H oW To S u b... I N S u r A N C E ...

H o w to s u b mit a H ealth
I ns u r ance A pplicati o n
In order to expedite the processing of your application, please make sure to complete the following
steps.
C o m p l e t e H e a lt h I n s u r a n c e A p p l ic at i o n
•Indicate deductible plan, mode of payment, physical address, and date of signature.
•Dependents 19-24 years old must be full-time students and attach proof of enrollment, providing
the name of the institution.
•Please answer all questions and provide an explanation where applicable.
•To expedite processing, be very specific as to for whom, when, where, and how a specific
condition has been diagnosed and treated (under Medical Information section).
•Please read the Acknowledgement and Authorizations section and make sure to indicate “Yes”
or “No”. As indicated there, selecting “No” will result in the rejection of the application for
enrollment.
T r e at i n g Ph y s ici a n S tat e m e n t
All applicants 65 years of age or older must submit a Treating Physician Statement completed by
their doctor and provide the most current results of the following exams:
•Chest X-ray (valid up to 12 months)
•Electrocardiogram EKG (valid up to 12 months)
•Lab work (valid up to 6 months)
•Pap Smear (valid up to 12 months)
•Mammogram results (valid up to 12 months)
Questionnaires
Additional coverage
•When requesting a rider for maternity and perinatal complications, a Maternity Questionnaire is
required and must be completed by the applicant.
•When requesting a transplant procedures rider at renewal time, an Application for Transplant
Procedures Rider signed by the policyholder is required.
Medical Conditions
If the insured declares any of the following conditions, his/her treating physician should complete the
corresponding questionnaire as specified below.
Conditions
Questionnaire
Asthma, emphysema
Asthma and Respiratory Disorders
Diabetes or hyperglycemia
Diabetes and Other Glucose
Metabolism Disorders
Gastritis, hiatal hernia, acid reflux GERD
(gastroesophageal reflux disorder)
Gastrointestinal Disorders
Hypertension, arrhythmia, or other cardiac conditions
Heart Disease and Hypertension
Epilepsy or convulsions
Seizures
Anxiety, depression, attention deficit disorder
Psychiatric Disorders
H o w to s u b mit a H ealth
I ns u r ance A pplicati o n
Wa i v e r o f Wa i t i n g P e r i o d
Bupa may waive the 60-day waiting period (except for Critical Care). Please submit the following
documents with the Health Insurance Application:
•Proof of previous coverage.
•Certificate of coverage for the last 12 months (provide with application).
•Last payment receipt (provide with application).
•Complete section 3: Other Insurance Information.
R e v i e w o f E x c l u s i o n s o r Li m i tat i o n s
If the policy is approved with some type of exclusion or limitation, it may be reevaluated on the
policy’s second anniversary. For this revision, please submit an Application to Request Review of
Exclusions and/or Limitations completed by the policyholder and any updated medical information
related to the exclusion or limitation.
S e r v ic e s
•Real Time Underwriting (RTU) - You may reach our staff at any point during the application
process.
•Direct calls to policyholders in order to explain the underwriting process.
•Direct calls to treating physician for additional information related to the declared condition(s).
C o n ta c t U s
For further assistance, please email us at [email protected] or call an RTU
representative at one of the following numbers:
Argentina
0 800 222 0270
Bahamas 800 393 9416
Mexico Peru Brazil 0 800 892 1652
Uruguay Chile 1 230 020 5466
U.S. Virgin Islands
Dominican Republic Ecuador 800 417 1746
02 396 5656 / 57
Venezuela Other Countries
800 426 3339
0 800 77 987
000 411 005 2684
866 872 1092
0 800 102 9560
305 271 4788
N E W BU S I N E S S A P P L I C AT I O N
CHECKLIST
Exclusive Care • Privilege Care • Advantage Care • Secure Care • Essential Care • Critical Care
BEFORE YOU SUBMIT AN INDIVIDUAL HEALTH INSURANCE APPLICATION FOR NEW BUSINESS,
PLEASE MAKE SURE YOU HAVE INCLUDED ALL THE NECESSARY INFORMATION:
1. PERSONAL INFORMATION
5. BENEFICIARY INFORMATION
oFill out all the boxes with name, date of birth,
height, and weight for each applicant.
oPlease make sure you complete the section
with the beneficiary information.
o Make sure the information is legible.
6. MEDICAL INFORMATION
oIf the application includes full-time students
ages 19 to 24, provide a certificate or affidavit
from the college or university as evidence of
full-time student status.
o If the application includes a person age 65 or
older, please also complete Treating Physician
Statement with all the required medical
information.
2.PRODUCT, PLAN AND
COVERAGE REQUESTED
ADDITIONAL
o Make sure you select a product and deductible
plan, as well as any additional coverage needed.
If no additional coverage is selected, none will
be granted.
o
If requesting additional coverage for
complications of maternity, please also
complete a Maternity Questionnaire.
o
If requesting additional coverage for
transplant procedures, please also complete
an Application for Transplant Procedures
Rider.
3. OTHER INSURANCE INFORMATION
oIf applicant has health insurance with another
company, please make sure you complete all
the necessary information and attach a copy of
the certificate of coverage, as well as receipt of
last payment.
4. GENERAL INFORMATION
oPlease make sure you provide a complete
address, telephone, fax, and email information.
oPlease make sure you complete this section
with information regarding family doctors,
medical check-ups, medical conditions,
medications, habits, and family history for all
applicants. Questions answered with “Yes”
need to be explained in section (6.4).
7. ACKNOWLEDGEMENT AND
AUTHORIZATIONS
oPlease read this section carefully and select
“Yes” or “No” for both the “Authorization to
collect information” and the “Authorization to
disclose health information”. As indicated in
this section, selecting “No” will result in the
rejection of the application for enrollment.
8. SIGNATURES
oMake sure both Policyholder and Spouse (if
applying for coverage) sign and date the
application.
9. PAPERLESS CUSTOMER SIGN UP
oSelect this option to sign up as a paperless
customer and receive all insurance documents
online.
10. PAYMENT INFORMATION
oComplete all the information required in this
section and select a payment method.
o Payment must be submitted together with the
application.
oSelect “Yes” for Bupa to automatically debit
the account for future renewals, and sign and
date this section too.
THE APPLICATION IS VALID FOR 90 DAYS AS OF THE DATE OF SIGNATURE.
Bupa Insurance Company
7001 S.W. 97th Avenue, Miami, Florida 33173
Tel. +1 (305) 398 7400 • Fax +1 (305) 275 8484 • www.bupalatinamerica.com • [email protected]