PRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE MID-TERM JOINER APPLICATION FORM SCHEMES OF 2 TO 19 EMPLOYEES

Transcription

1 PRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE MID-TERM JOINER APPLICATION FORM SCHEMES OF 2 TO 19 EMPLOYEES To be used for plans with a cover start date on or after 1st March 2011 and before 1st October To apply for VitalityHealth membership complete SECTIONS A to I. 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. Please read section H to ensure all applicants are eligible to apply for cover. A EMPLOYMENT DETAILS Employer name Company plan number Date of commenced employment D D M M Y Y Y Y Date you would like your cover to begin (if you are a new employee this is likely to be the date of employment. If you are an existing employee, this is likely to be the date you become eligible to join the plan). If required, a date up to 45 days in the future, from the date you have signed and dated this application form, can be requested. D D M M Y Y Y Y B EMPLOYEE DETAILS Title Mr Mrs Ms Miss Other Gender Male Female First name Last name Address Postcode Telephone number (home) Telephone number (work) Telephone number (mobile) Date of birth D D M M Y Y Y Y C COVER DETAILS Your employer has made some cover choices for you which are based on your Employer group (category). Please tell us in the boxes below which Employer group (category) you are in and also indicate which hospital list and underwriting choice applies. If you re not sure of the details, please ask your Group Secretary. Employer group (category) Hospital List Local Countrywide Premier Underwriting choice Continued personal Moratorium Full medical underwriting medical exclusions (switch) PRUHF22134 EVE 0315 VITALITY.CO.UK/HEALTH

2 D SPOUSE/PARTNER AND CHILD DEPENDANT DETAILS Complete only if there are other people to be covered by this plan. If you have more than five dependants please attach their details to this form using a separate sheet of paper. You can add up to a maximum of eight dependants to your plan. This could be up to eight children or your husband/wife/ 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 Date of birth D D M M Y Y Y Y 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 Date of birth D D M M Y Y Y Y Date of birth D D M M Y Y Y Y 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 Date of birth D D M M Y Y Y Y Date of birth D D M M Y Y Y Y Gender Male Female 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 of applicants Armed forces personnel (including territorial army). For details of what cover is available for these occupations please refer to your plan terms and conditions. PAGE 2 OF 12

3 E UNDERWRITING OPTIONS The underwriting choice is made by your employer. This choice will determine which of the following numbered sections E1, E2, or E3 you need to complete. If you are unsure how to proceed, please contact your Group Secretary. Please only complete one section. IMPORTANT: Full medical underwriting and Switch (CPME) options For the purposes of underwriting (assessing) your application, we usually rely solely on the information you provide on this form and also your most recent certificate of insurance if you re switching from another provider. 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 or any treatment costs already paid by us being reclaimed. Please note: If you re switching from an existing provider and based upon the information you provide, VitalityHealth reserves the right to apply additional personal medical exclusions or to decline this application. It is strongly recommended that you keep your existing cover in force until acceptance on switch terms is confirmed. E1 SWITCHING FROM AN EXISTING PROVIDER (CONTINUED PERSONAL MEDICAL EXCLUSIONS CPME) If your employer has selected this option, please provide the information below and attach a copy of your most recent certificate of insurance showing your original medical underwriting terms and any personal medical exclusions that apply. If you do not supply a copy of your most recent certificate of insurance, although we will proceed with your application, we won t be able to authorise any eligible claims until this is received. 1. Have you or anyone else to be insured on your plan had any in-patient or day-patient treatment in the last 6 months or have any planned or anticipated? 2. Have you or anyone else to be insured on your plan ever suffered from any heart, cancer or psychiatric related conditions? If you have answered yes to either question above, please provide further details below. 1. Name of person to whom the condition/symptom applies. 2. Condition/symptom and question(s) it relates to. 3. Details of medication/ treatment/ consultations/investigations. (Please include all dates) 4. What, if any, further consultations/ treatment/ investigations are required. 5. Present state of health (e.g. full recovery or symptoms still present). Additional information if you require more space, please use a separate sheet of paper, sign and date it, and attach it to this form. PLEASE NOTE: Any existing personal medical exclusions will continue with VitalityHealth. If you re switching from a moratorium clause, then we ll apply our own moratorium rules but backdated to your cover start date with your current insurer. We may also apply additional personal medical exclusions based on the information you ve provided. In some circumstances, we may be unable to offer any cover. All personal medical exclusions that apply to the plan will be shown on your certificate of insurance. There must be no break in cover between any applicant s current cover ceasing and their cover start date under this plan. PAGE 3 OF 12

4 E1 SWITCHING FROM AN EXISTING PROVIDER (CONTINUED) (CONTINUED PERSONAL MEDICAL EXCLUSIONS CPME) SWITCH (CPME) UNDERWRITING DECLARATION Please sign below to confirm that the information provided on page 3 is accurate. Signature of employee on behalf of all applicants. Date. D D M M Y Y Y Y Please go to Section F. E2 MORATORIUM UNDERWRITING Only complete this section if your employer has chosen the moratorium underwriting option. WHAT IS MORATORIUM UNDERWRITING?: Under moratorium underwriting, we do not ask you to give details of your 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 you have received medical treatment for, had symptoms of, asked advice on or to the best of your knowledge and belief were aware existed in the five years before the cover start date (a pre-existing medical condition ). After two years of continuous insurance cover from the cover start date, all pre-existing medical conditions will become eligible for benefit, subject to the terms and conditions of the plan. However, this only applies if you 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 pre-existing medical condition or any related condition for two continuous years after your cover start date. This clause can be broken down into three parts. Firstly, medical conditions that are covered from the first day of your insurance. These are conditions that are new to you after taking out your plan. Secondly, pre-existing medical conditions which become eligible for cover after at least two years continuous insurance. We cover them if you have stayed free from receiving any treatment, advice or medication for a continuous period of two years after your cover start date. Thirdly, pre-existing medical conditions which we permanently exclude from cover. We exclude them because you will need regular or periodic treatment, advice or medication and you will never be able to remain free of this help for any continuous two-year period. Your plan 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 you receive such treatment, so it s unlikely you ll ever have two continuous years free of treatment. Of course, we strongly advise you not to delay seeking medical advice or treatment for a preexisting condition during the moratorium period. MORATORIUM UNDERWRITING DECLARATION I understand that: Pre-existing medical conditions are subject to the terms and conditions of the moratorium as defined in the terms and conditions of the plan and as explained above. If any applicant makes a claim, VitalityHealth will have to request information from them or their GP to determine whether the condition was pre-existing or not. Signature of the employee on behalf of all applicants. Date. D D M M Y Y Y Y Please go to Section H. PAGE 4 OF 12

5 E3 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 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 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)? If all applicants have answered no to all 3 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 sign the declaration on page 7 now, and then go to section H. All applicants answering yes to any question above should now complete the rest of this section and then go to section F. PAGE 5 OF 12

6 E3 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 e.g. anaemia, leukaemia, bleeding, haemophilia, lymphoma, thrombosis (blood clots). b. Brain and nerve 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 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 e.g. SLE (systemic lupus erythematosus), scleroderma, mixed connective tissue disorder. f. Dental e.g. over/under bite problems, missing/skew teeth, impacted wisdom teeth or ongoing treatment. g. Ear, nose, throat, eye and speech e.g. cataracts, glaucoma, macular degeneration, hearing/ visual impairment, loss of speech, tonsillitis. h. Gastro-intestinal 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 e.g; ovarian cysts, endometriosis, fibroids, infertility, of the cervix, menstrual, penile/testicular, epididymitis, breast lumps/cysts, complications of pregnancy/ childbirth. j. Kidney/Urinary tract e.g. kidney failure, kidney stones, recurrent infections, nephritis, prostate problems, blood/protein in urine, polycystic kidneys. k. Liver/Pancreatic e.g. hepatitis, cirrhosis, liver failure, gallstones, pancreatitis. l. Mental health/psychiatric e.g. depression, anxiety, schizophrenia, eating, ADHD (attention deficit hyperactivity disorder), autism. m. Metabolic/Endocrine e.g. diabetes, thyroid abnormalities, growth disorder, Cushing s disease, Addison s disease. n. Musculo-skeletal (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 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 e.g. eczema, psoriasis, acne, hypertrophic scars (keloid). q. Sensory functions e.g. loss or impairment of sense of touch, smell or taste. PAGE 6 OF 12

7 E3 FULL MEDICAL UNDERWRITING (CONTINUED) If any applicant has answered YES to any of the questions 1-3 on page 5 and/or a-q on page 6, 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 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 employee on behalf of all applicants. Date. D D M M Y Y Y Y Please go to section F if you have answered yes to any of the medical questions within section E3. If you have answered no to all of the medical questions in section E3, please go to section H. PAGE 7 OF 12

8 Only complete sections F and G if you are applying under the Full medical underwriting or Switch (CPME) underwriting options. You do not need to complete sections F or G if you are applying under Moratorium underwriting terms. 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, please also give the name and address of your previous GP on a separate sheet of paper and attach it to this form. If the GP is different for any of the other applicants, please also give details on a separate sheet. GP s name Address Postcode Telephone number Fax number 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 Please tick one box only I do not need to see the report before it is sent to VitalityHealth PAGE 8 OF 12

9 G ACCESS TO MEDICAL REPORTS ACT 1988 (CONTINUED) 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 a separate sheet of paper and attach it to this form, stating the signatures apply to section G. Employee s signature Date D D M M Y Y Y Y Spouse/Partner s signature Date D D M M Y Y Y Y Parental guardian s signature Date D D M M Y Y Y Y (for children under 16) Signature of dependant Date D D M M Y Y Y Y (aged 16 or over) Signature of dependant Date D D M M Y Y Y Y (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. Please go to section H. H IMPORTANT INFORMATION GENERAL NOTES AND ELIGIBILITY Your cover will not start until we have accepted your application. Please check with your Group Secretary that you can apply to include your dependants to cover. 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. You must be aged 16 or over at the cover start date. Your wife / husband / partner must live at the same address as you and be aged 16 or over at their cover start date. Your children (including adopted children) must be aged 25 or under at their cover start date. NOTE: They can be aged 26 or over but only when you, the employee, are applying to switch your cover to us on a Switch (CPME) underwriting basis and the child in question is currently included on your cover. This must be evidenced by your current membership certificate. Children aged 21 or over at their cover start date, or the plan renewal date, whichever is sooner, will be charged at an adult rate. If an applicant has a birthday while your 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. 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 authorisation for an eligible claim by us. If you are applying under the Full medical underwriting or Switch (CPME) underwriting option and you do not wish to disclose the answers provided in section E1 or E3 to the your adviser or Group Secretary, you can provide your answers on a separate sheet of paper. It should be signed and dated by you and attached to this form in a sealed envelope. You are entitled to ask for a copy of our standard terms and conditions and a copy of your application form at any time. PAGE 9 OF 12

10 H IMPORTANT INFORMATION (CONTINUED) 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 now turn over to section I to read through and sign and date the declaration and complete the checklist. PAGE 10 OF 12

11 I VITALITYHEALTH PLAN DECLARATION TO BE SIGNED BY THE EMPLOYEE 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. That failure to take reasonable care in answering any questions may result in a claim not being paid, your underwriting terms being changed, your cover being cancelled 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 start date of any applicants cover under this plan (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 start date of any applicants cover under this plan unless, where requested within this application form, you have provided VitalityHealth with full details and they have agreed to accept it. You also understand that VitalityHealth will detail on your certificate of insurance any personal medical exclusions that they ve applied due to the information you have provided. You understand 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 H. That a copy of the application and plan terms and conditions are available on request. If you are applying under the Full medical underwriting or Switch (CPME) underwriting options, you also confirm: That, if a dependant is applying under the Switch (CPME) underwriting option, you will supply VitalityHealth with their current certificate of insurance so that they can confirm the acceptance terms that will apply. If you ve answered to any of the health questions on this application, you understand that VitalityHealth will advise you if they need to change the acceptance 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 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 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 that 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. In some circumstances a new application form will be required. Signature of employee on behalf of all applicants. Date. D D M M Y Y Y Y PAGE 11 OF 12

12 APPLICATION CHECKLIST Before you return this application, please use this checklist to confirm you have: Entered and checked all personal details for you and other applicants if applicable. Read section H or checked with your Group Secretary to ensure that all applicants are eligible to apply for cover. Fully answered all sections, including any relevant health history questions, signed the declaration statement for your chosen underwriting option(s) and attached a copy of your current certificate of insurance (if applicable). If applicable, completed the GP details and Access to Medical Reports Act 1988 consent form, including indicating whether or not you wish to see the report if VitalityHealth request one. Signed and dated the VitalityHealth plan declaration above on behalf of all applicants. 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. PRUHF22134 EVE 0315 Part of the Discovery Group