PRE-EXISTING MEDICAL DECLARATION FORM

Transcription

1 PRE-EXISTING MEDICAL DECLARATION FORM This form is for customers who reside in New Zealand and wish to be assessed for pre-existing medical conditions. Please return a signed copy to info@tinz.co.nz At TINZ, we treat pre-existing medical conditions in one of three ways: Conditions automatically covered at no cost TINZ provides cover for 36 pre-existing medical conditions automatically for free, even if you don t tell us about them. If your medical condition is in this list you re covered provided that: The condition has been stable for more than 12 months; You do not intend to have surgery, treatment or a specialist review; and You have not attended hospital for treatment for the condition in the past 12 months. If your condition is in the list of conditions covered but you do not meet the criteria for automatic cover, please complete the attached Medical Declaration Form Conditions requiring assessment We need to know about all other medical conditions which are not listed above so that we can evaluate whether we can provide you with cover. These conditions should be declared even if you are no longer affected by the condition or currently recieving treatment for it. Please complete the declaration form overleaf to get started on the assessment process. If you are over the age of 80, you will need to complete our Seniors Medical Declaration Form. We will assess your application and decide whether and to what extent we can offer you insurance for your condition and /or journey. If you have no told us about a pre-existing medical condition when you were required to do so, we may refuse your claim or reduce it to the amount we would have paid had you told us about the condition. What about pregnancy? Pregnancy of an insured person in itself is not considered a pre-existing medical condition. You are automatically covered under the policy while you are pregnant for the following circumstances: Single foetus pregnancies up to and inclusive of 24th week of gestation. Multiple pregnancies up to and inclusive of the 19th week of gestation. However, if you have experienced complications or your pregnancy arose from medical intervention, assisted conception or fertility treatment, you must complete the Medical Declaration Form for assessment. 1 OF 6

2 Conditions we don t cover We would not be able to cover you if the following circumstances applied to you: You require home oxygen therapy or will require oxygen for the journey; or You have chronic renal failure treated by haemodialysis or peritoneal dialysis; You have been given a terminal or palliative prognosis for any condition with a shortened life expectancy; You have aids or an aids defining illness or any condition or treatment causing immunosuppression; or You have had, or are on a waiting list for an organ transplant. If you have one of these medical conditions, unfortunately there is no cover under certain sections of the policy. However, your TINZ policy will still cover you for a range of other benefits. Please refer to the policy wording (PDS) for section exclusions. step 1: complete the form Please answer all questions on the form and sign the declaration. If you are uncertain about your conditions, you may take it to your doctor. In some cases we may need your treating doctor to provide further declaration - we will let you know if this is required. step 2: ASSESSMENT TINZ will assess your application as quickly as possible and advise you of the outcome. step 3: APPROVED COVER AND ADDITIONAL PREMIUM If approved, you will need to pay the additional premium required in order to take out the cover. You are not covered for approved conditions unless the required additional premium has been paid. Payment will be noted on your Certificate of Insurance, along with any special information you need to know, such as the reference number. Please Note: If there is more than one applicant, each applicant must complete a separate declaration form. Our friendly team are happy to help out with any questions. Simply call to speak to one of our specialists. 2 OF 6

3 APPLICANT DETAILS Title First name Surname Address Region Town/City Postcode Phone Date of birth Height (centimetres) Weight (kilograms) Have you smoked in the last six months? No Yes If yes, how many cigarettes per day Are you a New Zealand resident? No Yes TRAVEL DETAILS Type of travel insurance policy (please tick one) Single Trip Multi-trip (Frequent Traveller) Date of departure Date of return Are you intending to: Ski Snowboard Trek Hike Cruise N/A Area of travel (provide the country destinations you are visiting) Total trip value $ APPLICATION TyPE Category type (please tick the categories appropriate to your medical condition and application for cover) 1: Automatically Covered 2: Condition Requiring Assessment 3: Condition Not Covered Pregnancy (If ticked, please advise estimated date of delivery) 3 OF 6

4 MEDICAL INFORMATION MEDICAL CONDITION (LIST ALL) DATE DIAGNOSED MEDICATION (INCLUDE DOSAGE) Are you being treated for your blood pressure or diabetes? No Yes What was your latest reading? / Date of latest reading If you have been diagnosed with a heart condition, have you ever had: Angioplasty Stent Bypass Cardioversion N/A Other cardiac surgery (please provide details): Has your medication changed in the last 90 days? No Yes If yes, please provide details: 4 OF 6

5 Have you seen a doctor or had medical treatment by a health practitioner in the last 90 days? No Yes If yes, please provide details (include date and reason): Have you been treated in hospital (includes same day procedures or emergency visits) in the past 12 months? No Yes If yes, please provide details (include date and reason): Are you currently awaiting medical review, treatment or investigation? No Yes If yes, please provide details (include date and reason): APPLICANTS DECLARATION I authorise any hospital or medical adviser who has attended to or examined me to furnish to the insurer or its representative any and all information in respect of treatment given for any condition related to this application. A photocopy or facsimile copy of this authority shall be considered as valid as the original. I confirm that all my answers are correct and complete. I have not withheld any information likely to affect my application for cover. I understand that should cover be given for any Pre-Existing Medical Condition, it will be for UNEXPECTED TREATMENT ONLY. I have read and retained a copy of the Product Disclosure Statement (PDS). I acknowledge my Duty of Disclosure as detailed in the PDS. I have read the privacy information in the PDS and consent to the collection, use and disclosure of my health information for the purposes outlined within it. Signature of Applicant Print Name Date (if you are over 18 years of age, and this is being signed by someone for you, we require a copy of the power of attorney document providing them authority to act on your behalf) 5 OF 6

6 RELEASE OF INFORMATION I hereby authorise the release of any information required in the processing of this form to be released to: Name: Relationship: Contact number: I understand that: > > my records are protected and cannot be disclosed without written permission once the insurer discloses my health information by my request, it cannot guarantee that the Recipient will not re-disclose my health information to a third party DOCTORS DECLARATION This section is OPTIONAL, however if your doctor has assisted or completed any part of this form, they must complete this section. Please Note: Travel overseas, particularly by commercial aircraft, places significant stress on individuals with a medical condition which may result in decompensation. This fact must be taken into account when completing this declaration. In your opinion, is your patient medically fit to undertake the proposed journey without suffering a medical episode? Yes No I declare that I am familiar with the patient s medical condition and have been their doctor since. I hereby declare that the information detailed on this form is accurate and complete and that no information has been withheld that may influence the insurer. Signature of Doctor Print Name Date Qualifications Doctors Stamp and initial: Phone Fax 6 OF