - If you qualify for PLAN A+ we wil NOT cover expenses resulting from a sickness, injury
a) been prescribed or taken 7 or more prescription medications? .
NO to ALL conditions in SECTION 4, please go to SECTION 5.
or medical condition that is not stable* in the 3 months prior to each departure date.
Please initial here _________
b) been prescribed or taken ONLY 6 prescription medications? .
YES to 2 or more conditions in SECTION 4, you qualify for PLAN C. Please stop here and go to SECTION 7.
7. In the last 3 years, have you been diagnosed with and/or received medical treatment* and/or been
If you have had 2 or more incidents of any conditions listed in Section 4, you qualify for PLAN C. Please stop
PLAN A - If you qualify for PLAN A we will NOT cover expenses resulting from a sickness, injury
in hospital (including emergency department) and/or been prescribed or taken medication for ANY
or medical condition that is not stable* in the 3 months prior to each departure date.
of the following conditions:
YES to only 1 condition in SECTION 4, you qualify for PLAN B. Please stop here and go to SE CTION 7.
Please initial here _________
PLAN B - If you qualify for PLAN B we will NOT cover expenses resulting from a sickness, injury
• Lung condition* (medication includes any puffer(s)/inhaler(s) EXCEPT a single unrepeated
or medical condition that is not stable* in the 6 months prior to each departure date.
prescription used for a single incident) .
SECTION 5 – Complete this SECTION ONLY if you were instructed to do so in SECTION 4
Please initial here _________
• Diabetes (treated with medication and/or insulin) .
• Stroke/CVA (Cerebrovascular Accident) or mini-stroke/TIA (Transient Ischemic Attack) PLAN C - If you qualify for PLAN C we will NOT cover expenses resulting from a sickness, injury
13. In the last 2 years, have you been diagnosed with or received medical treatment* and/or been in
(including use of aspirin/Entrophen for this condition) .
or medical condition that is not stable* in the 12 months prior to each departure date.
hospital and/or been prescribed or taken medication for a blood disorder? .
• Alzheimer’s disease or any other form of Dementia .
Please initial here _________
14. In the last 12 months, have you been diagnosed with or received medical treatment* for cancer
• Peripheral vascular disease (blocked or narrowed arteries)? . . . . . . . . . . . . . . . . . . .
(other than routine follow-up), EXCEPT basal cell and squamous cell skin cancer and breast cancer
PLAN D - If you qualify for PLAN D we will NOT cover expenses resulting from a sickness, injury
treated only with hormonal thera py? .
or medical condition that is not stable* in the 12 months prior to each departure date.
15. In the last 5 years, have you smoked or used an y tobacco products? .
Please initial here _________
NO to ALL Questions in SECTION 2, please go to SECTION 3.
16. If you are age 65 or over, in the last 6 months, have you had a fall tha t you reported to a physician?
YES to question 6 a. and/or 3 or more conditions in Question 7, please consult your CAA
If you are age 64 or under, answer NO. .
professional for alternative options that may be available, as you are not eligible to
17. In the last 12 months, have you been prescribed or taken ANY puffer(s)/inhaler(s)? .
Applicant’s Signature
purchase this insurance.
YES to question 6 b. and/or 2 conditions in Question 7, you qualify for PLAN D. Please stop
NO to ALL Questions in SECTION 5, please go to SECTION 6.
Date of Application
YES to 1 condition in Question 7, you qualify for PLAN C. Please stop here and go to SECTION 7.
YES to ANY Question in SECTION 5, you qualify for PLAN B. Please stop here and go to SECTION 7.
For office use only (policy number):_________________________________ WHITE COPY – CAA BLUE COPY – CLIENT
47287_CAAMED0913E_July31_Layout 13-07-31 7:45 AM Page 2 CAA Travel
Medical Questionnaire
Insurance
DEFINITIONS
INSTRUCTIONS TO THE APPLICANT:
IT IS IMPOR TANT THA T YOU READ THESE INSTRUCTIONS CAREFULL Y
Change means you have experienced an incr ease in symptoms, developed new
BEFORE COMPLETING YOUR MEDICAL QUESTIONNAIRE.
symptoms, required investigation, r equired a change in fr equency or dosage of Heart Condition means ANY disorder relating to your heart. If you are unsure if you
medication, required a change in tr eatment, were hospitalized, r equired medical have ever had a heart condition, please consult your physician for advice 1. Only YOU, the applicant, can complete and sign your Medical Questionnaire,
consultation (other than a r outine examination) OR had a deterioration of an not your spouse or agent. Your CAA travel professional may not assist you completing your Medical Questionnaire. Heart conditions inc lude, but are not limited 2. You must answer each question truthfully. Your prior medical history will be Change in Medication means the medication dosage OR fr equency has been
reviewed at time of claim and if any of your answers ar e found to be untrue reduced, increased, stopped AND/OR new medications have been pr escribed. or incorr ect, your coverage will be null and void (even if the untruth or inaccuracy is not related to the claim reported).
EXCEPTIONS:
• Chest pain or discomfort due to your heart, or angina 3. Pay particular attention to the Definitions and Terms for words identified with • An adjustment to the insulin OR Coumadin (W • Heart attack, or myocardial infarction, or cardiac arrest an asterisk, as they relate to your answers to the questions asked. Definitions currently taking pr ovided it is not newly pr escribed or stopped AND ther e and Terms can be found on the left side of this page. has been no change in your medical condition; AND 4. If you have any doubts about your medical condition(s) as it r elates to the • A change from brand name medication to a generic brand medication • Heart murmur (Do not include a murmur you had as a child if your physician has (insofar as the dosage is not modified).
questions asked, you must consult your physician for advice advised that you do not ha ve a murmur as an adult) completing your Medical Questionnaire.
• Narrowing or blockage of a coronary artery, or coronary artery disease Check-up means a complete medical examination conducted by a physician or
e that you complete ALL applicable Sections, nurse practitioner where your medical history is updated, a physical examination • Prior heart surger y of any kind, including but not limited to angioplasty , bypass initial your PLAN type and sign and date your Medical Questionnair e at the is done and any symptoms wer e diagnosed and any r ecommended tests wer e surgery, valvuloplasty , valve replacement, heart abla tion surger y, heart time of application. INITIAL ONLY ONE PLAN.
transplantation or surgery for any congenital heart disorder 6. Mistakes cannot be initialled. Please complete another Medical
• Rapid, or slo w, or irregular heart bea ts for which your doctor has prescribed Questionnaire.
Medical Emergency means the unfor eseen and emer gent occurr ence of
medication, or for which you ha ve undergone surgery or cardioversion symptoms for a sickness or injury which, unless tr 7. Comments written on the Medical Questionnair physician, may lead to death or to serious impairment of your health.
• Treatment with a pacemaker and/or a cardiac defibrilla tor device specifically requested, will void the Medical Questionnair e.
• Water on the lungs or s welling of the ankles due to a heart disorder 8. Your medical insurance may be subject to a pr e-existing condition exclusion.
Medical T reatment means any r easonable pr ocedure which is medical,
To have a fully disclosed pr e-existing condition cover ed, you may want to therapeutic or diagnostic in natur e, which is medically necessary and which is Lung condition means an y disorder involving your lungs. If you are unsure if you
consider purchasing a CAA Medically Underwritten Plan. Please consult your Medical treatment includes hospitalization, basic have a lung condition, please consult your physician for advice before completing investigative testing, sur gery, pr escription medication (including pr escribed as needed) OR other treatment directly related to the sickness, injury or symptom.
ELIGIBILITY:
Stable means that you have NOT experienced the following for any sickness,
YOU ARE NOT ELIGIBLE FOR ANY COVERAGE UNDER THIS POLICY IF:
injury or medical condition befor e your trip: hospitalization AND/OR a medical A. YOU HA VE BEEN DIAGNOSED WITH A TERMINAL ILLNESS FOR
procedure or intervention AND/OR a change in medication AND/OR a change in WHICH A PHYSICIAN HAS ESTIMA
TED YOU HA VE LESS THAN 6
medical treatment AND/OR experienced new or mor MONTHS TO LIVE;
AND/OR are requiring investigation (other than a r outine check-up).
B. YOU HA VE BEEN ADVISED BY A PHYSICIAN AGAINST TRA
THIS TIME;
C. YOU REQUIRE KIDNEY DIALYSIS;
NOTICE ON PRIVACY AND CONFIDENTIALITY
D. YOU HAVE EVER HAD A BONE MARROW OR ORGAN TRANSPLANT
The specific and detailed information r equested on the application form is r equired to process the application. To protect the confidentiality of this information, (EXCEPT CORNEA TRANSPLANT);
CAA Insurance Company (Ontario) will establish a “financial services file” from which this information will be used to process the application, offer and administer E. YOU HA VE BEEN DIAGNOSED WITH AND/OR RECEIVED MEDICAL
services and pr ocess claims r elative to the insurance applied for . Access to this file will be r estricted to those CAA Insuranc e Company (Ontario) employees, TREATMENT FOR METASTATIC CANCER IN THE LAST 5 YEARS;
mandataries, administrators or agents who are responsible for the assessment of risk (underwriting), marketing and administration of services and the investigation F. YOU HA VE BEEN PRESCRIBED OR T AKEN HOME OXYGEN FOR A
of claims, and to any other person you authorize or as authorized by law . These people, organizations and service pr oviders may be in jurisdictions outside LUNG CONDITION IN THE LAST 12 MONTHS.
Canada, and subject to the laws of those for eign jurisdictions. Y our consent to the use of personal information to of fer you pr oducts and services which ar e endorsed or sponsored by CAA is optional and if you wish to discont inue such use, you may write to CAA Insurance Company (Ontar io) at the addr ess shown ® CAA and CAA logo trademarks o wned by, and use is granted by, the Canadian Automobile Association.
below, or to your CAA club. Your file is secured in our offices or those of our administrator or agent. You may request to review the personal information it contains CAA Travel Insurance is underwritten by CAA Insurance Compan y (Ontario).
and make corrections by writing to: Privacy Officer, CAA Travel Insurance, 60 Commerce Valley Drive East, Thornhill, Ontario L3T 7P9.

Source: https://www.orioninsurance.ca/ATL/Documents/Medical-Questionnaire.pdf