SRMRM/RSMRM

MRM Special Risks Inc.

Risques Spéciaux MRM Inc. MGA TPA

Tel:
1-877-385-2177
E-mail:
[email protected]

PRE-EXISTING CONDITIONS ARE NOT COVERED WITH THIS APPLICATION.

I confirm that I have followed the instructions set out below:

  1. I have reviewed my answer to each question to ensure that I have answered each question truthfully, accurately and completely so that SRMRM can accurately calculate premium appropriate for my health status,
  2. I selected the number of medications that I am taking for each medical condition (be sure the total number of medications that you are taking is correct) and then
  3. I selected the period my medical condition has been Stable since the last occurrence of any new or change in symptom, investigation, consultation, new or change in medication, new or change in Treatment, or Hospitalization that I had for each condition.

Key Terms Used in this Application

Answers on the application:
Each condition requires you to answer either "Yes" or "No" depending on whether you have had such a condition, including signs or symptoms or investigation or medical consultation concerning a certain condition. If the condition has been specifically ruled out and no further follow-up action has been or needs to be taken then you can answer "No" to the condition. If you answer "Yes" to any condition, you must state how many medications you are taking for that condition and for how long the condition has been stable. This information will help to determine if your condition may be covered. If you have too many medications for major conditions they may be excluded from coverage.
Auto-immune disorder
includes acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV), Grave's disease, Lou Gehrig's disease, multiple sclerosis, myasthenia gravis, sarcoidosis any location, scleroderma, systematic lupus erythematosis.
Blood Disorder
includes anemia (other than vitamin B-12 deficiency anemia), hemochromatosis, idiopathic thrombocytopenic purpura (ITP), hemophilia, polycythemia vera, Sickle-cell anemia.
Emergency
means an unexpected or unforeseeable sickness or injury which requires immediate medical attention or treatment to prevent or alleviate existing danger to life or health, or to relieve acute symptoms, that cannot be delayed until you return to your province.
Major organ
means heart, kidney, liver or lung.
Medical consultation
means any medical services obtained from a licensed medical practitioner for a sickness, injury or medical condition, including but not limited to any or all of: history taking, medical examination, investigative testing, advice or treatment, and during which a diagnosis of the condition need not have been definitively made. This does not include regular medical check-ups where no medical signs or symptoms existed between check-ups or were found during the check-up.
Minor Ailment
means any sickness or injury which does not require:
  1. the use of medication for a period greater than 15 days;
  2. more than one follow-up visit to a physician;
  3. hospitalization, surgical intervention, or referral to a specialist; and
  4. which ends at least thirty (30) days prior to your effective date.
A chronic condition or any complication thereof is not considered a minor ailment; it is a pre-existing condition.
Other Cerebrovascular or Neurological conditions or disorders:
includes Parkinson's disease, epilepsy, cerebral palsy, multiple sclerosis, brain injury or brain tumor, seizure disorder, Lou Gehrig's disease (ALS), Creutzfeldt-Jakob disease, Cushing's syndrome, Guillain-Barré syndrome (GBS), trigeminal neuralgia (TN or TGN).
Pre-existing condition
means a medical or physical condition, symptom, illness or disease, whether diagnosed or not, for which treatment has been received or taken, or which exhibited signs or symptoms, at any time preceding your effective date and includes a medically recognized complication or recurrence of a medical condition but does not include a minor ailment.
Recurrence
means the appearance of signs or symptoms caused by or related to a medical condition which was previously diagnosed by a physician or for which treatment was previously received.
Signs or symptoms
means any evidence of disease experienced by you or recognized through observation.
Stable
as indicated on your medical statement summary (if applicable), means that during the specified period:
  1. there has been no new treatment; and
  2. there has been no change in treatment or change in treatment frequency or type; and
  3. there have been no signs or symptoms or new diagnosis; and
  4. there have been no test results showing deterioration; and
  5. there has been no hospitalization; and
  6. there has been no referral to a specialist (made or recommended) and you are not awaiting the results of further investigations performed by any medical professional.
Exceptions:
  1. the routine adjustment of Coumadin, warfarin, or insulin (as long as the medication is not first prescribed or stopped during the 90 days prior to the effective date);
  2. change from a brand name medication to a generic medication provided the medication was not first prescribed during 90 days prior to the effective date and there is no increase or decrease in dosage;
  3. a minor ailment.
Stomach, bowel, digestive, gastrointestinal disorder
includes any condition along the gastrointestinal tract (from the mouth to the anus) and can include (among others) esophagus disorder, stomach disorder, ulcer, hernia, irritable bowel syndrome (IBS), inflammatory bowel disease, gastrointestinal bleeds, gastritis, Chrohn's disease, Celiac disease, diverticulitis, ulcerative colitis, colitis, bowel obstruction, bowel resection or ostomy.
Exceptions:
The following conditions are not subject to any surcharge but must be noted in the note section of the medical questionnaire:
  1. Gastroesophageal reflux disease (GERD); or
  2. removal of polyps during a routine colonoscopy where no signs or symptoms were present; or
  3. diverticulosis.
Terminal
applies to a medical condition for which a physician gave a prognosis of eventual death or for which palliative care was received prior to the effective date.
Treatment
means a medical, therapeutic or diagnostic procedure prescribed, performed or recommended by a physician including, but not limited to, prescribed medication, investigative testing or surgery.