Travel insurance and medical evacuation: view from the far side

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

Hospitals in places like Vanuatu often do not have the resources available to care for critically ill patients.

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:

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:

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.