Private medical insurance application form

Transcription

1 Private medical insurance application form Adding a new dependant to individual policies. To be used for policies taken out with PruHealth prior to March 2011 and where the policy number does not start with 10. To apply to add a dependant to your policy, please complete SECTIONS A to I inclusive and as applicable for your chosen underwriting option. 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 use BLOCK CAPITALS and black ink when filling in this form. Application checklist Before you return this application, please use this checklist to confirm that you have: Selected only one underwriting option for all applicants, that they are eligible for your selection and it is the same as your underwriting terms (this information can be found on your membership certificate). Checked that the maximum number of dependants allowed on your policy will not be exceeded. Entered and checked all personal details for you and all other applicants. Provided your quote reference in Section C if you asked for a quotation to apply to add the dependants. Fully answered all relevant health history questions and signed the declaration statement for the chosen underwriting option, and if applicable attached a copy of the applicant s current membership certificate. Signed the PruHealth policy declaration in section I on behalf of all applicants. A Who is this form for? Your spouse / partner who lives at the same address as you and is aged between 16 and 79 (inclusive) at their cover start date. Your children, including adopted children, who are aged 20 or under (or 25 or under if they are eligible to apply under the CPME/Switch underwriting option), at their cover start date. Applicants who 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 policy year. B Policyholder details Policyholder s first name Policyholder s last name Policy number C Quote and cover details All dependants who are included under this policy will have the same cover and benefits, where available, as the policyholder. If you requested a quotation to add additional dependants to your policy, please enter the quote reference below and attach a copy of the relevant quote to this application form. Quote reference number If you re applying to include your dependants: a) On a moratorium underwriting basis or a full medical underwriting basis and all health history questions have been answered no, providing all the required sections have been fully and correctly completed their cover will commence on the date PruHealth receive this application form. b) On a full medical underwriting basis and any health history questions have been answered yes, their cover (if available), will commence on the date PruHealth finish their assessment of this application form. A future cover start date may be requested up to 45 days in the future (from the date you have signed and dated this application form). If this is preferred and available, please enter the future date requested here: Future start date BRAVO_IND_AOD PRUHF6485/0614 Page 1 of 12

2 D Spouse/Partner and child dependant details If you are applying to include more than five dependants to your policy, please attach their details on a separate sheet of paper, or use the tes section at the back of this form. You can include a maximum of eight eligible dependants on your policy. This could be up to eight children or your spouse / partner and up to seven children. 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 of birth Gender Male Female Child (dependant 2) Child (dependant 3) Title Mr Mrs Ms Miss Other Title Mr Mrs Ms Miss Other First name Last name First name Last name of birth of birth Gender Male Female Gender Male Female Child (dependant 4) Child (dependant 5) Title Mr Mrs Ms Miss Other Title Mr Mrs Ms Miss Other First name Last name First name Last name of birth of birth Gender Male Female Gender Male Female Please enter below the names of any applicants who are employed in the occupations that are listed (leave blank if this doesn t apply to any applicants): Name of applicants Working offshore in the extraction / refinery of natural / fossil fuels Armed forces personnel (including territorial army) For details of what cover is available for these occupations please refer to your policy terms and conditions. Page 2 of 12

3 E Underwriting options By selecting full medical underwriting, you will know exactly what is covered and what conditions are excluded from your dependants cover. You need to provide full medical details in the PINK section of this form. If you select moratorium underwriting, you will not have to provide full medical details on this form but we may have to request information from your dependant s GP when they make a claim to determine whether the condition was pre-existing. Please complete the PURPLE section of this form. If you select continued personal medical exclusions (CPME / Switch) underwriting, you will know exactly what is covered and what conditions are excluded from your dependant s cover. Existing personal medical exclusions will be continued with us and you will need to provide a limited amount of medical history in the GREEN section of this form. For the purposes of underwriting (assessing) this application, we usually rely solely on the information you, the policyholder, provide on this form on behalf of the additional dependants, and also their most recent membership certificate if they are switching from another provider. Please help us, therefore, by completing all of the health questions honestly and fully for all applicants. Failure to do so may result in a claim not being paid, the underwriting terms being changed or your cover being cancelled. Please select the same underwriting option that applies to you, the policyholder, as shown on your membership certificate in the Underwriting section. If this underwriting option is not available and/or suitable for your dependants or if you are unsure of which underwriting option you can select, please call us on and we ll be happy to discuss further. 1. Full medical underwriting 2. Moratorium underwriting 3. Continued personal medical exclusions (CPME / Switch) E1 Full medical underwriting Only complete this section if you have chosen the full medical underwriting option. Should you have any relevant medical reports, please attach copies to this application. 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 & 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 3 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 you have answered NO on behalf of ALL applicants to the 3 questions above you do not need to answer any more questions in this section and your dependants can be accepted on full medical underwriting with no personal medical exclusions. Please continue with the application form and go to section F. For ALL applicants that you have answered YES to any question above, you must now complete the rest of section E1 of this application form. Page 3 of 12

4 E1 Full medical underwriting continued Only complete this section for any applicants who answered YES to any of the previous full medical underwriting questions. 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 dates 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 a definitive list. a. Blood disorders b. Brain and nerve disorders c. Cancer d. Cardiac and vascular disorders e. Connective tissue disorders f. Dental disorders g. Ear, nose, throat, eye and speech disorders h. Gastro-intestinal disorders i. Female/male reproductive system disorders j. Kidney/Urinary tract disorders e.g. anaemia, leukaemia, bleeding disorders, haemophilia, lymphoma, thrombosis (blood clots) e.g. stroke, multiple sclerosis, epilepsy, migraine, paralysis, Parkinson s disease, quadriplegia, paraplegia e.g. any form of cancer or pre-cancerous growth, tumours or moles that have changed in appearance 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.g. SLE (systemic lupus erythematosus), scleroderma, mixed connective tissue disorder e.g. over/under bite problems, missing/skew teeth, impacted wisdom teeth or ongoing treatment e.g. cataracts, glaucoma, macular degeneration, hearing/visual impairment, loss of speech, tonsillitis e.g. peptic ulcer, hiatus hernia, heartburn, changed bowel habits, rectal bleeding, Crohn s disease, ulcerative colitis, IBS (irritable bowel syndrome) e.g; ovarian cysts, endometriosis, fibroids, infertility, disorders of the cervix, menstrual disorders, penile/testicular disorders, epididymitis, breast lumps/cysts, complications of pregnancy/childbirth 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 m. Metabolic/Endocrine disorders n. Musculo-skeletal disorders (bone, joint, muscular) o. Respiratory disorders e.g. depression, anxiety, schizophrenia, eating disorders, ADHD (attention deficit hyperactivity disorder), autism e.g. diabetes, thyroid abnormalities, growth disorder, Cushing s disease, Addison s disease 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 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 4 of 12

5 E1 Full medical underwriting continued Further information If any applicant has answered YES to any of the questions 1-3 on page 3 and/or a-q on page 4, please supply full details below Name of applicant to whom the condition/symptom applies Condition/symptom (and number and/or letter 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 use the tes page at the back of this form, or continue on a separate sheet of paper, sign and date it, and attach it to this form. Full medical underwriting declaration. Please sign and date below to confirm the details provided (and any additional information you have supplied) are accurate. Signature of the policyholder on behalf of all applicants Please go to section F. Page 5 of 12

6 E2 Moratorium underwriting Only complete this section if you chose the moratorium underwriting option. What is moratorium underwriting?: If you select moratorium underwriting, we do not ask you to give details of your dependant s medical history. Instead, we apply a straightforward exclusion clause (our moratorium clause ) which says: We cannot pay claims for the treatment of any medical condition which the applicant has received medical treatment for, had symptoms of, asked advice on or to the best of their knowledge and belief were aware existed in the five years before their cover start date (a pre-existing medical condition ). After two years of continuous insurance cover from the applicant s cover start date, all pre-existing medical conditions will become eligible for benefit, subject to the terms and conditions of the policy. However, this only applies if, when they first receive treatment, they have not: consulted anyone (e.g. a GP, dental practitioner, optician or therapist, or anyone acting in such a capacity) for medical treatment or advice (including check-ups), or taken medication (including prescription or over-the-counter drugs, medicines, special diets or injections), for that medical condition or any related condition for two continuous years after their cover start date. This clause can easily be broken down into three parts. Firstly - Medical conditions that are covered from the first day of their insurance. These are conditions that are new to the applicant after their cover start date. Secondly - Pre-existing medical conditions which become eligible for cover after at least two years continuous insurance. We cover them if the applicant has stayed free from receiving any treatment, advice or medication for a continuous period of two years after their cover start date. Thirdly Pre-existing medical conditions which we permanently exclude from cover. We exclude them because the applicant will need regular or periodic treatment, advice or medication and they will never be able to remain free of this help for any continuous two year period. The applicants cover will probably never cover any pre-existing long-term medical conditions such as heart problems, cancer and psychiatric conditions, which are likely to require regular or periodic treatment, medication or advice. This is because the moratorium period starts each time they receive such treatment, so it s unlikely that they will ever have two continuous years free of treatment. Of course, we strongly advise all applicants not to delay seeking medical advice or treatment for a pre-existing condition during the moratorium period. Moratorium underwriting declaration I understand and agree that: Pre-existing medical conditions are subject to the terms and conditions of the moratorium as defined in the terms and conditions of the policy and as explained above. If any applicant makes a claim, PruHealth will have to request information from them or their GP to determine whether the condition was pre-existing or not. Signature of the policyholder on behalf of all applicants Please go to Section H Page 6 of 12

7 E3 Continued personal medical exclusions (CPME / Switch) underwriting Only complete this section if you chose the switching from another provider underwriting option. The CPME / switch underwriting option is available to eligible applicants who currently have comparable private health insurance and would like to apply to transfer to PruHealth. Current cover and claims history These questions are used to determine your dependants eligibility for transferring their cover to PruHealth. 1. Do all of the dependants detailed on this application form currently have health insurance? 2. If yes for how many years have they continuously had health insurance? 3. How many relevant claims* have they made in total on their health insurance in the past 5 years? 4. Name of current health insurer 5. Current health insurance renewal date *te: Relevant claims are those which have been made by all applicants in the last five years on health insurance, not on dental or travel insurance. You do not need to include health insurance claims that meet the following criteria: A. The total cost of the claim was less than 350. B. Is one of the following conditions/procedures: gall bladder removal (if due to gallstones), hysterectomy (provided not related to cancer), adenoidectomy, appendectomy, wisdom teeth removal, fractures (provided no pins or plates are in place), tonsillectomy, or normal pregnancy. C. For both A and B above, treatment must have been completed more than 12 months ago, a full recovery must have been made and no further consultations, investigations or treatment be planned or recommended. Medical questions Please answer questions 1 and 2 on behalf of all applicants if you have chosen this underwriting option. Only complete questions 3 and 4 for applicants aged 55 or over. Questions 1 & 2 for all applicants 1. In the last 5 years has any dependant included on this application form, seen a GP, Consultant or other health professional for advice on, or treatment for, any of the following conditions: (a) any heart condition or stroke/transient ischaemic attack (mini stroke)? (b) cancer? (c) any mental health illness? 2. During the last 12 months has any dependant included on this application form: (a) been treated and/or received medical advice at a hospital, clinic or nursing home (whether private or NHS) for any reason, or (b) undergone tests or check-ups, or been referred for consultations, tests or check-ups, where they are still awaiting a first or follow-up appointment, test results or treatment for any symptoms or condition not mentioned above? Questions 3 & 4 - additional for all applicants aged 55 and over 3. Has any dependant included on this application form ever had any joint disorder or disease (including arthritis), or suffered from regular or persistent pain in any joints? 4. Does any dependant included on this application form have any medical condition or symptoms for which they are receiving treatment or taking medication (whether prescribed or over-thecounter); or where further check-ups are considered necessary or advisable? Page 7 of 12

8 E3 Continued personal medical exclusions (CPME / Switch) underwriting continued Further information If any applicant has answered YES to any of the questions on the previous page, please supply full details below. Name of applicant to whom the condition/symptom applies Condition/symptom and questions it relates to Details 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 use the tes page at the back of this form, or continue on a separate sheet of paper and attach it to this form. IMPORTANT INFORMATION you would like cover to begin Please note, we must receive this completed application form (and any other requirements) within 45 days of the date you have stated you would like your dependants cover to begin. We will not backdate cover any further than 45 days and there must be no break in cover between the date your dependants current cover ceases and the start date of their cover with PruHealth. We strongly advise any applicant not to cancel their existing health insurance cover until we have confirmed our terms in writing and they are happy to accept those terms. For any dependants who are applying on CPME/ switch underwriting terms, you will need to supply a copy of their current membership certificate or renewal notice. This must state their current underwriting terms, any personal medical exclusions that apply and confirm that their cover is still in force. If we do not receive a copy of your dependants current membership certificate or renewal notice, whilst we will proceed with their application, we will not be able to authorise any eligible claims until this is supplied. Any existing personal medical exclusions will continue with PruHealth. If any dependants are currently on a moratorium clause, then we ll apply our own moratorium rules but backdated to their cover start date with their current insurer. We may also place additional personal medical exclusions or in some circumstances we may be unable to offer cover. Switch underwriting declaration Please sign and date below to confirm the details provided (and any additional information you have supplied) are accurate. Signature of the policyholder on behalf of all applicants Please go to section F Page 8 of 12

9 Only complete sections F and G if you are applying to include dependants under the full medical underwriting or continued personal medical exclusions (CPME / Switch) underwriting options. You do not need to complete these sections if you are applying to include your dependants to cover on a moratorium underwriting basis. F GP s details Please state the name and address of your dependants usual GP (to whom requests for information are usually made). If they have changed their GP in the past year, please also give the name and address of their previous GP in the tes page at the back of this form or attach it on a separate sheet of paper. If the GP is different for any of the other dependants who are applying for cover under your policy, please also provide their details. GP s name Address Postcode Telephone number Fax number G Access to Medical Reports Act 1988 Please ensure any dependants applying for cover on this policy read and sign this declaration. 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 PruHealth 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 PruHealth Please tick one box only I do not need to see the report before it is sent to PruHealth To avoid delay, each person may choose to give their consent by signing in the box below. If additional signature space is required, please use the tes section at the back of this form, stating the signatures apply to section G. Spouse / 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 this application based on all of the health questions being fully and honestly completed. If we do ask an applicant s GP for information we will keep you advised and we may ask you to contact the GP if we request a medical report and experience delays in receiving it. Page 9 of 12

10 H Important information General notes Cover for your additional dependants will not start until we have accepted this application. If the dependants cover starts in a different month to that stated on the quotation (if provided), the terms may differ from those originally quoted. If an applicant has a birthday while this application is being processed, the terms may differ from those originally quoted. We may offer revised terms and premium, unless the dependant is now over the maximum age for joining this policy. If they haven t already done so, all applicants should ensure they are registered with a UK GP and Dentist who holds their full medical and dental records. This will help avoid a 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 tice 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. PruHealth* 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 PruHealth 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 PruHealth 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. * PruHealth is a joint venture between Prudential in the UK and Discovery Holdings Limited in South Africa. **The PruHealth group includes Prudential Health Limited and Prudential Health Insurance Limited, both trading as PruHealth, and Prudential Health Services Limited trading as PruHealth and/or PruProtect. Please go to Section I and read the policy declaration before signing and dating on behalf of all applicants. Page 10 of 12

11 I Policy declaration to be signed by the policyholder on behalf of the additional dependants By submitting this application you confirm your understanding of the following: That this application is subject to written acceptance by PruHealth. That by completing this application you are applying on behalf of all applicants to be covered by this policy and are doing so with their full consent. You also agree to receive all policy-related documentation on behalf of all applicants. That the information given on this application form must be full and accurate. That failure to take reasonable care in answering any questions may result in a claim not being paid, your underwriting terms being changed or your cover being cancelled. That you must advise us of any change to the information given in this application which occurs between the date of signing the policy declaration below and the applicants cover 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 condition which exists or has existed before the applicants cover start date unless, where requested within this application form, you have provided PruHealth with full details and they have agreed to accept it. You also understand that PruHealth will detail on your membership certificate any personal medical exclusions that they ve applied due to the information you have provided. You understand that in certain circumstances PruHealth may be unable to offer cover. That you consent to PruHealth using the information supplied for the purposes shown in the data protection notice in Section H. That a copy of the application and policy terms and conditions are available on request. If you are applying under full medical underwriting or switching from another provider, you also confirm: That, if a dependant is applying under the Switch (CPME) underwriting option, you will supply PruHealth with their current membership certificate so that they can confirm the underwriting terms that will apply. If you ve answered to any of the health questions on this application, you understand that PruHealth will advise you if they need to change the underwriting terms for anyone included on this application, from those that apply with their current insurer. That you give permission for the medical information you ve provided to be disclosed to any employee in the PruHealth group for risk management and underwriting purposes. This information can also be used to maintain management information for business analysis. That you agree to PruHealth accepting medical reports faxed directly to PruHealth from the GP s surgery of any applicant to be covered by this policy. 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 all applicants have read the important notes and information relating to their rights under the Access to Medical Reports Act 1988 and have completed the declaration. 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 your dependants. In some circumstances a new application form will be required. Signature of the policyholder on behalf of all applicants Page 11 of 12

12 tes PruHealth is a trading name of Prudential Health Limited and Prudential Health Services Limited. Prudential Health Limited, registration number is the insurer that underwrites this insurance policy. Prudential Health Services Limited, registration number acts as an agent of Prudential Health Limited and arranges and provides administration on insurance policies underwritten by Prudential Health Limited. Registered office at Laurence Pountney Hill, London EC4R 0HH. Registered in England and Wales. Prudential Health Services Limited is authorised and regulated by the Financial Conduct Authority. Prudential Health Limited is authorised by the Prudential Regulation Authority and is regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Calls may be recorded/monitored to help improve customer service. Call charges may vary. BRAVO_IND_AOD PRUHF6485/0614 Page 12 of 12