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Short Term Medical Insurance by The IHC Group: Pre-Existing Conditions
Answer to all these questions should be “No” to be eligible for this insurance
ANSWER THE FOLLOWING MEDICAL HISTORY QUESTIONS
Misstatements and omissions may be a material misrepresentation and a basis for rescission of
coverage.In the event of rescission; (1) coverage will be void as of the Effective Date; (2) all
premiums paid will be refunded; (3) all claims that have been submitted will be denied; (4) if any
claims have been paid, the amount of claims paid will be deducted from any premium refund
due.
Will there be any other group or individual major medical health insurance in force on the policy
effective date
Yes / No
Are you or any person applying for coverage now pregnant?
Yes / No
Are you or any person applying for coverage currently eligible for Medicaid?
Yes / No
Within the past 5 years have you or any person applying for coverage been aware of, received an
abnormal test report for, been diagnosed with, been treated by or received follow-up care with a
member of the medical profession, taken medication for or had a device surgically implanted or in
place for:
heart disorder, heart attack, coronary artery disease, coronary bypass or stent
peripheral vascular disease or carotid artery disease
stroke or other neurological disorder
cancer or tumor
paraplegia, quadriplegia or multiple sclerosis
stem cell transplant
emphysema or COPD (chronic obstructive pulmonary disease)
insulin-dependent diabetes
liver disorder
kidney disorder other than stones
degenerative disc disease or herniated disc
rheumatoid or psoriatic arthritis
degenerative joint disease of the knees or hips
alcohol or drug abuse or dependency
hemophilia
Yes / No
Have you or any person proposed for coverage been diagnosed or treated for Acquired Immune Deficiency
Syndrome (AIDS), AIDS-related complex, or any other immune system disorder? Answer this question “No” of
you have tested positive for HIV but have not developed symptoms of the disease AIDS.
Yes / No
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Answer to all these questions should be “No” to be eligible for this insurance
ANSWER THE FOLLOWING MEDICAL HISTORY QUESTIONS
Misstatements and omissions may be a material misrepresentation and a basis for rescission of
coverage.In the event of rescission; (1) coverage will be void as of the Effective Date; (2) all
premiums paid will be refunded; (3) all claims that have been submitted will be denied; (4) if any
claims have been paid, the amount of claims paid will be deducted from any premium refund
due.
Will there be any other group or individual major medical health insurance in force on the policy
effective date
Yes / No
Are you or any person applying for coverage now pregnant?
Yes / No
Are you or any person applying for coverage currently eligible for Medicaid?
Yes / No
Within the past 5 years have you or any person applying for coverage been aware of, received an
abnormal test report for, been diagnosed with, been treated by or received follow-up care with a
member of the medical profession, taken medication for or had a device surgically implanted or in
place for:
heart disorder, heart attack, coronary artery disease, coronary bypass or stent
peripheral vascular disease or carotid artery disease
stroke or other neurological disorder
cancer or tumor
paraplegia, quadriplegia or multiple sclerosis
stem cell transplant
emphysema or COPD (chronic obstructive pulmonary disease)
insulin-dependent diabetes
liver disorder
kidney disorder other than stones
degenerative disc disease or herniated disc
rheumatoid or psoriatic arthritis
degenerative joint disease of the knees or hips
alcohol or drug abuse or dependency
hemophilia
Yes / No
Have you or any person proposed for coverage been diagnosed or treated for Acquired Immune Deficiency
Syndrome (AIDS), AIDS-related complex, or any other immune system disorder? Answer this question “No” of
you have tested positive for HIV but have not developed symptoms of the disease AIDS.
Yes / No
COPYRIGHTED©
