Travel insurers and medical evacuation companies have a responsibility to provide an efficient high-quality service to their clients.
These companies often deliver a standard far short of best practice and far short of their promotional brochures. Their services are overdue for governmental review and a lifting of standards.
Travellers must be given realistic advice about the risks of foreign travel and that healthcare resources at their destination may be very limited.
Travellers must check with their insurer that the policy they buy truly meets their needs.
Some people should not travel overseas.
You’re booking your flight. On the travel agent’s desk are glossy travel insurance brochures — “WhiteKnight”, “GlobalDefender”, “Sleepwell travel” or similar promotional byline. Most travel agents discuss travel insurance1 and yours is no exception. They suggest you sign up. Who are you joining? What do they provide? What service do they deliver?
We describe some experiences with the travel insurance and medical evacuation industry from “the far side” — from Vila Central Hospital in Vanuatu. Vanuatu is a popular tropical island holiday destination, 2 hours and 45 minutes flying time from Brisbane. Vila Central Hospital has approximately 120 beds, serving a local population of 40 000 and a national population of approximately 200 000. Similar articles have been published, but not from the perspective of the referral service.2
At 03:00 local time on a remote island, Mr A, 75 years old, developed severe retrosternal chest pain, radiating down his arm, and profuse sweating. He somehow located a telephone and rang his insurer. The call-centre staff instructed him to “get an ECG [electrocardiogram] and fax it to us”. No first aid advice was given. Mr A made his own way to the main island. By 11:00, acute anteroseptal myocardial infarction was confirmed on ECG. Mr A was ashen, grey and unwell. The insurance company was contacted again, and informed of their client’s condition and his need for repatriation. Despite knowing of the potential for an evacuation (pending confirmation of the diagnosis), no plan to retrieve him had been formulated. Local medical staff were never referred to a company medical representative. Sixteen hours after it had been initially alerted to the potential need for an evacuation, the company still had no evacuation plan. Only after threat of exposure in Australian newspapers was evacuation organised. Mr A was evacuated 32 hours after his insurance company had initially been notified. He did not reach an Australian hospital for another 5 hours.
Commentary: Travel insurance companies may be fronts for reinsurers. They also frequently contract the services of a call centre and a separate evacuation company. Thus, some travel insurance companies themselves are quite small. It may be difficult for these companies to provide a service when a client needs help.
This case shows a common misconception about service availability in remote locations. Requesting a faxed ECG at 03:00 from a remote island in Vanuatu is farcical. It also demonstrates a common lack of trust in local medical knowledge.
Most insurers demand a written report before arranging retrieval. However, call centres generally log each call. This should be sufficient to plan and initiate an evacuation; a written report can follow.
Miss B, 26 years old, presented with severe abdominal pain, after ringing her 24-hour helpline without answer. No answer was obtained until the next day.
Commentary: We have had more than a few reports of 24-hour numbers being unavailable. Answering machines and phone diversions are not unusual.
Even if you do get an answer, call centres do not know if you are insured. After taking your call, they must contact the insurer to determine your status. This creates additional delays and confusion.
Mr C, an obese 55-year-old with sleep apnoea, was disembarked from a cruise ship after developing respiratory failure secondary to pneumonia. The severity of the situation was conveyed to the insurer and the evacuation company. It was still 23 hours before an evacuation team arrived. The delay largely arose from waiting for the evacuation doctor to finish his day shift elsewhere. The doctor’s daughter also came for the ride. When they arrived, they had no ventilation equipment. The patient was intubated with local help and hand ventilated during the flight to Brisbane.
Commentary: This type of response places local facilities under strain. Many evacuation companies have difficulty getting medical staff and teams at short notice. However, as experts in their field, they should be prepared for this. The staff are of variable calibre and frequently unfamiliar with their equipment, which is often inadequate. Deficiencies are often made up from local supplies.
Cruise ships are notorious for disembarking ill passengers. In this case, pressure was placed on local health providers to take over care. The patient was hurried off the ship at a small island and then transported to Port Vila. However, the facilities on cruise ships are often better than at Vila Central Hospital.
Evacuation companies staff and equip teams according to the patient’s condition at the time the call is received. In the meantime, patients can and do deteriorate. In our opinion, all teams should be equipped for the sickest patients, not just “hand-holds”.
Evacuation company D was asked to retrieve a patient with encephalitis. Hours passed; each time the company was contacted they stated the plane would be leaving soon. Twenty-six hours later, the plane arrived. The delay was because the plane was doing a mail delivery.
Commentary: Unnecessary delays place patients under prolonged local care when they have paid a premium to be repatriated. Evacuation companies should be prepared to attend promptly. Insurers should not be contractually limited to one evacuation company, but should be able to tender to whoever can provide the earliest service.
Because of her age, Mrs E, 80 years old, paid a surcharge to be insured while on holiday in Vanuatu. Unfortunately, she fell and fractured her femur in one of the northern islands. Her insurance company refused to arrange retrieval, insisting she use local resources to travel to Vila for local treatment. After repeated requests for repatriation, the company ultimately refused to take calls. Only after consular intervention did the company agree to retrieve her — 48 hours later.
Commentary: Insurance companies ask overseas medical practitioners to justify requests for evacuation of insured travellers. This is understandable. However, it is commonly done in a confrontational fashion. Many companies have little comprehension of the minimal resources available to care for critically ill patients in places like Vanuatu. They will request that the patient be treated locally if at all possible. There is a great divide between what is possible, what is reasonable, and what is in the insured person’s best interest.
Mrs F, 53 years old from Perth, was disembarked from a cruise ship with acute myocardial infarction. She was uninsured. She contacted an evacuation company who agreed to repatriate her. Although Perth is significantly further away, the company suggested repatriation to Perth rather than Brisbane.
Commentary: Brisbane is less than 3 hours from Vanuatu and has the nearest coronary care unit. Repatriation to Perth delayed her hospital admission and access to specialist care. It was not in her best medical interests. The recommendation to fly to Perth meant a significantly longer trip and a greater cost to the patient.
Travel insurance and medical evacuation are competitive businesses. Thus, it is interesting to postulate why insurers and evacuation companies so often fail to provide a high-quality service. Are the premiums too low? Has competition driven the margins down too far? Does lack of continuity of care have an effect? As much of the industry’s work is done outside Australia with minimal regulation, does this affect standards? Looking at it from the “far side”, both industries could be improved.
It is estimated that 30%–50% of travellers become ill or injured while abroad. Most of these conditions are trivial. However, the risk of serious injury may be greater when travelling.3-5 In a study of travel insurance claims made by returning tourists, two out of three claims were for medical and dental conditions and most claimants were older than 60 years.6,7 In another study, only two-thirds of travel insurance claims were fully met.6 Poor documentation and pre-existing illness were the main reasons listed for refusal. Pre-existing illness is often contentious, particularly in regard to pre-existing versus pre-disposing. An example might be someone who has hypercholesterolaemia but no history of coronary artery disease. If this person were to have a myocardial infarction while overseas, was the coronary artery disease pre-existing because of the hypercholesterolaemia (and hence, not covered by the policy) or was hypercholesterolaemia merely pre-disposing?
Travellers must read the policy carefully and discuss any concerns with the insurer before departure. Some companies offer a 14-day “cooling off” period, during which a full refund is available if the traveller feels the policy is not suitable. In March 2004, the Financial Services Reform Act 2001 (Cwlth) will be fully implemented. This ought to lead to greater transparency. In an ideal world, policies should mention that retrieval delays are inevitable, you initially depend on local healthcare, and that ultimately you travel at your own risk.
Travel insurance and medical evacuation companies often give the impression of being contemptuous of the opinions of practitioners in the field. Yet they rely on these practitioners to care for their clients — often for free or minimal cost. In the developing world, hospitals generally do not have the infrastructure to obtain payment for services rendered to foreign nationals. Insurance companies are aware of this.
We have described our genuine experiences in Vanuatu, and more cases could be provided. The situation is similar elsewhere in the Pacific. There is a wide gap between the brochure and the reality. We do not know if insurers must meet standards. If so, we feel these standards need upgrading. Guidelines do exist for the medical evacuation industry. ISAS (Australasia) is the regional chapter of the International Society for Air Medical Services, an association of organisations working in air medical transport. They produce clinical standards to which the industry voluntarily adheres.8 The standards are not comprehensive.
The Australian and New Zealand College of Anaesthetists and the Australasian College of Emergency Medicine have a policy document for the Minimum Standards of Transport of the Critically Ill.9 This document states:
Initiation of patient transport should be simple, with clear guidelines and communication channels. Ideally the referring doctor should have to make one telephone call to initiate retrieval . . . In all situations requiring transport of the critically ill, rapid response of the transport system and minimal delays are paramount . . . management during transport should be equal or better than at the point of referral.
This document should be the gold standard for the travel insurance and medical evacuation industries. The document continues: “There should be a process to investigate delays in transport and any specific incidents.” From our experience in the field, we have some recommendations we would like to see addressed by the travel insurance and medical evacuation industry under government review (Box).
Other issues in the industry could also be addressed, such as doctors practising in foreign countries, transport of controlled substances, patient death abroad in the care of the evacuation team, the role of diplomatic missions, and indemnity issues arising from delays.
General practitioners with previous experience in tropical medicine and in developing countries are significantly more likely to advise travellers on personal safety abroad.10 However, all medical practitioners should talk realistically with their patients about overseas travel.10 It is easy to forget how little is available in other countries. Some people should simply not travel overseas. They place themselves at risk and risk stressing foreign health services. Additionally, it must be remembered that all the insurance in the world will not get you out of some places in a hurry. Travellers are well advised to become informed of the risks they face and to take steps to minimise those risks.11 Part of this should include awareness of the capacity of local healthcare and the understanding that, in the event of serious illness, this will be your first port of call.
The travel insurance and medical evacuation industry needs improving. Even so, insurance must still be recommended. Uninsured travellers who experience major illness are a burden on foreign healthcare resources. There is a perception that the Australian Government will fly Australians home in the event of a major mishap. This is not the case. The Department of Foreign Affairs and Trade’s brochure “Travelling Overseas” emphatically states: “If you can’t afford travel insurance you can’t afford to travel.”12 The brochure continues: “If you don’t have the correct travel insurance policy, you will be personally liable to pay for evacuation. Medicare and domestic private health insurance do not cover you overseas.”
The cost of insurance is comparatively small. It has been argued that “Utilising a valuable limited resource of a country that struggles to supply this resource is morally wrong when it could have been avoided by appropriate insurance.”13 Travellers should be advised to procure comprehensive travel insurance and to read their policies carefully.3 The Department of Foreign Affairs current General Travel Advice states:
Travel and medical insurance is strongly recommended for all overseas travel. Travellers should check with their insurer to make sure that their policy meets their needs. In particular, travellers should be aware that some insurance companies will not pay claims which arise when travellers have disregarded the Government’s travel advice.14
This latter advice is usually contained within DFAT’s country-specific travel advice.
More older Australians are travelling abroad than ever before. This, coupled with the increasing interest in adventure travel, means that more Australians than ever are likely to find themselves in distress in medically inadequate environments. We hope that our article will provide some impetus for change and improvement in the travel insurance and medical evacuation industry. Otherwise, stories such as these will become the norm.
Suggested standards for travel insurance and medical evacuation
A single outgoing telephone call needed to contact insurer and initiate an evacuation sequence if required.
All 24-hour help lines to be staffed 24-hours — no answering machines, no “call another number”.
Travel insurance policies to be written in plain language.
Insurance company staff to follow a standard code of polite behaviour.
A maximum 30-minute decision time for companies to decide if the patient is covered for evacuation.
A maximum 60-minute time for initial relay of evacuation plan to the referring hospital.
Evacuation jobs not contracted, but tendered to whichever company is able to do the job first.
Time standards to “aircraft airborne” en route for pick-up.
Written advance evacuation plans for each world region, with back-up plans if preferred evacuation companies are unavailable.
If evacuation is from an economically disadvantaged nation, an industry standard payment to be sent to the referring hospital if no invoice is received.
Mandatory dialogue with a company’s medical representative when contacted by an overseas medical practitioner.
If there is a reasonable expectation that the standard of care will be higher in Australia and if there is a reasonable expectation that treatment in Australia will produce a better outcome, then the insured person is covered for repatriation.
No right of refusal if evacuation is requested by an overseas medical practitioner and the patient is covered.
Verbal medical report sufficient to initiate evacuation plan, written report to follow.
Basic first aid advice to be issued over the telephone. All telephone operators to have some medical knowledge.
Medical evacuation companies to provide retrieval kits with sufficient equipment to ventilate patients on each evacuation. Evacuation teams to be self-sufficient.
Evacuation medical personnel to be able to intubate and ventilate, and have attended a training session with company equipment.
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