Medical Declaration Form. Important information to read before completing the form:
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1 Administered by Medical Declaration Form Important information to read before completing the form: Pre-Existing Medical conditions Travel insurance only provides cover for emergency medical events that are unforeseen. Medical conditions that were pre-existing at the time of the policy being issued are not covered, unless they are a condition that we expressly agree to cover. If you have a Pre-existing Medical Condition that is not covered, we will not pay any claims arising from, related to or associated with that condition. Definition of a Pre-Existing Medical Condition: 1. Any past or current Medical Condition that has given rise to symptoms or for which any form of treatment or prescribed medication, medical consultation, investigation or follow-up/check-up has been required or received during 6 months prior to the commencement of cover under this policy and/or prior to any Trip: and 2. Any cardiovascular or circulatory condition (e.g. heart condition, hypertension, blood clots, raised cholesterol, stroke, aneurysm) that has occurred at any time prior to the commencement of cover under this policy and/or prior to any Trip. Examples of three (3) common Pre-existing Medical Conditions are set out below: Cardiovascular Disease: Medical conditions involving the heart and blood vessels are collectively called cardiovascular disease (CVD). Al such conditions are interrelated. If you have ever needed to see a specialist cardiologist, or been diagnosed with a form of CVD such as (but not limited to): 1 Aneurysms 2 Angina 3 Cardiomyopathy 4 Cerebrovascular Accident (Stroke) 5 Disturbances in Heart rhythm (cardiac arrhythmias 6 Previous heart surgery (including valve replacements, bypass surgery, stents) 7 Myocardial infarction (heart attack) 8 Transient Ischaemic Attack And you do not purchase adequate cover for CVD, you may not be covered for any claims relating to hart/cardiovascular system (including heart attacks and strokes). If any of these conditions are expressly excluded from the policy, all CVD is excluded. Warfarin Use: Taking the medication Warfarin (also known under the brand names of Coumadin, Jantoven, Marevan, and Waran) has a complex range of serious complications and side effects. These risks are in excess of those associated with the underlying condition for which you take this medication. If you are currently prescribed the drug, you must complete a Medical Declaration Form (even if you decide not to apply for cover for a Pre-existing Medical Condition) and we must agree in writing to provide cover. If you do not submit a completed Medical Declaration Form, the general Exclusions will apply and you will not have cover. Chronic Lung Disease: If you have ever been diagnosed with a chronic lung disease including (but not limited to) Emphysema and Chronic Bronchitis, Bronchiectasis, Chronic Obstructive Airways Disease (COAD), Chronic Obstructive Pulmonary Disease (COPD) or Asthma and you do not purchase adequate cover for your respiratory disease, you may not be covered for any claims relating to a new airways infection. Group 1: Pre-Existing Medical Conditions that are automatically excluded: OOJAH TRAVEL PROTECTION (Pty) Ltd (Reg. No. 2008/013637/07) Oojah is an authorised Financial Services Provider, no Underwritten by The Hollard Insurance Company, an authorised Financial Services Provider PO Box 41641, Moreletapark, 0044 Tel: Fax: Directors: U Jansen (M.D.), CH v Staden, D Sutton-Pryce, L Dobrescu
2 We will not pay for any costs or expenses arising directly or indirectly from any of the following Pre-existing Medical Conditions. This includes cost of medical care while overseas, or cost of cancellation of your travel plans due to a change in health. Travel insurance is available to you; however there is no provision to claim for any of the Medical conditions as listed in A. 1. Any condition for which you have undergone surgery in the past 6 weeks 2. Neoplasia (cancer of any kind) including secondaries from that cancer 3. Where a terminal or malignant prognosis has been given 4. Any condition for which you have ever required spinal or brain surgery 5. Any condition for which has caused a seizure in the last 12 months 6. Therapeutic or illicit alcohol or drug addiction 7. Any mental illness including dementia, depression, anxiety, stress or other nervous conditions 8. Behavioural diagnoses such as autism 9. Chronic pain syndrome(including back pain) managed by a specialist pain management physician or clinic 10. Joint replacement surgery over 10 years ago 11. Pregnancy and Childbirth: Cover under this policy is provided for unexpected complications related to pregnancy. Pregnancy and Childbirth are not considered to be either an illness or injury. Please refer to the Meaning of Words Section: Complications of Pregnancy and Childbirth, and each Section of cover to establish whether You are covered. 12. Organ transplantation, previous organ transplantation, or any condition for which you are awaiting organ transplantation. 13. Any condition that is currently under investigation to define diagnosis 14. Any cardiovascular disease or cerebrovascular disease if you have: a) Experienced angina (chest pain) within the past 6 months; or b) Had a stroke (cerebrovascular accident or CVA) or a Transient Ischaemic Attack (TIA) within the past 12 months. 15. Any cardiac or respiratory condition if you: a) Require home oxygen therapy; or b) Will require oxygen for your Journey; or c) Have been diagnosed with Congestive Heart Failure. Group 2: Pre-existing conditions which are automatically covered You will be automatically covered for the Medical conditions below (excluding chronic medication), provided that you have not been hospitalised for that condition in the past 24 months and therefore you do not need to submit an application. Cover is subject to a minimum of 48 hours inpatient treatment. Allergies limited to Rhinitis, Chronic Sinusitis, Eczema, food Intolerance, Hay fever Asthma, providing that you have no other lung disease, and are less than 60 years of age at the date of policy purchase Bell s palsy Diabetes provided you were diagnosed over 12 months ago and has no eye, kidney, nerve or vascular complications. Do not suffer from a known cardiovascular disease, hypertension, hyperlipidaemia or hypercholesterolaemia and your blood sugar level reading shows between 4 and 8. Epilepsy provided there has been no change to your medication regime in the past 12 months Hypercholesterolemia (High Cholesterol) provided you do not also suffer from a known cardiovascular disease and/or diabetics Hyperlipidaemia (High Blood Lipids) provided you do not also suffer from a known cardiovascular disease and/or diabetics Hypertension (High Blood Pressure) provided you do not also suffer from a known cardiovascular disease and/or diabetics Impaired Glucose Tolerance Insulin Resistance Iron Deficiency Anaemia Migraine Please note: Diabetes (Type I and Type II), Hypertension, Hypercholosterolaemia and Hyperlipidaemia are risk factors for cardiovascular disease. If you have a history of cardiovascular disease, cover for these conditions are also excluded. If you have been hospitalized or your condition does not meet the description above, cover is NOT automatic. You are required to submit a medical declaration form (below). Group 3: Pre-existing conditions requiring a medical assessment: Page 2 of 5
3 If you have any condition described below, you are required to complete the medical declaration form (below): a) Any condition for which you have been hospitalized in the last 24 months. b) Any condition that requires ongoing treatment (e.g.) arthritis, colitis, chronic respiratory disease, etc.) c) You have had angina (chest pain)in the past 6 months d) You have a Pacemaker or AICD (internal Defibrillator) e) Epilepsy due to an underlying medical condition, or you have had a seizure in the last 12 months f) Past history of deep vein thrombosis (dvt) or pulmonary embolism g) Joint replacement surgery over 10 years ago h) You have a Cerebrovascular Accident (stroke) or transient ischaemic attach (TIA) in the past 24 months. i) You have had heart problems requiring coronary angiography, stents or bypass grafting in the past 12 months, or You had such procedures more than 3 years ago. Passenger Declaration: This form should be completed by the traveller. If you do not feel comfortable, or confident answering the medical questions below, you should request the assistance of your usual doctor. (Any costs incurred are the responsibility of the traveller.) Note: You cannot apply for cover for conditions outlined in Group 1. Please complete in block letters and fax back to Oojah Travel Protection on or to travelinsurance@oojahtravel.co.za Title: Name: Surname: Address: (SA) Contact (SA) Fax: (SA) address: Please tick (X) / complete Male Female Height Weight Identity Number/Date of Birth Departure date: Return date: Mode of travel: Do you smoke? Yes/No? Are you intending to participate in hazardous pursuits (ski, bungee jumping, river rafting, etc) Yes/No? Do you play sport or exercise regularly? Yes/No Have you previously submitted a claim in respect of your medical condition whilst overseas? Yes/No? Have you visited a doctor in the last 90 days? Yes/No Contact information of treating Medical Practitioner: Name: Daytime contact information: Medical History Please answer Yes or No to all questions in this section. If you answer Yes to any of the questions, please complete all details in that question. a) Have you ever had a blood clot, such as a Deep Vein Thrombosis (DVT or Pulmonary Embolism? (Yes) (No) If yes: Date:.../.../... Reason for clot (e.g. pregnancy, after surgery, aeroplane journey):... b) Have you ever been diagnosed with a chronic lung disease (including Emphysema and Chronic Bronchitis, Cbronchiectasis, COAD (Chronic Obstructive Airways Disease) or COPD (Chronic Obstructive Pulmonary Disease), Cystic Fibrosis, Asbestosis or Asthma)? (Yes) (No) If yes: Name of condition?... Date you were last in Hospital/Emergency Department with this condition:.../.../... Do you require home oxygen therapy? (Yes) (No) Will you require oxygen for the journey? (Yes) (No) c) Do you have Diabetes Mellitus? (Yes) (No) Page 3 of 5
4 If yes: Date of Diagnosis:.../.../... Currently controlled with: Diet only Insulin injections Insulin Pump Other medication Please specify medication:... Do you have any resulting problems with your: Eyes Kidneys Legs d) Do you take medication for Hypertension (High blood pressure)? (Yes) (No) List medications:... e) Do you take any medication for Hypercholesterolaemia (High Cholesterol)? (Yes) (No) List medications:... f) Have you ever had Angina (Chest Pain)? (Yes) (No) If yes: When was your last attack:.../.../... Frequency of attacks:... What treatment do you take for it?... g) Have you ever had a heart attack (myocardial infarct)? (Yes) (No) If yes: Date of heart attack:.../.../... h) Have you ever had coronary angiography, stents or bypass grafting (CABG)? (Yes) (No) If yes: Name of procedure and date:.../.../ Have you experienced any angina since that procedure? (Yes) (No) I) Have you ever had a stroke (CVA) or mini-stroke (TIA)? (Yes) (No) If yes: Name of the event and date:.../.../ i) Have you ever been diagnosed with a heart arrhythmia such as atrial fibrillation? (Yes) (No) If yes: Name of condition... Date of diagnosis:.../.../... List of medications:... j) Do you have a Pacemaker or AICD (internal defibrillator)? (Yes) (No) If yes: Type of device inserted:... Date of insertion:.../.../... k) Do you take any other medication for your heart, or to thin your blood? (Yes) (No) E.g. Warfarin (also known as Coumadin, Jantoven, Marevan, and Waran) If yes: list medications:... l) Have you ever been diagnosed with epilepsy? (Yes) (No) If yes: Have you experienced a seizure in the last 12 months? (Yes) (No) Have there been any changes to your seizure medication in the last 12 months? (Yes) (No) m) Have you been hospitalised (including day surgery), or attended an Emergency Department in the past 24 months? (Yes) (No) If yes: Please provide details: (if one to these attendances was for routine colonoscopy, please indicate whether the result was normal) Date of Event Reason for attendance.../.../ /.../ /.../ n) Please provide details of any other Pre-existing Condition (as defined on page 1 of this document) not mentioned: Medical condition Current medication/treatment Were any of these conditions newly diagnosed in the last 3 months? (Yes) (No) Page 4 of 5
5 If yes, please provide details: Passenger Declaration: All the answers given herewith are true, correct and complete. I have not withheld any information likely to affect my application for cover. I hereby authorise my doctor, hospital, clinic or any other person to provide Oojah Travel Protection any medical information (past and current). I agree not to be covered for any Pre-Existing condition unless disclosed in this form and Oojah Travel Protection has agreed to cover those conditions. Signature of applicant:... Date:.../.../... Signature of legal guardian:... Date:.../.../... (Required if traveller under 18Yrs) Page 5 of 5
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