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Travel & Medical
Medical Declaration
Insurance
Effective October 1, 2012
Name:______________________________________________________________________________________________
Date of Birth: ______________________ Membership Number: _________________________________________
Policy Number: _______________________________________________
INSTRUCTIONS TO THE APPLICANT:
IT IS IMPORTANT THAT YOU READ THESE INSTRUCTIONS CAREFULLY BEFORE COMPLETING YOUR MEDICAL
DECLARATION.
1. Only YOU, the applicant, can complete and sign your Medical Declaration, not your spouse or agent. Your CAA travel
professional may not assist you in the completion of this document.
2. You must answer each question truthfully. Your prior medical history will be reviewed at time of claim and if any of your answers are found to be untrue or incorrect, your coverage will be null and void (even if the untruth or inaccuracy is notrelated to the claim reported).
3. Pay particular attention to the Definitions and Terms for words identified with an asterisk, as they relate to your answers to the questions asked. Definitions and Terms can be found on the back of this form. 4. If you have any doubts about your medical condition(s) as it relates to the questions asked, you must consult your physician for advice before completing your Medical Declaration.
5. You must make sure that you complete ALL applicable Sections, initial your PLAN type and sign and date your Medical Declaration at the time of application. INITIAL ONLY ONE PLAN.
6. Mistakes cannot be initialled. Please complete another Medical Declaration.
7. Comments written on the Medical Declaration, other than those specifically requested, will void the Medical Declaration.
8. Your medical insurance may be subject to a pre-existing condition exclusion. To have a fully disclosed pre-existing condition covered, you may want to consider purchasing a CAA Medically Underwritten Plan. Please consult your CAATravel Professional.
ELIGIBILITY:
YOU ARE NOT ELIGIBLE FOR ANY COVERAGE UNDER THIS POLICY IF:
A. YOU HAVE BEEN DIAGNOSED WITH A TERMINAL ILLNESS FOR
WHICH A PHYSICIAN HAS ESTIMATED YOU HAVE LESS THAN 6 MONTHS TO LIVE;
B. YOU HAVE BEEN ADVISED BY A PHYSICIAN NOT TO TRAVEL AT THIS TIME;
C. YOU REQUIRE KIDNEY DIALYSIS;
D. YOU HAVE EVER HAD A BONE MARROW OR ORGAN TRANSPLANT (EXCEPT CORNEA TRANSPLANT);
E. YOU HAVE BEEN DIAGNOSED WITH AND/OR RECEIVED MEDICAL TREATMENT FOR METASTATIC CANCER
IN THE LAST 5 YEARS;
F. YOU HAVE BEEN PRESCRIBED OR TAKEN HOME OXYGEN FOR A LUNG CONDITION IN THE LAST 12 MONTHS.
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DEFINITIONS
Change means you have experienced an increase in symptoms, developed new symptoms, required investigation, required
a change in frequency or dosage of medication, required a change in treatment, were hospitalized, required medical
consultation (other than a routine examination) OR had a deterioration of an existing condition.
Change in Medication means the medication dosage OR frequency has been reduced, increased, stopped AND/OR new
medications have been prescribed.
EXCEPTIONS:
• An adjustment to the insulin OR Coumadin (Warfarin) dosage you are currently taking provided it is not newly prescribed or stopped AND there has been no change in your medical condition; AND • A change from brand name medication to a generic brand medication (insofar as the dosage is not modified).
Check-up means a complete medical examination conducted by a physician or nurse practitioner where your medical
history is updated, a physical examination is done and any symptoms were diagnosed and any recommended tests were
completed.
Medical Emergency means the unforeseen and emergent occurrence of symptoms for a sickness or injury which, unless
treated immediately by a physician, may lead to death or to serious impairment of your health.
Medical Treatment means any reasonable procedure which is medical, therapeutic or diagnostic in nature, which is
medically necessary and which is prescribed by a physician. Medical treatment includes hospitalization, basic
investigative testing, surgery, prescription medication (including prescribed as needed) OR other treatment directly related
to the sickness, injury or symptom.
Stable means that you have NOT experienced the following for any sickness, injury or medical condition before your trip:
hospitalization AND/OR a medical procedure or intervention AND/OR a change in medication AND/OR a change in medical
treatment AND/OR experienced new or more frequent symptoms AND/OR are requiring investigation (other than a routine Heart Condition means ANY disorder relating to your heart. If you are unsure if you have ever had a heart condition,
please consult your physician for advice before completing your Medical Declaration. Heart conditions include,
but are not limited to the following:
• Chest pain or discomfort due to your heart, or angina • Heart attack, or myocardial infarction, or cardiac arrest • Heart murmur (Do not include a murmur you had as a child if your physician has advised that you do not have • Narrowing or blockage of a coronary artery, or coronary artery disease • Prior heart surgery of any kind, including but not limited to angioplasty, bypass surgery, valvuloplasty, valve replacement, heart ablation surgery, heart transplantation or surgery for any congenital heart disorder • Rapid, or slow, or irregular heart beats for which your doctor has prescribed medication, or for which you have • Treatment with a pacemaker and/or a cardiac defibrillator device • Water on the lungs or swelling of the ankles due to a heart disorder Lung condition means any disorder involving your lungs. If you are unsure if you have a lung condition, please
consult your physician for advice before completing your Medical Declaration.
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Please refer to page 2 for DEFINITIONS and TERMS*. Comments written on the Medical Declaration, other
than those specifically requested, will void the Medical Declaration.
SECTION 1 – Must be completed
1. Have you had a heart bypass, angioplasty or heart valve surgery before 2004? .
2. In the last 6 months, have you received chemotherapy and/or radiotherapy and/or
received medical treatment* for cancer, (other than routine follow-up), EXCEPT basal cell
and squamous cell skin cancer and breast cancer treated only with hormonal therapy? .
3. In the last 2 years, have you:
a) been prescribed or taken Lasix or Furosemide for any reason?.
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)
If you answered:
NO to ALL Questions listed in SECTION 1, please go to SECTION 2.
YES to ANY Question in SECTION 1, please consult your CAA professional for alternative
options that may be available, as you are not eligible to purchase this insurance.
SECTION 2 – Complete this SECTION ONLY if you were instructed to do so in
SECTION 1
6. In the last 4 months, how many prescription medications have you been prescribed or taken, including
any oral, inhaled, or injected medications, as well as any medications applied to the skin that contain
any form of nitroglycerine or any drug(s) for angina? Do not count the following medications: hormonal
replacement therapy (thyroid or menopausal); drugs used for osteoporosis, or traveller’s diarrhea; or any
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:
a) been prescribed or taken 7 or more prescription medications? .
b) been prescribed or taken ONLY 6 prescription medications? .
7. In the last 3 years, have you been diagnosed with and/or received medical treatment* and/or been
in hospital (including emergency department) and/or been prescribed or taken medication for ANY
of the following conditions:
• Lung condition* (medication includes any puffer(s)/inhaler(s) EXCEPT a single unrepeated
prescription used for a single incident).
• Diabetes (treated with medication and/or insulin) .
• Stroke/CVA (Cerebrovascular Accident) or mini-stroke/TIA (Transient Ischemic Attack) (including use of aspirin/Entrophen for this condition) .
• Alzheimer’s disease or any other form of Dementia .
• Peripheral vascular disease (blocked or narrowed arteries)? .
NO to ALL Questions in SECTION 2, please go to SECTION 3.
YES to question 6 a. and/or 3 or more conditions in Question 7, please consult your CAA
professional for alternative options that may be available, as you are not eligible to
purchase this insurance.
YES to question 6 b. and/or 2 conditions in Question 7, you qualify for PLAN D. Please stop
here and go to SECTION 7.
YES to 1 condition in Question 7, you qualify for PLAN C. Please stop here and go to SECTION 7.
Page 3 of 6
SECTION 3 – Complete this SECTION ONLY if you were instructed to do so in SECTION 2
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 following
conditions:
• Heart condition*? .
• Aneurysm? .
9. In the last 6 months, have you received advice or medical treatment* for a medical emergency* more
than once in the emergency room of a hospital? .
10. In the last 3 months, have you been prescribed or taken a total of 3 or more medications for high
blood pressure (hypertension) and/or a heart condition*? .
11. In the last 5 years, have you smoked /used any tobacco products and, during the last 12 months,
have you been prescribed or taken ANY puffer(s)/inhaler(s)? .
If you answered:
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.
SECTION 4 – Complete this SECTION ONLY if you were instructed to do so in SECTION 3
12. In the last 2 years, have you been diagnosed with and/or received medical treatment* and/or been in hospital
(including emergency department) and/or been prescribed or taken medication for:
prescription medication or surgery.
• Kidney disorder (including stones).
• Gall bladder disorder (including stones).
(If gal bladder has been removed, answer NO).
• Bleeding or perforated ulcer(s).
If you answered:
NO to ALL conditions in SECTION 4, please go to SECTION 5.
YES to 2 or more conditions in SECTION 4, you qualify for PLAN C. Please stop here and go to SECTION 7.
If you have had 2 or more incidents of any conditions listed in Section 4, you qualify for PLAN C. Please stop
here and go to SECTION 7.
YES to only 1 condition in SECTION 4, you qualify for PLAN B. Please stop here and go to SECTION 7.
SECTION 5 – Complete this SECTION ONLY if you were instructed to do so in SECTION 4
13. In the last 2 years, have you been diagnosed with or received medical treatment* and/or been in
hospital and/or been prescribed or taken medication for a blood disorder? .
14. In the last 12 months, have you been diagnosed with or received medical treatment* for cancer
(other than routine follow-up), EXCEPT basal cell and squamous cell skin cancer and breast cancer
treated only with hormonal therapy? .
15. In the last 5 years, have you smoked or used any tobacco products? .
16. If you are age 65 or over, in the last 6 months, have you had a fall that you reported to a physician?
If you are age 64 or under, answer NO. .
17. In the last 12 months, have you been prescribed or taken ANY puffer(s)/inhaler(s)? .
If you answered:
NO to ALL Questions in SECTION 5, please go to SECTION 6.
YES to ANY Question in SECTION 5, you qualify for PLAN B. Please stop here and go to SECTION 7.
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SECTION 6 – Complete this SECTION ONLY if you were instructed to do so in
SECTION 5
18. Has it been more than 18 months since your last regular check-up* with a physician or
19. Do you have diabetes that is ONLY treated by diet?.
20. Have you ever had a heart condition* or stroke/CVA (Cerebrovascular Accident) or a
mini-stroke/TIA (Transient Ischemic Attack)?.
21. In the last 3 months, have you had high blood pressure (hypertension) for which you have
been prescribed or taken 2 medications? .
22. In the last 12 months have you been prescribed or taken or have you refilled more
than 2 prescriptions for the treatment of pain? .
If you answered:
NO to ALL Questions in SECTION 6, you qualify for PLAN A+. 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
SECTION 7.
SECTION 7 – Agreement, Understanding and Authorization
Please read the following important statements carefully. Once you have read and understood the
statements, please initial the PLAN you qualify for and sign below to complete this Medical
Declaration.
• I personally completed this Medical Declaration and all information disclosed on it is true and accurate.
I ful y understand that if any of my answers are untrue or incorrect, then any coverage offered wil be nul and void. • I confirm I have read and understood the Instructions to Applicant, Eligibility, Definitions and Terms
sections on the reverse side of this Medical Declaration Form, prior to completing my Medical Declaration.
• I understand Manulife Financial, its agents, third party administrators or its legal representatives may investigate any claim. I authorize any hospital, physician, other medical service provider, or any other organization or person that has any records or knowledge of me and my health to release to third partyadministrators, CAA and/or Manulife Financial and its reinsurers any such information for the purpose ofthis application and contract and any subsequent claim.
INITIAL ONE PLAN ONLY
PLAN A+ - If you qualify for PLAN A+ we will NOT cover expenses resulting from a sickness, injury
or medical condition that is not stable* in the 3 months prior to each departure date.
Please initial here _________
PLAN A - If you qualify for PLAN A we will NOT cover expenses resulting from a sickness, injury
or medical condition that is not stable* in the 3 months prior to each departure date.
Please initial here _________
PLAN B - If you qualify for PLAN B we will NOT cover expenses resulting from a sickness, injury
or medical condition that is not stable* in the 6 months prior to each departure date.
Please initial here _________
PLAN C - If you qualify for PLAN C we will NOT cover expenses resulting from a sickness, injury
or medical condition that is not stable* in the 12 months prior to each departure date.
Please initial here _________
PLAN D - If you qualify for PLAN D we will NOT cover expenses resulting from a sickness, injury
or medical condition that is not stable* in the 12 months prior to each departure date.
Please initial here _________
Applicant’s Signature
Date of Application
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NOTICE ON PRIVACY AND CONFIDENTIALITY
The specific and detailed information requested on the application form is required to process the application.
To protect the confidentiality of this information, Manulife Financial will establish a “financial services file” from
which this information will be used to process the application, offer and administer services and process claims
relative to the insurance applied for. Access to this file will be restricted to those Manulife Financial employees,
mandataries, administrators or agents who are responsible for the assessment of risk (underwriting), marketing and
administration of services and the investigation of claims, and to any other person you authorize or as authorized
by law. These people, organizations and service providers may be in jurisdictions outside Canada, and subject to
the laws of those foreign jurisdictions. Your consent to the use of personal information to offer you products and
services which are endorsed or sponsored by CAA is optional and if you wish to discontinue such use, you may
write to Manulife Financial at the address shown 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 and make
corrections by writing to: Privacy Officer, Affinity Markets, Manulife Financial, 6th Floor, 2 Queen Street East, Toronto,
Ontario M5W 5M3.
Manulife, Manulife Financial, Manulife Financial For Your Future logo and the block design are service marks and trademarks of The Manufacturers Life Insurance Company and are used by it and its affiliates under license.
® CAA and CAA logo trademarks owned by, and use is granted by, the Canadian Automobile Association.
CAA Travel & Medical Insurance is underwritten by The Manufacturers Life Insurance Company (Manulife Financial) and by First North American Insurance Company, a subsidiary of Manulife Financial.
CAAMED1012E
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Source: http://caaneo.ca/sites/all/files/27652_CAA_Med_Dec_Fax_20121002150521_503942.pdf