PRIVATE MEDICAL INSURANCE

Transcription

1 PERSONAL HEALTHCARE APPLICATION FULL MEDICAL UNDERWRITING PRIVATE MEDICAL INSURANCE To be used for new plans commencing from 01 July To apply for VitalityHealth membership complete SECTIONS A to L where applicable. Please check all details on the application. If any details are incorrect put a line through them, write in the correct details and initial the change. Please ensure you complete all fields unless advised otherwise. Please complete the form using black ink in BLOCK CAPITALS. Please ensure that you have selected the application form which relates to the product and underwriting option required. The plan declaration must be signed and dated by the main applicant. All individuals to be covered under this plan must select the same underwriting terms as the main applicant. ELIGIBILITY CRITERIA - WHO IS THIS FORM FOR? You, the main applicant, who must be aged between 18 and 79 (inclusive) at the plan start date. Your spouse/partner who lives at the same address as you and must be aged between 16 and 79 (inclusive) at their cover start date. Your children, including adopted children, who must be aged 25 or under at their cover start date. If you wish to apply for Worldwide Travel Cover, all applicants must be aged 64 or under at their cover start date. All applicants must live in the UK (Great Britain and rthern Ireland, including the Channel Islands and the Isle of Man) for at least 180 days in each plan year. A MAIN APPLICANT DETAILS Title Mr Mrs Ms Miss Other Gender Male Female First name Last name Address Postcode Telephone number (home) Telephone number (mobile) Telephone number (work) Date of birth Your occupation industry type: Banking/Financial Entertainment/Leisure/Recreation Computing/IT/Data Processing Farming and Agriculture Manufacturing Restaurant/Hotels/Catering Education Retail/Wholesale Trade Construction Professional Sports Club Other (please specify): PRUHF21835_0415_ENP/PHC FMU VITALITY.CO.UK/HEALTH

2 B SPOUSE/PARTNER AND CHILD DEPENDANT DETAILS COMPLETE ONLY IF THERE ARE OTHER ELIGIBLE PEOPLE TO BE COVERED BY THIS PLAN. If you have more than five dependants, please provide their details on a separate sheet of paper, sign and date it, and attach it to this form. details are only required for child dependants aged 18 and over. SPOUSE/PARTNER/CHILD (DEPENDANT 1) Title Mr Mrs Ms Miss Other First name Last name Date of birth Gender Male Female CHILD (DEPENDANT 2) Title Mr Mrs Ms Miss Other First name Last name Date of birth Gender Male Female CHILD (DEPENDANT 3) Title Mr Mrs Ms Miss Other First name Last name Date of birth Gender Male Female CHILD (DEPENDANT 4) Title Mr Mrs Ms Miss Other First name Last name Date of birth Gender Male Female CHILD (DEPENDANT 5) Title Mr Mrs Ms Miss Other First name Last name Date of birth Gender Male Female Please enter below the names of any applicants who are employed in the occupations listed (leave blank if this doesn t apply to any applicants): Working offshore in the extraction / refinery of natural / fossil fuels. Name(s) of applicant(s) Armed forces personnel (including territorial army). Professional or semi-professional sports. For details of what cover is available for these occupations, please refer to your plan terms and conditions, or the Guide to Personal Healthcare. PAGE 2 OF 12

3 PLEASE COMPLETE EITHER SECTION C OR SECTION D THEN GO TO SECTION E. C QUOTE AND COVER DETAILS BY COMPLETING THIS APPLICATION FORM, YOU ARE APPLYING FOR THE COVER AND BENEFITS PROVIDED IN YOUR PERSONAL HEALTHCARE QUOTE. Please enter the quote reference number and quote variation number below and attach a copy of the relevant quote to this application form. Quote reference number* Quote variation number* Campaign code (if applicable) * If you don t have these, please complete the cover options in section D. Requested plan start date If a start date is requested, then cover, if offered, may commence on this date provided that: The requested start date is no more than 45 days after the date that you have completed, signed and dated the application form. This application form is received by VitalityHealth within 30 days of the requested start date. Please note that cover cannot be backdated to prior to when the application has been signed and dated. If no start date is given, then the plan will commence from the date the plan declaration is signed and dated, subject to the above mentioned points. D COVER OPTIONS ONLY COMPLETE THIS SECTION IF YOU VE NOT PROVIDED QUOTE REFERENCE AND VARIATION NUMBERS IN SECTION C. Mark the table below to show your choice of cover options. Use the options detailed against each benefit (eg. if you choose 1,000 Out-patient Cover write 1,000 in the Choice box). Where there are no options listed, please use a tick or a cross. Please complete all benefit choices. BENEFIT CHOICE Core Cover 3 Cancer Cover (Cancer cover / Extended Cancer cover) Out-patient Cover (ne / 500 / 750 / 1,000 / 1,250 / 1,500 / Full Cover) Out-patient Diagnostics O = As above + other diagnostics to Out-patient Cover limit F = Full Cover If not selected, Out-patient Diagnostics will fall within the selected limit, as above. MRI, CT and PET scans will be covered in full. Therapies Cover (ne / 350 / Full Cover) Psychiatric Cover (ne / 15,000 / 20,000) Dental Cover (ne / Major / Major and Routine) Worldwide Travel Cover (ne / 120 days) Excess Type (per claim / per year / no excess) Excess Amount ( 0 / 100 / 250 / 500 / 1,000) Hospital list (Local / Countrywide / Countrywide Plus / Vitality GP Select) PAGE 3 OF 12

4 E FULL MEDICAL UNDERWRITING Underwriting reference number, as supplied by VitalityHealth (if applicable) For the purposes of underwriting (assessing) your application, we usually rely solely on the information you provide on this form. Please help us, therefore, by completing all of the health questions honestly and fully for both yourself and any other person to be covered by the plan. Failure to do so may result in a claim not being paid, your underwriting terms being changed, your cover being cancelled, and/or any treatment costs already paid by us being reclaimed. 1. Are any applicants currently: (a) taking regular medication (whether prescribed or over the counter, but excluding contraception, HRT or medicines used to treat minor illnesses such as colds and flu)? (b) awaiting any medical test results, follow-up consultations, treatment or investigations? (c) experiencing symptoms of any health problems (or had symptoms in the last three months), whether or not medical advice has been sought? (d) being regularly monitored by a Consultant, GP or other health professional? 2. In the last five years, has any applicant attended a hospital, clinic or nursing home as an in-patient, day-patient or out-patient (excluding attendance for normal pregnancy and/or natural childbirth)? 3. Have any applicants ever been treated for, diagnosed with or advised that they may have any of the following: (a) heart condition or stroke/transient ischaemic attack (mini-stroke)? (b) cancer? (c) any form of arthritis, or joint or muscular problems that have resulted in regular, recurrent or persistent pain? (d) mental health illness (including stress, anxiety and depression)? IMPORTANT If ALL applicants have answered NO to all three questions above you do not need to answer any more questions in this section and you can be accepted on full medical underwriting with no personal medical exclusions. Please go to section H and continue with the application form. ALL applicants answering YES to any question above must now complete the rest of section E of this application form. PAGE 4 OF 12

5 E FULL MEDICAL UNDERWRITING (CONTINUED) ONLY COMPLETE THIS SECTION FOR ANY APPLICANTS WHO ANSWERED YES TO ANY OF THE PREVIOUS FULL MEDICAL UNDERWRITING QUESTIONS ASKED ON PAGE 4. FURTHER HEALTH QUESTIONS Has any applicant ever experienced or been treated for, or are they currently suffering from, any of the following conditions or symptoms? If YES, please provide full details including date(s) of treatment, consultations and investigations where appropriate on the next page. Please be aware that the middle column below provides examples only and is not an exhaustive list. a. Blood disorders e.g. anaemia, leukaemia, bleeding disorders, haemophilia, lymphoma, thrombosis (blood clots). b. Brain and nerve disorders e.g. stroke, multiple sclerosis, epilepsy, migraine, paralysis, Parkinson s disease, quadriplegia, paraplegia. c. Cancer e.g. any form of cancer or pre-cancerous growth, tumours or moles that have changed in appearance. d. Cardiac and vascular disorders e.g. angina/heart attack, heart failure, heart murmurs, rheumatic fever, high blood pressure, rhythm disturbance (palpitations), varicose veins (including haemorrhoids/piles), poor circulation, raised cholesterol, heart surgery. e. Connective tissue disorders e.g. SLE (systemic lupus erythematosus), scleroderma, mixed connective tissue disorder. f. Dental disorders e.g. over/under bite problems, missing/skew teeth, impacted wisdom teeth or ongoing treatment. g. Ear, nose, throat, eye and speech disorders e.g. cataracts, glaucoma, macular degeneration, hearing/visual impairment, loss of speech, tonsillitis. h. Gastro-intestinal disorders e.g. peptic ulcer, hiatus hernia, heartburn, changed bowel habits, rectal bleeding, Crohn s disease, ulcerative colitis, IBS (irritable bowel syndrome). i. Female/male reproductive system disorders e.g. ovarian cysts, endometriosis, fibroids, infertility, disorders of the cervix, menstrual disorders, penile/testicular disorders, epididymitis, breast lumps/cysts, complications of pregnancy/childbirth. j. Kidney/Urinary tract disorders e.g. kidney failure, kidney stones, recurrent infections, nephritis, prostate problems, blood/protein in urine, polycystic kidneys. k. Liver/Pancreatic disorders e.g. hepatitis, cirrhosis, liver failure, gallstones, pancreatitis. l. Mental health/psychiatric disorders e.g. depression, anxiety, schizophrenia, eating disorders, ADHD (attention deficit hyperactivity disorder), autism. m. Metabolic/Endocrine disorders e.g. diabetes, thyroid abnormalities, growth disorder, Cushing s disease, Addison s disease. n. Musculo-skeletal disorders (bone, joint, muscular) e.g. arthritis, rheumatoid arthritis, myasthenia gravis, muscle weakness/injury, gout, osteoporosis, back problems, (e.g. slipped disc, backache, sciatica, pinched nerve), loss of limb, breaks/fractures, sports injuries, hernia. o. Respiratory disorders e.g. asthma, emphysema, bronchitis, shortness of breath, persistent cough, coughing up blood, cystic fibrosis, sinusitis, allergic rhinitis, COAD/COPD (chronic obstructive airways/ pulmonary disease) or any lung surgery. p. Skin disorders e.g. eczema, psoriasis, acne, hypertrophic scars (keloid). q. Sensory functions e.g. loss or impairment of sense of touch, smell or taste. PAGE 5 OF 12

6 E FULL MEDICAL UNDERWRITING (CONTINUED) FURTHER INFORMATION If any applicant has answered yes to any of the questions 1-3 on page 4 and/or a-q on page 5, please supply full details below. Name of applicant to whom the condition/symptom applies Condition/symptom (and question number/letter(s) it refers to) Description of medication/ treatment/consultations/ investigations (PLEASE INCLUDE ALL DATES) What, if any, further consultations/ treatment/ investigations are required Present state of health (e.g. full recovery or symptoms still present) Additional information if you require more space, please continue on a separate sheet of paper, sign and date it, and attach it to this form. PAGE 6 OF 12

7 F GP S DETAILS Please state the name and address of your usual GP (to whom requests for information are usually made). If you have changed your GP in the past year or if the GP is different for any of the other applicants, please provide their name(s) and address(es) on a separate sheet of paper, sign and date it and attach it to this form. GP s first name GP s last name Address Postcode Telephone number Fax number PAGE 7 OF 12

8 G ACCESS TO MEDICAL REPORTS ACT 1988 Before we can assess your application, we may need to get a medical report from a GP who has cared for you. The Access to Medical Reports Act 1988 gives you certain legal rights. These are: We need your agreement before we can apply for a medical report from your GP. You can refuse but, if you do, we will not be able to assess your application. You can ask to see the report before the GP sends it to us, or up to six months after. If you tick the box below to indicate that you want to see the report, your GP can charge you a reasonable fee to cover costs. If you think part of the report is incorrect or misleading when you see it, you can ask to have it changed. If your GP will not agree to do this, you may attach a statement of your own. You will not be entitled to see any part of the report which: The GP believes could seriously harm your physical or mental health, or that of others. Indicates the GP s intentions in respect of you. Reveals information about another person, or the identity of someone who has given the GP information about you (unless that person consents or is a health professional involved in caring for you). We will write and tell you when we have requested the report. If you ve asked to see the report before your GP sends it to us, you will have 21 days from the date of receipt of our letter to contact your GP. Once you have seen the report, your GP needs your agreement to send it to us. If you don t arrange to see the report within 21 days, your GP will be free to send it to us. Declaration of consent I have been informed of my statutory rights under the Access to Medical Reports Act 1988, as explained above. In connection with my insurance application I consent to VitalityHealth being provided with medical information from my GP or any other health professional who at any time has attended me concerning anything which affects my physical or mental health. I agree that a copy of this consent shall have the validity of the original. I would like to see the report before it is sent to VitalityHealth. I do not need to see the report before it is sent to VitalityHealth. Please tick one box only. To avoid delay, each person may choose to give their consent by signing in the box(es) below. If additional signature space is required, please use a separate sheet of paper, sign and date it, and attach it to this form, stating the signatures apply to section G. Applicant s signature. Spouse s/partner s signature. Parental guardian s signature (for children under 16). Signature of dependant (aged 16 or over). Signature of dependant (aged 16 or over). Please be aware that we rarely contact GP s as we assess your application based on all of the health questions being completed honestly and fully. If we do ask your GP for information we will keep you advised and we may ask you to contact your GP if we request a medical report and experience delays in receiving it. PAGE 8 OF 12

9 I HOW TO PAY You can choose to pay your premium monthly, quarterly or annually by Direct Debit. How would you like to pay? Monthly Quarterly Annually When paying by Direct Debit, the collection date will be the same day of the month as your cover start date. Please note that the Direct Debit should be set up from your own personal bank account unless otherwise agreed by VitalityHealth. DIRECT DEBIT INSTRUCTION Please fill in the whole form using a ball point pen and send it to: VitalityHealth, Stirling FK9 4UE Name(s) of Account Holder(s) Instruction to your Bank or Building Society to pay by Direct Debit Service User Number Bank or Building Society Account Number Branch Sort Code Name and full postal address of your Bank or Building Society To: The Manager Bank/building society name Reference Instructions to your Bank or Building Society. Please pay Vitality Corporate Services Limited Direct Debits from the account detailed on this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Vitality Corporate Services Limited and if so, details will be passed electronically to my Bank/Building Society. Signature(s) Address Postcode Date Banks and Building Societies may not accept Direct Debit instructions for some types of account. This guarantee should be detached and retained by the Payer THE DIRECT DEBIT GUARANTEE This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit Vitality Corporate Services Limited will notify you three working days in advance of your account being debited or as otherwise agreed. If you request Vitality Corporate Services Limited to collect a payment, confirmation of the amount and date will be given to you at the time of request. If an error is made in the payment of your Direct Debit, by Vitality Corporate Services Limited or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society - If you receive a refund you are not entitled to, you must pay it back when Vitality Corporate Services Limited asks you to. You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. PAGE 9 OF 12

10 I IMPORTANT INFORMATION GENERAL NOTES The plan will not start until we have accepted your application. If your plan starts in a different month to that stated on the quotation, the terms may differ from those originally quoted. If an applicant has a birthday while this application form is being processed, the terms may differ from those originally quoted. We may offer revised plan terms, but in certain circumstances, we may not be able to offer cover. Children aged 21 or over at their cover start date, or the plan renewal date, whichever is the sooner, will be charged at an adult rate. You should ensure that all applicants are registered with a UK GP and Dentist and that they have your full medical and dental records, if you haven t already done so. This will help avoid delay in getting an eligible claim authorised by us. You are entitled to ask for a copy of our standard terms and conditions and a copy of your application form at any time. DATA PROTECTION NOTICE A copy of our full data protection notice is included in the terms and conditions document. Please ask if you would like to see a copy. VitalityHealth and our business associates, service providers and agents will use your information, together with other information, for administration, customer services, marketing and profiling your purchasing preferences and fraud prevention. We will pass your information to them for these purposes. We will pass your information to any legal or regulatory body if required to do so. By submitting this form you consent to us processing your sensitive personal information; such as health information. We may disclose your personal information to other companies in the Vitality Group*, our business associates, agents or service providers for the purposes above. Your information may be used by service providers in a country outside the European Economic Area, which may not have the same standard of data protection as in the UK. We will ensure appropriate safeguards are in place to protect your information. Acting on someone s behalf? When giving us information about another person, you confirm that they have appointed you to act on their behalf. This includes providing consent to process their personal information, receive this data protection notice on their behalf and receive marketing information. Marketing choice The Vitality Group* of companies and our business associates, service providers and agents would like to use your personal information to inform you of other services and products that may be of interest to you by telephone, post, or text. You can exercise your right to opt out of future marketing campaigns by ticking this box. * The Vitality Group includes Vitality Health Limited and Vitality Health Insurance Limited, both trading as VitalityHealth, and Vitality Corporate Services Limited trading as VitalityHealth and/or VitalityLife. Please go to Section J and read the plan declaration before signing and dating on behalf of all applicants. PAGE 10 OF 12

11 J VITALITYHEALTH PLAN DECLARATION TO BE SIGNED BY THE MAIN APPLICANT By submitting this application you confirm your understanding of the following: That this application is subject to written acceptance by VitalityHealth. That by completing this application you are applying on behalf of all applicants to be covered by this plan and are doing so with their full consent. You also agree to receive all plan-related documentation on behalf of all applicants. That the information given on this application form must be full and accurate. Failure to do so may result in a claim not being paid, your underwriting terms being changed, your cover being cancelled, and/or any treatment costs already paid by us being reclaimed. That you must advise us of any change to the information given in this application which occurs between the date of signing the plan declaration below and the plan start date (including changes to any applicants state of health). That no cover will apply for investigations or treatment of any medical condition or related conditions which exists or has existed before the start date of this plan unless, where requested within this application form, you have provided VitalityHealth with full details and they have agreed to accept it. That VitalityHealth will detail on your certificate of insurance any personal medical exclusion(s) that they ve applied due to the information you have provided. That in certain circumstances VitalityHealth may be unable to offer cover. That you consent to VitalityHealth using the information supplied for the purposes shown in the data protection notice in Section I on page 10. That you give permission for the medical information you ve provided to be disclosed to any employee in the Vitality Group for risk management and underwriting purposes. This information can also be used to maintain management information for business analysis. That you agree to VitalityHealth accepting medical reports faxed directly to VitalityHealth from the GP s surgery of any applicant to be covered by this plan. You also do not object to copies of the report being faxed to any other company that you have applied to at their request. That you have completed the declaration and read the important notes and information relating to your rights under the Access to Medical Reports Act That a copy of the application and plan terms and conditions are available on request. This application and the medical information disclosed on it is valid for 45 days from the date the application is signed (date recorded below). We may need you to confirm there has been no change in health since you signed this form if the final assessment of your application form takes longer than 45 days from the date the application was signed, or in the event we require further medical information from you or your dependants. In some circumstances a new application form will be required. Signature of the main applicant on behalf of all applicants. K TO BE COMPLETED BY THE ADVISER/VITALITY CONSULTANT Your FSA number (Registered individuals) e.g. A B C Phone number address Registered individual s first name Registered individual s last name Your VitalityHealth agency details Agency name and address e.g X PAGE 11 OF 12

12 K TO BE COMPLETED BY THE ADVISER/VITALITY CONSULTANT (CONTINUED) Routing of documentation In line with Data Protection regulations, all information and questions regarding this application that are of a confidential nature will be addressed directly to your client. Your client s welcome documents We will send your client s certificate of insurance and payment summary through the post. If you re an adviser, you can choose if you would like to route these documents via yourself or we can send them directly to your client. You ll receive details of how to access our online Adviser Service Area where you can view your client s plan details and premium information. Your client will also receive a welcome from us with a link through to our secure Member Zone where they will be able to view and download their certificate of insurance, plan terms and conditions and payment summary. Please indicate where you would like your client s printed plan documents posted to: You* (the adviser) Your client (the customer) IMPORTANT: Only one recipient can be chosen. You will always have access to your clients plan details through the online Adviser Service Area. For Direct Customers, all documents will be routed to the client. * Please note that if you choose to have your client s documents routed to you, it is your responsibility to ensure that your client receives them in a timely way. I confirm that all the information required and provided in relation to the medical information requested for this individual (and their dependants) for which I am aware, has been passed to VitalityHealth for consideration. Signature. L APPLICATION CHECKLIST BEFORE YOU RETURN THIS APPLICATION, PLEASE USE THIS CHECKLIST TO CONFIRM THAT YOU HAVE: Read or been given the Guide to Personal Healthcare brochure. Ensured all applicants are eligible to apply for cover as per the Eligibility criteria detailed on page 1. Entered and checked all personal details for you and other applicants, if applicable. Checked your quote and variation number to ensure that the cover and benefit options you have selected are correct and you have detailed the references in Section C or fully completed Section D if you do not have a quote reference number. Answered all health history questions as asked on pages 4 and / or 5, either yes or no and supplied full information for any answered yes on page 6. If you have answered yes to any health history question asked, you have also read and completed the GP details and Access to Medical Reports Act consent form, including whether or not an applicant wishes to see the report, if VitalityHealth request one. Completed your payment details. Read and kept for your information The Direct Debit Guarantee. Signed and dated the VitalityHealth plan declaration in section J on behalf of all applicants. Completed Section I - applies to the Adviser or Vitality Consultant only. VitalityHealth is a trading name of Vitality Health Limited and Vitality Corporate Services Limited. Vitality Health Limited, registration number is the insurer that underwrites this insurance plan. Vitality Corporate Services Limited, registration number acts as an agent of Vitality Health Limited and arranges and provides administration on insurance plans underwritten by Vitality Health Limited. Registered office at 3 More London Riverside, London, SE1 2AQ. Registered in England and Wales. Vitality Corporate Services Limited is authorised and regulated by the Financial Conduct Authority. Vitality Health Limited is authorised by the Prudential Regulation Authority and is regulated by the Financial Conduct Authority and the Prudential Regulation Authority. PRUHF21835_0415_ENP/PHC FMU Part of the Discovery Group