Q

Has any Proposed to be Insured been diagnosed with or suffered from / is suffering from or is currently under medication for the following. If Your response is yes to any of the following questions, please specify details of the same in the addition information section?

Q

Have any of the person(s) to be insured ever filed a claim with their current / previous insurer?

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Is any of the person(o) to be insured, already coverd under any other health insurance policy of Religare Health Insurance?

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Has any Proposed for Health insurance been declined, cancelled or changed a higher premium?

Q

Has any of the above mentioned person(s) to be insured been diagnosed / hospitalized for any illness / injury during the last 48 months?

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Cancer?

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Any cardiovascular/Heart Disease (including but not limited to Coronary artery disease/ Rheumatic heart disease/ Heart Attack or Myocardial infarction / Heart failure / Bypass Grafting or CARB / Angioplasty or PTCA / Heart valve diseases / Pacemaker implantation)?

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Congenital Disorder?

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Diabetes Mellitus type 1 or Diabetes on insulin or Diabetes associated with blindness or chronic foot ulcer?

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Any disorders of the endocrine system (including but not limited to Pituitary / Parathyroid / adrenal gland disorders)?

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HIV/AIDS/STD?

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Hypertension?

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Pancreatitis or Liver disease (including but not limited to Cirrhosis / Hepatitis B or C / Willsons disease) or any other digestive track disorder (disorders of esophagus or stomach or intestine or any other)?

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Any Neuromuscular (muscles or nervous system) disorder or Psychitric disorders (including but not limited to Motor Neuron Disease, Muscular dystrophies, Epilepsy, Paralysis, Parkinsonism, multiple sclerosis, stroke, mental illness)?

Q

Any Respiratory disease / Disease of Lungs, Pleura and airway (including but not limited to Asthma / Tuberculosis / Pleural effusion / Bronchitis / Emphysema)?

Q

Do You smoke, consume alcohol, or chew tobacco, ghutk or paan or use any recreational drugs? If Yes then please provide the frequeny & amount consumed.

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Has any of the Proposed to be Insured been hospitalized or has been under any prolonged treatment for any illness/injury or has undergone surgery other than for childbirth/minor injuries?

Q

Any other diseases or ailments not mentioned above?