Manhattan Life Health Underwriting Questions
The following are the application questions for the Manhattan Life Fixed Benefit and supplemental plans.
You will note that some of the questions are asked more than one time with different time frames. That is because you are applying for two separate policies at the same time and each has it’s own set of questions.
To review the benefits of the specific plans associated with these questions, please visit the Manhattan Life page.
Affordable Choice Fixed Benefit Plans
1. Do all members to be insured reside in the home of the applicant? If “NO,” provide details.
2. Has any applicant been declined for insurance due to health reasons? If “YES,” provide details.
3. Are you or your spouse now pregnant? If “YES,” provide details.
4. Are all applicants citizens of the U.S.? If “NO,” provide details.
5. Is the policy intended to replace any other insurance now in force? If “YES,” provide company name, policy number, and type of coverage.
1. Has any person proposed for insurance had surgery within the last 5 years? If “YES,” provide details (date, reasons, results): ______________________________________________________________________________________________
2. Has any person had surgery advised but not yet performed? If “YES,” provide details. ______________________________________________________________________________________________
3. Has any person proposed for insurance been seen within the last 12 months by a physician? If “YES,” please list the person(s), types of treatment, and date last seen by the physician. ______________________________________________________________________ ___________________________________________________________________________________________________________________
3a. Please list all prescribed medications taken in the last 12 months, condition taken for, and dosage for each proposed insured (attach an additional sheet if necessary): __________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
4. Has any person proposed for insurance been diagnosed or been treated by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS), “AIDS” related complex (ARC), or “AIDS” related conditions, or tested positive for Human Immunodeficiency virus (HIV) or its antibodies?
5. To the best of your knowledge and belief, in the last 10 years has any person proposed for insurance now have or had cancer in any form including, carcinoma in situ?
6. To the best of your knowledge and belief, within the last 12 months, has any person to be insured had elevated or rising prostate specific-antigen (PSA) or carcinoembryonic antigen (CEA) test, abnormal mammogram, abnormal pap smear, or abnormal biopsy?
7. To the best of your knowledge and belief, within the last 12 months, has any person to be insured, received treatment or had tests performed where the results were other than normal or still pending or received treatment for any abnormal tests?
8. Within the past five years has any person proposed for insurance been diagnosed (or treated) as having or been told by a doctor that they had any of the following conditions? If “YES,” circle the applicable condition(s) shown below and provide details in the detail space below.
a. Alcoholism, Alcohol, Chemical Dependency, or Drug or Alcohol Abuse
b. Autism Spectrum Disorders, Autism, Asperger’s Disorder, Rett’s Syndrome, Pervasive Developmental disorders, or Pervasive Developmental Delay
c. Basal Cell or squamous cell carcinoma with recommended surgery that has not been completed
d. Crohn’s Disease or Ulcerative Colitis
e. Diabetes (Type I or Insulin controlled)
f. Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Fibrotic Lung Disease, or Primary Pulmonary Hypertension
g. Heart Disorder, Heart Disease, Heart Attack, Coronary Bypass
h. Hernia Uncorrected
i. Kidney disorders, excluding Kidney Stone
j. Liver disorders, excluding fully recovered Hepatitis A
n. Peripheral Vascular Disease or Peripheral Arterial Disease
o. Rheumatoid Arthritis
p. Sickle cell anemia
q. Stroke or Brain Aneurysm
r. Tuberculosis (TB)
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