International Travel Insurance Journal DECEMBER 2008

2008 SOUVENIR REVIEW

2 CONFERENCE REVIEW

CONFERENCE REVIEW 3

Introduction

Welcome to ITIJ’s annual review of the International Travel Insurance Conference (ITIC), which took place at the InterContinental Hotel

in Budapest from 10th to 14th November. This year, the review comes in the form of a special souvenir edition, packed with more photos than ever before, as well as the usual comprehensive round-up of the week’s conference sessions, forums and seminars.If you were in Budapest for ITIC 2008, you’ll enjoy re-living the networking and social events via our photo galleries, and will fi nd the speaker presentation summaries a useful reminder of the topics covered in the various conference sessions. If you weren’t at the conference this year, the review provides a valuable insight into the many hot topics debated by the key players in the international travel insurance industry.The conference was a huge success, with a packed agenda and the highest number of attendees and represented countries to date: over 400 delegates took part from 40 different countries. The range of topics covered and the standard of the conference speakers was also unsurpassed.Additionally, delegates enjoyed a variety of networking and social activities – including a walking tour around the city and various drinks receptions – as well as an extensive exhibition area, and of course the grand fi nale gala dinner and ITIJ Awards ceremony. We’d like to take this opportunity to once again thank all this year’s Awards sponsors and say a massive congratulations to the 2008 winners! We’re already looking forward to next year’s events, and look forward to seeing you there …

International Travel Insurance Journal

Publisher: ...............................................Ian CameronEditor: .................................................. Sarah WatsonCopy editors: ....................................Mandy Aitchison................................................................James WallisDesigners: ...................................................Eli Butler.................................................................Dave OakleyWeb: ......................................................Steve AnnettePhotography: ......Sánta István Csaba [www.photo-santa.com]

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Would you like to make a comment?Are you interested or involved in any aspect of the travel insurance industry? Whether you are a professional journalist or an industry professional we would love to hear from you.Call Ian Cameron at the ITIJ offi ces or: ian@itij.co.uk

Published on behalf of Voyageur Publishing & Events LtdVoyageur Buildings, 43 Colston Street, Bristol BS1 5AX, UK

The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy. Neither the publisher nor Voyageur Ltd can accept any responsibility for any error or misinterpretation. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or fi rm mentioned, is hereby excluded.

Printed by Pensord Press Limited ........................................Copyright Voyageur Publishing 2008 Materials in this publication may not be reproduced in any form without permission.

INTERNATIONAL TRAVEL INSURANCE JOURNAL .............................................................ISSN 1743-1522

ITIC 2008 Proud Sponsors

4 AIR AMBULANCE

Andrew LeeCEO – Air Ambulance Connection LLC

Only two decades after the World Wide Web was created, the Internet has become an irreplaceable tool for air ambulance clients and operators alike, said Andrew Lee. It provides a worldwide sales and demonstration tool previously unavailable. Clients are able to receive quotes and research providers, while operators are able to promote their services to millions of prospective clients, provide quotes and monitor the industry. However, warned Lee, the ability to reach millions can give companies a false sense of worth, and users viewing websites can gain a false sense of trust. With a lack of checks in place to ensure that the information displayed is accurate, a service, such as Air Ambulance Connection (AAC), is needed to enable clients to assess the quality of a provider, argues Lee. By auditing an air ambulance provider’s personnel, equipment and aircraft, AAC is able to say ‘with clear confi dence’ whether a provider is working to AAC’s standards. A particular danger is that the perceived

quality of an operator can increase with the client’s distance from the operator’s location. “Clients are not as diligent as

they should be,” warned Lee. Great care must be taken to check the information given through such websites in order to avoid those who seek to use the Internet to trick and deceive for profi t. To illustrate this point, Lee showed an example of a plausible-looking, but entirely fi ctitious, air ambulance company website.

Aaron HawkinsManaging director – Harley Hawkins

Of the approximately 75,000 fi xed-wing air ambulance fl ights taking place each year in the US, and the 100,000 annual fl ights in Europe, a proportion are being researched via the Internet, believes Aaron Hawkins. In order to stand out from the crowd, a company can employ techniques such as search engine optimisation (not least for a search for its premium route, such as ‘air ambulance London to New York’), advertising in print news and media, listings on air ambulance network websites, network development, and paid keyword Internet advertising. A particularly popular service is Google’s AdWords, where a company registers search keywords, such as ‘air ambulance’, in order to be listed as a ‘sponsored link’ at the top of a search results page. The service is paid for on a pay-per-click basis. Hawkins’ research indicates that for the search term ‘air ambulance’ on Google’s US site, google.com, there are 23 companies paying between $1.69 and $28.18 for four to six clicks per day. The fi gures for ‘medevac’ are $1.01 to $5.68 per click, 12 to 16 clicks per day, with eight competing companies. Some companies

will also register keywords in order to be posted with results for another company – for example, there are 23 companies that have registered the search term ‘air ambulance specialists’. Hawkins looked at a sample of four unnamed US air ambulance operators and determined they were spending around $10,000 per year on Internet advertising.Addressing the question of whether Google and other Internet search engines are an important consideration for air ambulance providers, Hawkins said that it is important to remember that not all clients of air ambulance companies come from within the industry – for example, many of those searching for an air ambulance company through the Internet are travellers without insurance in need of repatriation.As a fi nal comment, Hawkins stated that although the Internet is a valuable marketing tool, providers should not lose sight of the fact the Internet will never take the place of direct personal communications.

Brian WeiszPresident – Air Ambulance Professionals

Brian Weisz gave his advice as an air ambulance aircraft owner on the information that insurers and assistance

companies should look for when investigating air ambulance providers through the Internet. Key details to look for include: the insurance held; the type of aircraft used; whether the aircraft used are dedicated medical aircraft or temporarily converted from use as passenger or cargo transport; and how long the fi rm has been trading. The qualifi cations and any specialist skills held by the crew should be considered, as well as capabilities for interventions such as intubation, chest tubes, ICU monitoring, and medications such as narcotics and paralytics. Accreditations and licences held should be checked, along with any feedback available from clients or government bodies. Weisz also suggested using Internet searches to research aspects such as a company’s history, including any incidents or problems they’ve experienced in the past. In addition to gathering information from websites, site visits should be carried out, as should meetings with offi ce staff, support staff, the chief fl ight nurse and medical director to check whether the company’s advertised claims are matched by reality. When looking at brokers and network sites, it is important to check whether air ambulance providers are paying to be listed. In conclusion, Weisz stated that although it is hard to know what is real when checking a website, assistance companies are becoming increasingly knowledgeable about what to look for.

Internet marketing for air ambulance companies

the perceived quality of an operator can increase with the client’s distance

from the operator’s location

In order to stand out from the crowd, a company can employ techniques such as search engine optimisation

Aaron Hawkins

Andrew Lee

Brian Weisz

© ITIC / Photos by Santa Istvan Csaba

AIR AMBULANCE 5

Lessons learned by the air ambulance industry

John GobbelsVice-president and COO – Medjet Assist

“Be ready: it’s not if, but when,” advised John Gobbels. To illustrate this point, Gobbels presented the case of the repatriation of a 37-year-old woman from Kazan, Russia to the US. During a year-long trip to Russia, and after a 12-year history of infertility, she was 22 weeks into her fi rst pregnancy when she presented at hospital with premature labour. She was stable and put on MgSO4, and attending physicians prescribed that she should stay in hospital indefi nitely.At the beginning of the pregnancy, her US physicians had stated that although they would have preferred her to return to the US, she could remain in Russia until delivery. However, following hospitalisation, they decided she should be repatriated as a precaution. The attending physician in Russia disagreed with the planned move, becoming fi rst anxious then angry. Communications broke down and the patient was thrown out of the

facility; returning to the apartment she was sharing with her husband. The repatriation team now faced a lack of information on the patient’s condition and therefore the equipment and crew that would be needed to treat her during transport to the US. Air ambulance fi rm Skyservice Lifeguard provided a team including a physician and equipment for delivery. Back-up plans were also formed for ground transport to a secondary medical facility if needed, or air transport to a closer medical facility should hospital treatment be needed before the patient could reach her destination in Oklahoma. It is wise to plan for the worst-case scenario in terms of both equipment and crew and to think two steps ahead on all repatriation missions, said Gobbels: have a back-up plan for your back-up plan. He also stated the need to constantly monitor your operations and to look for opportunities to improve. In this mission, Gobbels suggested a better outcome might have been achieved if staff had been able to spot the subtle clues when things began to get out of control and been able to change tactics to maintain relationships.

David SinclairMedical supervisor – European Air Ambulance

David Sinclair presented the lessons learned from the air ambulance transport of an 81-year-old male from Aswan, Egypt to London, UK. Two days after an unspecifi ed incident on a cruise ship, the man sought treatment and was found to have fractured the neck of his femur (thigh bone). His blood pressure was 130/75

mmHg, he had an arrhythmic heart rate of 65 to 120 beats per minute and a numeric analogue scale (NAS) pain score of 4/10 at rest. In addition, he was dehydrated and undernourished. Although hospitalisation for treatment and diagnosis was considered, it was decided that the man would be repatriated by air ambulance.During the fl ight, the patient became agitated, perhaps due to hypoxia or claustrophia, and was sedated and a nasal cannula was replaced with an oxygen mask to increase oxygen fl ow. The fl ight crew now faced a dilemma. The patient could be intubated to avoid increasing hypoxia, but this made it necessary to transfer the patient to an intensive care unit (ICU) bed at the destination hospital. With an oxygen mask, however, a possibly diffi cult intubation could be avoided and it would be easier to locate a bed as the man would not be an ICU patient. A good solution here, said Sinclair, would have been to employ non-invasive ventilation (NIV), but this was not used, either because the attending physician was unaware that it was available or decided not to use it. NIV is common in hospitals, but rarely used in the pre-hospital setting. The patient’s condition was worse at the end of the fl ight than at the beginning, said Sinclair; the admitting hospital was dissatisfi ed, and the customer complained. The case was reviewed and all European Air Ambulance’s (EAA’s) physicians were informed of the availability of NIV onboard its aircraft and the indications of when it should be used. In addition, EAA improved its medical operational manual, enhanced its briefi ng for new physicians, and introduced regular morbidity and mortality training sessions.

Marcus TrosinHospital Leonberg, Klinikverbund Südwest

In January 2005, a 33-year-old male in Marcus Trosin’s care was diagnosed with severe lung fi brosis with superimposed cytomegalovirus infection, requiring urgent transport from Heidelberg to Hanover, Germany. The patient suffered low compliance and gas exchange problems, consistent with acute respiratory distress syndrome. There were no signs of hypoxia despite hypoxaemia, with blood oxygen saturation of 94 per cent, acceptable blood pressure and no problems with airway obstruction.As Trosin outlined, successful

transport required three ingredients: an available bed at the hospital in Hanover, a suitable transportation vehicle, and payment for the cost incurred. Initially, an attempt was made to secure payment from the patient’s insurance company; on Friday evening an answer had not been received and the insurer was no longer answering phone calls. However, by Saturday evening it had been established that Hanover hospital had a bed available and could draw from a fund to cover the cost of the transport. Due to the patient’s condition, transport by ground or helicopter had to be ruled out as too slow. A turboprop aeroplane would have been acceptable, but availability meant a DRF jet was chosen for the fl ight.The key lesson learned, said Trosin, was that healthcare professionals and pilots are available 24 hours a day, and insurers should be also. He advised clinicians to get in touch with the ground and air ambulance services to determine the best vehicle available for transport.

constantly monitor your operations and to look for opportunities to

improve

NIV is common in hospitals, but rarely used in the pre-hospital setting

healthcare professionals and pilots are available 24 hours a day, and

insurers should be also

John Gobbels

David Sinclair

Marcus Trosin

6 AIR AMBULANCE

Fleet renewal

Russell PaysonCEO – Skyservice Inc.

The aeroplanes used by air ambulance providers were primarily designed as business aircraft, explained Russell Payson. Business aviation saw a boom in the 1960s and 1970s, the era from which most medical aircraft date, but an economic recession in the 1980s created a void in aircraft design. Predominant aircraft types are the Learjet 35, Citation II and Citation III. These are relatively low cost, with a purchase price of US$2 to $3 million and an operating cost of around $2,000 per hour. Replacement aircraft and parts are

readily available and there is a good pool of support services. Suitable alternatives include newer, smaller jets such as the Learjet 45 and Citation Encore or Bravo, but these come with a price penalty, costing $5 to $7 million to buy and $3,000 per hour to operate. Newer, midsize jets are more expensive still – Learjet 60s and Citation Excels come at a price of around $8.5 to $11 million, and cost some $3,400 per hour to run. The advent of very light

jets (VLJs) is yet to bring any credible options for air ambulance use, said Payson, due to small cabins and inadequate take-off weight limits to carry crew, patient and medical equipment. Payson also suggested that VLJs are unlikely to be viable due to insuffi cient power and range to travel the distances required for international repatriations.In conclusion, said Payson, no aircraft on the market match the Lear 35 and Citation II / III for air ambulance users, and operators have little option but to keep their current, ageing fl eets and deal with any maintenance problems that arise. Skyservice has, he said, been looking at ways to extend aircraft life, including replacing all electrical wiring. Payson believes that with proper maintenance, the current fl eet can keep fl ying for a long time yet.

Scott SarverManager for special missions – Cessna

The predominance of older aircraft in fi xed-wing medevac fl eets arises from the availability of cheap, used aircraft, explained Scott Sarver. However, ageing fl eets offer a false economy as low purchase prices

are offset by higher fuel consumption, increasing maintenance costs and the diffi culty of locating out-of-date spare parts. Accident rates are also higher for older aircraft, said Sarver, as their less advanced avionics lack safety features found in newer systems, such as terrain collision avoidance systems. New aircraft come with newer, fuel-effi cient engines, benefi ting from developments like full authority digital engine control. In terms of maintenance, buying new brings purchasers the benefi t

of a warranty and built-in troubleshooting technology to further reduce maintenance costs. There are more effi cient support programmes available too, for example ‘power by the hour’, which fl attens budgeting spikes making repair costs more predictable. Pilots and maintenance technicians also benefi t from factory training from the manufacturer. Owners have the peace of mind that aircraft bought new have had to meet newer, more stringent certifi cation and regulation requirements. Also, said Sarver, the higher value of a new plane gives the owner a higher resale value when the time comes to sell. Taking all these factors into account, Sarver advised that the optimal time to replace an aircraft is at an age of fi ve to eight years.Where the purchase of a brand new aircraft is out of the question due to budget constraints, air ambulance providers should consider buying a used aircraft from the manufacturer, or taking their aircraft bought elsewhere to the manufacturer for inspection and upgrading, advised Sarver. Cessna, for example, will thoroughly check a used aircraft and renew or replace items

such as the interior and paintwork.Sarver doubts that aeroplanes will ever be designed for air ambulance work as their primary mission, although some features being developed are of benefi t to the industry: for example, he has urged the designers to develop larger doors, which are advantageous in a variety of roles.

Joszef VagoDirector – National Transport Authority, Hungary

Joszef Vago gave an overview of state-run air ambulance provision in Hungary. The country’s fi xed-wing propeller-powered air ambulance aircraft was withdrawn a few years ago, but there are plans to establish a new service in the next few years. Vago outlined Hungary’s helicopter air ambulance programme, which has seven bases across the country. The service began in the 1990s, fl ying Eurocopter Ecureils AS350Bs. Helipads at hospitals across Hungary enable country-wide coverage, and the service co-operates with the military, which operates MI8 helicopters for search and rescue.

Russell Payson

Scott Sarver

Joszef Vago

ageing fl eets offer a false economy as low purchase prices are offset by

higher fuel consumption

AIR AMBULANCE 7

The future of HEMS and travel

Olivier SeilerMedical director – Rega

Oliver Seiler began by reviewing the history of medical transport in Switzerland, which began in 1952 when Swiss Air Rescue was created. A Bell 47J helicopter was put into service in 1957. In 1960, the fi rst international repatriation fl ight was performed with a Piaggio P66, and in 1973 the world’s fi rst private ambulance jet, a Learjet 24D named ‘Henri Dunant’, began fl ights. A Challenger CL600 was acquired in 1982 and in 2002 a single-type fl eet was introduced with three Challenger 604s. EC145 helicopters were introduced in 2003.When helicopters were fi rst used to rescue people in mountainous areas, the patient was housed outside of the cabin in an enclosed pod. Being outside the cabin, it was impossible to deliver any medical care to the patient during fl ight. Rega’s modern helicopter fl eet includes EC145s, which are used in lowland areas thanks to their large cabins and low running costs, and A109s, which perform better at altitude. The A109s are due to be replaced by AgustaWestland Grands.Reviewing some statistics for Rega’s operations, Seiler stated that 9,949 helicopter missions were fl own in 2007. Of these, 5,779 were primary missions, 2,726 secondary, and 1,059 were missions transporting livestock for mountain farmers. In the same year, Rega transported patients on 1,240 fi xed-wing fl ights: 851 by ambulance jet, 362 on scheduled airliners and 27 by chartered aircraft. Forty-one per cent of these were trauma patients, 10 per cent cardiovascular, nine per cent gastrointestinal, eight per cent cerebrovascular and six per cent were suffering malignancies. The remaining 26 per cent included psychiatric patients transported via scheduled airline under medication.According to Seiler, HEMS operations are set to become more standardised around the world. Capacity and

capability will increase due to the rising number of inter-hospital transfers resulting from an increasing prevalence of specialist centres. The number of very intensive care transports will rise, using techniques such as extra corporeal membrane oxygenation. Technology will allow for safer fl ights in worse weather conditions. There will be a spread of fl ights under instrument fl ight rules, global position system assisted landings and anticollision systems such as FLOICE and FLARM, and use of twin-engined helicopters. Fixed-wing aircraft will also see an increase in very intensive care fl ights, along with combined transports of multiple patients using large aircraft and the introduction of medical standards and certifi cation from bodies such as Eurami and CAMTS.

Michael BraidaChief medical offi cer – AXA Assistance

The HEMS market requires proper regulation, said Michael Braida. Although accreditation may not help decrease accidents, it is required for proper operational and medical care and therefore for safety. In some countries, medical helicopters are used as a patient acquisition tool. Braida gave the example of Tyrol in Austria, where in winter around 18 helicopters deal with accidents on the ski slopes. Many of these cases are

not serious injuries, however, and the operations appear to be fi nancially, rather than medically, driven, said Braida. In addition, the JAR-OPS rules require helicopters to be twin-engined, but Austria is exempt and can fi eld single-engined aircraft. In the US, HEMS providers seem to be pressuring crews to fl y when their judgement would rule conditions unsafe, and to be ignoring the importance of crew resource management.

Peter TuriManaging director – National Air Ambulance

Hungary’s National Air Ambulance Public Company (NAA) is non-profi t air ambulance organisation entirely fi nanced by the state with no membership fees or donations, said Turi. The service is free of charge to anyone in Hungary requiring emergency transport (primary missions). The service is also available to paying customers for secondary missions including international repatriations, particularly relevant in a country such as Hungary where several countries can be reached by car in an average of fi ve hours. Turi commented that from his experience over the last few years, a confl ict of interest exists – in HEMS, everything is medically driven, whereas insurance companies are fi nancially driven. Turi presented the case study of a man injured in a road traffi c accident in Montenegro. He spent a few days in a local hospital where his condition deteriorated. Faced with an eight-hour ground transport to Hungary, with the risk of ‘transportation trauma’ from repeated acceleration and deceleration, the patient’s insurer approached NAA for a quote for what would be a fl ight of one and a half hours, but did not accept the quote. Later, the trauma surgeon who received the patient by ground transport in Hungary called NAA to complain that the patient was in much worse condition, asking why he hadn’t been fl own. Turi suggested that the insurer had let the fi nancial picture come before the patient’s medical needs and called for all ground ambulances crossing an international border to be fully vetted to ensure quality of crew and equipment. With

an increasing number of international trips, there is an increasing number of people suffering accidents while abroad, and Turi added that a competent and effective control system should be implemented to monitor air ambulance services from a medical perspective.

Olivier Seiler

Michael Braida

Peter Turi

In the US, HEMS providers seem to be pressuring crews to fl y when their judgement would rule

conditions unsafe

© ITIC / Photos by Santa Istvan Csaba

8 CONFERENCE REVIEW 8 CONFERENCE REVIEW

on the Columbus Jazz boat – Tuesday11th November

The UnitedHealth welcome function was hosted on the fantastic Columbus Jazz boat, nestling by the bank of the Danube with stunning views of the Fisherman’s Bastion and Cathedral. An enthusiastic crowd enjoyed the champagne, schnapps and canapés, and judging by the roars of laughter heard echoing across Budapest, a good time was had by all.

UNITEDHEALTH INT. SPONSORED WELCOME FUNCTION

CONFERENCE REVIEW 9 CONFERENCE REVIEW 9 CONFERENCE REVIEW 9

The fi rst-ever new delegates welcome function was a huge success for all those who attended. A fantastic mix of old and new faces, it was the fi rst opportunity for new delegates to network and meet the experienced conference attendees to soak up some of their knowledge and contacts. Next year’s

new delegate function will be even bigger and better, after the feedback showed how useful it was, both to fi rst-timers and old hands.

ITIJ NEW DELEGATES WELCOME FUNCTION

© ITIC / Photos by Santa Istvan Csaba

10 AIR AMBULANCE

Medical Directors’ Forum

Moderated by

Michael Churchill-SmithMedical director – Skyservice Aviation

The aim of the Medical Directors’ Forum, part of the ITIC Air Ambulance Forum (AAF), noted Michael Churchill-Smith, is to advance the overall state of aviation medicine. The session began with a review of the recommendations agreed at the fi rst AAF Medical Directors Forum (AAF MDF) at ITIC 2007 in Venice, and the points where consensus was not reached: vaccination profi les and duty times for medical crew, evidence for medical outcomes, issues relating to confi dentiality and development of continuing medical education (CME) for in-fl ight medical crew. There is no formalised CME structure in air transport medicine, and no central body regulating or accrediting the various fl ight medicine courses around the world. It was suggested that the AAF MDF should, as a body, develop recommendations for course contents, and collate and

publish a list to detail the relevant courses available worldwide, which Churchill-Smith agreed to take forward. A concern was raised about whether adding further requirements would make it even harder to recruit suitable physicians.Commenting on the need for an overarching group to regulate ‘the practice of medicine in the air’, Churchill-Smith informed the group that both the International Air Transport Association and International Civil Aviation Organization had declined to oversee aviation medicine. The idea of the AAF MDF requesting the World Health Organization (WHO) to take up this role, including acting as accreditor to organisations such as CAMTS and EURAMI, was discussed, but was countered by the argument that the urgent need is to make sure medical crews maintain their licences and can continue practising aviation transport medicine, and therefore a fi rst step would be to approach national licensing bodies to determine their requirements.Michael Weinlich, president of EURAMI, shared his experience of formulating standards for air medical transportation: the European Union declined to be

involved with setting standards, and EURAMI also faced diffi culty consulting with the Joint Aviation Authorities (JAA) as the JAA lacked expertise in this area. He advised against going to the WHO, as this risked mandatory standards being imposed on the industry, and said that the standards should be set by the AAF MDF as recommendations. Weinlich also suggested that when training courses are held, their content be detailed in publications such as Waypoint AirMed & Rescue Magazine in order to share knowledge across the industry.There was a general feeling among the group that the AAF MDF should act before an outside body imposes regulations that may be inappropriate. To this end, a vote was held and the group agreed by a show of hands that by the next meeting of the AAF MDF at ITIC 2009, it will form a society and will work towards defi ning the basic knowledge recommended for air medical crew, with a view to then creating an examination that medical crew can sit. A working group will formulate the name of the society and determine the content required for the examination.

Michael Churchill-Smith

by the next meeting of the AAF MDF at ITIC 2009, it will form a society and will work towards defi ning the

basic knowledge recommended for air medical crew

ASSISTANCE MEDICINE 11

The In-Flight Nurses Association (IFNA)

Alan ShewardChairman – Royal College of Nursing (RCN)

Alan Sheward began by explaining that the IFNA is a forum of the RCN with a nationwide (UK) network of members. Originally set up in the 1980s to share nurses’ concerns, it now has the power to lobby the government for change, helping to develop future nursing policies. The focus of the IFNA, said Sheward, is to support experienced nurses in obtaining improved patient outcome, improve operational outcomes and to reduce costs.The requirement for an in-fl ight nurse, according to the RCN, is that they must have a high level of skill, knowledge, and standards of behaviour. In order to reach these high levels of skill, the IFNA works closely with the Royal Air Force, South Bank University, assistance companies and local authorities, as well as attending aviation medicine training sessions and holding

regular forum study events so that the level of skill is the same across the board.There are three levels of assessment for an in-fl ight nurse: competence, experience and expertese. Sheward also detailed the fi ve core competencies a nurse should have under their belt: self assessment; being patient and person-centred; using evidence-based medicine; practice expertise, and leadership and management of in-fl ight nursing.During the session, several questions came from the fl oor in relation to standing orders of medicines, and the problems of nurses independently prescribing drugs they shouldn’t, as well as the nurse needing a drug in fl ight that they are not allowed to give the patient because they are not a doctor. In addition, the standardisation of medical documentation for transfers was raised as an industry-wide issue – Sheward said he thought the future could be electronic data transfer, eliminating the need for complex and varying medical

forms for nurses. Also discussed was the European Working Time Directive – many doctors and nurses will have treated a patient after a 12-hour day in a ward and a four-hour fl ight to get to the patient in the fi rst place, so there are concerns about whether the nurses and doctors working in the air should be subject to the same rules as pilots. Suggestions to get around

this problem include taking two crews, but for many companies that would be a prohibitive expense and a diffi cult one to justify to the insurer. The fi nal word on the topic is that assistance companies have a responsibility to make sure the nurses they employ abide by working time directives. Alan Sheward

the future could be electronic data transfer, eliminating the need for complex and varying medical

forms for nurses

© ITIC / Photos by Santa Istvan Csaba

12 ASSISTANCE MEDICINE

Passengers with medical problems

Mark PopplestoneHead of medical services – Virgin Atlantic Airways

First of all, Mark Popplestone dispelled some of the more common myths of air travel – the air in the cabin is fully replaced every few minutes and the HEPA fi lters are over 90 per cent effi cient, so illnesses and diseases will not be passed to everyone onboard through the fi ltration system. The only people at risk from the air are COPD sufferers, but that is due to the pressure effect on the lungs, not the quality of air they are breathing! He then described problems that the airline will know about, having either been told by the passenger or from a member of staff spotting that someone is unwell before they board the aircraft. Then there are the problems they know they will not know of – i.e. there will always be a passenger who has decided not to tell the airline of his recent heart attack in case they are

not allowed on the fl ight as a result. There have also been cases where the treating physician has changed the ‘MEDIF’ form so that the airline will allow the patient on, despite the doctor knowing that the patient

was unstable. The fi nal problem is one the airline cannot predict – where the passenger doesn’t know anything is wrong, has no physical signs of illness and is suddenly taken ill onboard.There are no clear criteria for

clearance to fl y, as it is subjective to the treating physician, although there are several publications that have issued guidelines that airlines can follow. There are also several situations that Popplestone highlighted where the person would not be able to travel with Virgin, which include ICU patients, those with unstable conditions such as angina, the very infectious and the very mentally disturbed.At the moment, only around one in every thousand fl ights is diverted for a medical emergency, but the problem could be worse in the future as medical tourism continues to rise and there are bigger planes taking longer fl ights. In addition, with an increase in the number of older people fl ying, the chances of an in-fl ight emergency are increased, and as Internet bookings and online check-ins catch on, airlines have even less of a chance than before to catch an ill passenger before they board a fl ight.

Mark Popplestone

At the moment, only around one in every thousand fl ights

is diverted for a medical emergency,

ASSISTANCE MEDICINE 13

Assistance medicine in Latin America

Virginia Villanueva de PedroMedical director & network manager – Mapfre Asistencia

In South and Central America, said Virginia Villanueva, quality in healthcare providers varies widely. Public health systems tend to have a low standard of care, but there is a spread of small private clinics of medium quality and high cost, and a good level of care in private hospitals in major cities. Travellers are often fi rst treated at a high cost within their hotels, and prices can vary depending on the nationality of the patient. Hotel doctors also sometimes exaggerate a patient’s condition to spur higher-cost treatment, said Villanueva.To deal with these problems, Mapfre has a network of primary medical clinics to better manage travel assistance services. They have taken the situation from over 60 per cent of patients being inpatient cases to over 90 per cent being treated

as outpatients. The clinics’ aim is to avoid unnecessary hospitalisation. Mapfre also operates its own ground ambulances, for example in Venezuela, where local providers do not provide a quick, low-cost and high-quality service. Cases are managed in real time through the fi rm’s

local alarm centres, which have a thorough knowledge of the local area and network, and can evaluate the necessity of each test or service.Rural areas and tourist resorts often lack high-quality care, though in general, larger cities have hospitals of a high standard. In Brazil, Rio de Janeiro and Sao Paolo have good quality hospitals at a reasonable price; Chile, Argentina and Bogota, Columbia also offer a good standard of care. Facilities

in Central America are of a lower quality, with procedures that differ from Western standards. Average diagnosis prices differ greatly between different countries, said Villanueva.

For example, in Central America, an appendicitis case will cost around $4,000 to $5,000, whereas in Chile the price is $3,000 and in Brazil $1,800. Standards also differ – in Chile and Brazil, gastroenteritis is more commonly dealt with as an inpatient case than elsewhere. Overall, noted Villanueva, it’s important to recognise that prices are

lower if a patient is a local national or the company managing the case is based in Latin America.

Virginia Villanueva de Pedro

in Central America, an appendicitis case will cost around $4,000 to $5,000, whereas in Chile the price is $3,000

and in Brazil $1,800

© ITIC / Photos by Santa Istvan Csaba

14 PRIVATE HEALTHCARE

Political and high-risk evacuation policiesNeil ThompsonSpecial risks director – Red24

Red24 is a UK-based company that provides personal and corporate security solutions, including emergency response to disasters and outbreaks, to many multi-national fi rms. Neil Thompson began by describing the different sorts of political evacuations that can be undertaken. The examples he gave included Thailand, where a relatively peaceful coup was known about in advance in 2006, and all was calm afterwards, in comparison to 2008 when, following some more political troubles, several Western governments decided to evacuate their citizens. The recent confl ict in Georgia was a great deal more complex because it happened quite suddenly, but the evacuation fi rms had to wait to see how Russia responded before evacuating their clients. When Russia responded with such force, expatriates and visitors were at risk, and were taken out of the country. In Kenya, meanwhile, the sudden riots and demonstrations in Nairobi took everyone by surprise. Although they involved local tribal fi ghting confi ned to a specifi c area, the risk that the local confl ict could escalate and spread had to be considered, and so clients were evacuated.There are several triggers that can start off a political evacuation, as is evidenced above, but for insurance companies the issue is whose advice to follow; private companies might update their websites more often than the Foreign and Commonwealth Offi ce, but if a policy relies on a government deeming a country unsafe, they are stuck in the middle. Red24 tends to prevent rather than cure, preferring to get its clients out before

the political trouble has become a major international incident, partly for safety but also because in the long run it will save money evacuating a person before the local airport is closed and an armed guard has to be sent to retrieve the insured.

Tom HudsonLegal counsel – Medex

Tom Hudson discussed personal security assistance in the context of emergency medical assistance, as in many cases the two go hand in hand. The medical service and travel service of an assistance fi rm must work closely with the security departments to produce reports that will inform the client of all the risks and the solutions available to them in any given situation. Having an informed expat/business traveller/leisure traveller is vital to them keeping safe while abroad. One way to do this is to buy your security fi rm partner – this May, Medex bought ASI, a long-term partner of the fi rm, and the merger has confi rmed that by combining these entities

together, lessons can be learnt from each other.Medex uses three categories of evacuation notices, which are usually issued after or along with an alert, depending on how quickly a situation has developed. The three categories are ‘warning’, which is a moderate risk; ‘alert’, which is a high-risk situation, and ‘evacuate’, which is only used in extreme circumstances. Medex, according to Hudson, also experiences similar problems to Red24 in

terms of government advisories, which can be unclear and confl icting. Some policies state that the insured’s home country must advise immediate evacuation, whereas others state it is the host country that needs to call the situation. In addition, there is also a lack of clarity regarding

whether or not a natural disaster should be included in an emergency evacuation policy – in many situations where a natural disaster has occurred, the government will step in as well. When it comes to co-ordinating rescue teams on the ground, Medex evaluates the security offi cials present and credits those that are acceptable, thus hopefully maintaining a quality database of rescue professionals in the country in question.

Stephen HartiganCEO – InterGlobal

For Stephen Hartigan, it is vital that the client be fully informed of all the risks before they leave their home country; the needs of the client are properly evaluated; and the insurance policy evaluated to make sure all the risks that have been identifi ed are correctly covered.The ideal markets to work in would be politically stable, with low crime rates and a good healthcare infrastructure. However, as many of the emerging markets around the world do not fi t into this category, an evacuation policy, combined with a medical evacuation policy, is essential. It is a lifeline to the client, the value of which cannot be

overestimated.Hartigan also gave some words of warning to the audience about the pitfalls in some international private medical insurance policies: some products will cover an emergency evacuation, but not repatriation back to the country from where they were evacuated after the incident is over. Other policies, he continued, will cover the costs of the insured plus one accompanying person for the evacuation, and some policies will simply cover the insured. His

fi nal recommendation was that corporates looking for cover for their employees scrutinise the fi ne print of the policy for get-out clauses such as those above.A lively discussion followed the panel session, where questions included: “What if the insured person doesn’t want to leave the country?” – the answer to this is that a corporate employee will often not be given the choice, but when it comes to missionaries, it is very diffi cult to persuade them that they should be leaving the people in their care at such a diffi cult time. Also discussed was the age-old problem of pirates, not in the Caribbean, but off the East coast of Africa. Somalian pirates

are taking many more vessels and people hostage for ransom than in previous years, and it was revealed that all the experts in kidnap and ransom are already in the area dealing with cases. This prompted some concern that if all the experienced negotiators are already incredibly busy, companies should be on the lookout for ‘rogue’ negotiators cashing in on a new trend.

Neil Th ompson

Stephen Hartigan

Tom Hudson

© ITIC / Photos by Santa Istvan Csaba

PRIVATE HEALTHCARE 15

Medical tourismCai GlushakInternational medical director – AXA Assistance

International medical tourism is on the rise, said Cai Glushak, with the number of medical tourists travelling from the US predicted to increase from 750,000 in 2007 to over 10 million in 2017. If current trends continue, in 2010 around $10 billion worth of care will be provided to US medical tourists around the world. Glushak described the incentives for seeking care abroad as including: avoiding delays, particularly for patients travelling from countries with socialised healthcare systems such as in the UK; access to a higher quality of care; and access to treatments not otherwise available, for example stem cell treatments.There is also often a strong fi nancial case. In the US, for example, there are around 45 million people without health insurance and a rising number

with inadequate insurance. For their part, employers are looking to reduce medical insurance costs and may implement high-deductible policies or seek lower-cost treatment alternatives.Key to a successful medical tourism framework is the credentialing of healthcare providers to ensure they deliver high-quality care. Credentialing is the administrative process of validation of qualifi cations and relies in part on accreditation performed by relevant bodies, explained Glushak. Recognised accrediting organisations include the Joint Commission International, national health regulatory authorities, quality organisations and forums such as the US National Committee for

Quality Assurance or the European Society for Quality in Healthcare. Glushak noted that national health authorities

will only judge providers against their national standards and this is not standardised between different countries.A good accreditor, said Glushak, is a public, non-profi t organisation that has clearly defi ned standards and a credible board of distinguished multilateral experts. It should look at both processes and, importantly, patient outcomes. It should carry out site audits and the accredited status awarded to providers should be subject to periodic renewal.

The American Medical Association recommends that patients should only be sent to facilities that have been accredited by an international body such as the International Society for Quality in Health Care, and that patients should be advised of their rights to legal recourse before travelling outside the US. International accreditation agencies, noted Glushak, aim for a minimum universally accepted level of medical performance. Standards are not, he said, created to meet the needs of Western medical tourists.

Operating an expat clinicSue McGladderyDirector – FirstMed Centers

Sue McGladdery explained fi rst how expat clinics must differ from normal healthcare clinics because they are geared towards an expatriate population. Such differences include information and communication all being done in English, a 24-hour helpline, direct billing for some insurance companies, and a central location; the aim of these is to ensure the client feels comfortable with and confi dent in the care they are being given.McGladdery then used her experience of setting up an expat clinic in Budapest to demonstrate the problems that can arise when operating in a foreign country. One of the early problems she found was attracting and retaining the right staff who had the correct level of expertise and English. There are three main challenges to operations in Budapest: the patients, the staff and third parties (hospitals that patients can be referred to for care or diagnostic tests). Regarding patients, the problems are that expats are by their nature mobile, so the clinic loses one third

of its patients annually simply because they move. There is also pressure from some high-powered patients to get instant results, which is simply not always possible. The cross-culture issue must also be considered – for instance, treating a Muslim woman is vastly different from treating a non-muslim expat. Staffi ng problems include ensuring your staff are multilingual, skilled in cross-cultural communication, have the appropriate medical training and are experienced in overseas healthcare. The brain drain is also an issue, with Hungary losing many skilled physicians to Western pay packets.

When it comes to using Hungarian hospitals, McGladdery explained how important it is for a clinic to choose their providers extremely carefully, and ensure the patient is taken to the best speciality hospital: Variable quality is a problem in Hungarian hospitals while the food may

be awful and décor very dated in some, the care is excellent, whereas in more ‘cappuccino’ style hospitals, they look great but do not deliver on quality of care. It is vital, therefore, to build strong relationships with the right providers to ensure your patient’s care is not compromised.

Sue McGladdery

Cai Glushak

national health authorities will only judge providers against their national standards and this is not

standardised between different countries

expats are by their nature mobile, so the clinic loses one third of its patients annually simply because

they move

16 PRIVATE HEALTHCARE

What does the expat want and need?

Sarah DennisInternational business consultant – Jelf Wellbeing Ltd

Sarah Dennis fi rst allayed some fears and said her company had seen minimal impact so far as a result of the credit crunch – corporates are still purchasing cover for their employees, although the cover they offer might be toned down slightly. For example, dental cover could be taken off the policy to bring down the premium. The latest fi gures show that there are 30 million expats around the world, though Dennis believes the real fi gure could be a lot higher, and it was predicted that by 2012, gross underwritten premium income from International Private Medical Insurance (IPMI) could reach as much as £4 billion.There are several different groups that need IPMI, including expats, in-patriots, third-country nationals and locals. All these groups however, need the same information about policies and have similar concerns: language barriers, cultural barriers and worries about an unfamiliar environment. The clients must fi rst be evaluated: where are they going, which benefi ts will they need, how long are they staying, and whether they want the policy to be medically underwritten. In addition, there are concerns over local licensing and regulatory laws – some countries, Abu Dhabi for one, require IPMI before allowing an expat in, while other countries will insist the expat has cover with a local insurer in addition to their IPMI. Dennis forecast that the IPMI prerequisite will become a particular issue that the industry will see more of in the future, as other countries in the Middle East are also trying to ensure expats arrive

with insurance cover.It is possible that IPMI will be known in the future by a different title, with regional policies on offer. Instead of just roundly being dubbed ‘international’ cover, the insurance will be tailored to refl ect the needs and requirements of the insured and the regulator of the country they are moving to. IPMI providers must ensure that if they are required to use a local partner, that the partner is compliant and will not let them down when the client needs the cover the most.

Laura HiltonHead of global health and safety resources – HTH Worldwide

Laura Hilton discussed the management of chronic conditions in expats, and how although patients can keep most chronic conditions under control themselves, when they are out of their country of residence without access to the right drugs or care, the situation can quickly deteriorate. The latest World Health Organization report into the problem showed that chronic illness is overtaking infectious disease as the main problem in the world, describing it as ‘a quiet epidemic’. Its research of fi ve countries showed that 34 per cent of the population had one or more chronic disease, and 41 per cent were taking long-term medication. In children, the incidence of chronic illness is also worsening, with 30 per cent of children having a chronic condition.Expats with chronic illnesses need an active, trusted and personal health interaction with their insurer to keep on top of the problem – HTH uses technology to keep in touch with its clients to ensure they are taking insulin, checking their blood sugar levels or taking pills. Text messages are sent on a regular basis, so the insurer and the insured are constantly in contact. It was also pointed out that by properly managing the illness, the insurer can save the client money in the long run by getting rid of the need for expensive

emergency medical evacuations. Hilton also gave a defi nition of the goal of expat care: to replicate the home country’s medical support system in terms of primary care relationships, appropriate specialist access, medications, notable hospitals and clinics, maternity care and mental health provision. The right IPMI policy can be extremely useful for an international fi rm, as it can help to attract and retain the right employees as well as reduce the number of failed expat assignments. The correct preparation must be organised and all the information presented to the prospective expat before they go, so they are aware of all the benefi ts and exclusions the policy offers. In order for insurers to be competitive, the management of chronic conditions must be included on IPMI policies – the high number of sufferers dictates that a certain number will be expats.

Sarah JewellManaging director – A La Carte Healthcare

Sarah Jewell began by detailing the issues that must be considered by an insurer before selling an IPMI policy. These include asking where the customer is moving to, and considering local licensing and regulation and the effect that such regulation could have on the provisions in a policy. The Internet has made such research much easier, so there is no excuse for not obtaining this information. The insurer must also investigate the possibilities offered by reciprocal healthcare agreements – these agreements can negate the need for IPMI in the fi rst place.Regarding medical underwriting of IPMI,

the prospective expat must ask if they are already insured under another policy, and if so, then does the current provider offer IPMI – it could be simpler to stay with the same insurer so the client doesn’t have to go through medical screening again. If a person has to purchase a new policy, they should always ask if the original underwriting criteria can be transferred. The problem of different insurance companies having varying defi nitions of full medical underwriting and moratoria was mentioned at this point, and it was agreed that it is one that the industry must deal with in order to maintain competition. The choice between a local or global insurer is also one that the expat or broker must face – although local cover could offer a cost saving, is the care and cover going to be good enough? There are also decisions to be made by the expat or company they are working for regarding the wide choice of benefi ts available, and again at this point local healthcare and assistance provision must be brought into play – what is and isn’t necessary for the expat? Jewell agreed that the coverage of chronic conditions must be considered, but cover will differ between insurers – most will cover acute episodes, but for some routine management and palliative care are not part of the policy. This will depend, in the future, on drug development, and as it becomes easier for chronic patients to look after themselves, coverage will increase to refl ect the increased stability of a disease.For the broker selling the IPMI policy, it is vital to listen to the client and ensure that the policy being offered accurately meets the needs and requirements of the company in question. It is also very important, though diffi cult, to make sure your client has read the full terms and conditions of their IPMI policy. There was a particular problem highlighted at this point, whereby the HR department of a company will know all the terms and conditions, but some fail to pass on this knowledge to the staff, leaving them vulnerable to misunderstandings and miscommunication problems.

Sarah Dennis Laura Hilton Sarah Jewell

by 2012, gross underwritten premium income from International

Private Medical Insurance (IPMI) could reach as much as £4 billion

Expats with chronic illnesses need an active, trusted and personal health

interaction with their insurer to keep on top of the problem

TRAVEL INSURANCE 17

Specialist insurance

Benjamin FrancisProject offi cer, insurance templates – Genetic Interest Group

The Genetic Interest Group (GIG) is an organisation for all patients in the UK affected by genetic disorders, explained Francis. GIG’s primary goal is to promote awareness and understanding of genetic disorders so that high quality services can be developed and made available for sufferers.From a project funded by BUPA UK with support from Swiss Re titled ‘Asking Relevant Questions’, GIG gained feedback from patient groups and individuals indicating that those with pre-existing medical conditions have clear problems in obtaining insurance. Outlining the potential market for insurers, Francis stated that in the UK alone, there are approximately 8,000 people with cystic fi brosis, around 25,000 with neurofi bromatosis, and around 250,000 with a genetic predisposition to haemochromatosis. As part of this project, GIG created a series of templates to make the underwriting process quicker and easier for insurers. The templates are completed by the customer, putting the emphasis on them from a non-disclosure perspective. The forms are also signed by a medical professional and marked with their British Medical Association number. Initial feedback from insurers has been positive, said Francis, and the templates have been taken up by life insurers. They are clearer than doctors reports, and quicker to process. In addition, the insurer benefi ts from being able to control the information that is asked for. The underwriting model used by some insurers for cancer is ideal, said Francis, and there is no reason why this can’t be expanded to cover other conditions.According to Francis, travel insurance is a major concern for GIG, as its research shows that many customers are frustrated when searching for travel insurance as they are repeatedly declined due to pre-existing medical conditions after answering a raft of questions, often, unknown to them, for the same third-party underwriting agency. The upside for the insurer of covering this group is that a customer will often stay with an insurer, renewing year on year, if their condition is well understood. Furthermore, a company that will cover a customer’s condition is likely to gain that customer and their family, with possibilities to cross-sell other lines of insurance.

Pradeep DharmapalanRegional general manager – Neuron Group

Introducing the topic of Sharia-compliant insurance, Pradeep Dharmapalan stated that to be effective in the global marketplace, it is both useful and possible to understand regional differences. As a concrete example of how this can be of benefi t, Dharmapalan noted that Islamic funds have so far been less affected by the credit crunch than has the general market.Defi ning terms, Dharmapalan explained that ‘Sharia’ means ‘allowed by Islamic law’, and ‘takaful’ is sharing or guaranteeing risk, which fi ts with the Islamic concept of participating and sharing. In effect, takaful policyholders share risk.Takaful plans fall into two categories, ‘mudharabah’ and ‘wakalah’. Under mudharabah, the plan is operated by a third-party administrator, which receives a percentage of profi ts. Under wakalah, the administrator receives a fi xed, up-front fee. In practice, said Dharmapalan, many plans are a mix of both types.

Takaful insurers must be competitive and offer appropriate cover in order to compete commercially with non-takaful insurers, stated Dharmapalan. In general, Islamic fi nancial institutions recognise that it is preferable to adopt takaful insurance, but are free to choose other insurance based on the commercial benefi ts. As an example, a budget airline being set up in the Middle East is using non-takaful insurers and assistance companies. Similarly, takaful groups often use non-takaful reinsurers, though the number of so-called ‘retakaful’ operators is growing.

Frank GillinghamMedical director – HTH Worldwide

The inbound and outbound student market presents insurers with unique underwriting and customer service challenges, said Frank Gillingham. The market is large, with six to seven million international students entering the US alone each year, and nearly two million undergraduate and graduate students studying abroad, approximately 30 per cent of them in the US, which is the world’s most popular destination.It is also a competitive market, where insurers must go the extra mile to compete, using tools such as digital proof of insurance, where students are able to access their insurance details from a digital ID card on a mobile phone or wireless device.Important health issues to consider include alcohol and drug abuse, psychological disorders, culture shock, sexually transmitted diseases, infectious diseases, chronic medical conditions, and the effect of ‘helicopter parents’. Gillingham commented that alcohol use among students abroad is affected by legal drinking age limits, which may be lower than in their home country, a feeling that they’re ‘on holiday’, and varying customs. These factors can add up to disaster, as in the case of a male student travelling from the US to Madrid, who drank the equivalent of 30 beers on the plane and had to be taken home by his father without attending a single class in Spain.Insurers face the diffi culty of wording a policy document to exclude the effects of alcohol. Gillingham gave the example of a court case involving a man who jumped from a balcony aiming for, but missing, a swimming pool. Although his blood

alcohol level had been ‘above the legal limit’, as stated in the policy, a court case went in his favour as he had not been arrested and therefore wasn’t ‘illegally intoxicated’. It’s also worth considering differences between countries’ legislation – for example, a mention of ‘illegal drugs’ will include cannabis in the US, but not in Holland where it can be legally taken in some circumstances.Psychological disorders can be particularly problematic for insurers. Conditions to consider include anorexia nervosa, bulimia, attention defi cit disorder, panic syndrome, manic depression, schizophrenia, personality disorder, and culture shock syndrome. A particular diffi culty can be getting the student home, given that airlines may refuse to fl y a passenger unless they are stabilised.

Krish ShastriDirector – InsureCancer

InsureCancer is a specialist insurer only dealing with clients who have been diagnosed with cancer in the last fi ve years. Its underwriting philosophy is to base decisions purely on clinical fi tness to travel for the duration of the policy, not on prognosis in the longer term, said Krish Shastri. The potential market for insurers dealing with cancer is not insignifi cant, with a third of people in the UK developing cancer in their lifetime. In the UK, cancer is the single biggest cause of death, resulting in 50 times as many deaths as road traffi c accidents. The diffi culty is that there are over 200 different types of cancer, all with different treatments.InsureCancer underwrites each case individually on the basis of fi tness to travel and clinical indicators, and therefore does not impose any arbitrary conditions such as age limits. The company has a panel of consultants, and is not dependant on self-declaration of customers’ conditions as applications are supported by information from clinicians. The fi rm is able to cover those undergoing therapy and those with a terminal prognosis, giving full emergency and medical expenses cover of £5 million. The cover is available for worldwide travel, including the US, though following immunosuppressant surgery travellers will need to renew vaccinations, noted Shastri.Complex underwriting algorithms are used to arrive at a risk rating, and the traveller’s precise destination is required in order to assess whether hospital facilities are available. Every claim not down to a fortuitous event is treated as a failure of underwriting, and leads to an examination to correct the process. Due to this approach, the premiums offered are affordable, with travel to the US being covered for an average premium of £500. Shastri underlined this point with the example of a man who was quoted £42,000 by a mainstream insurer for travel cover for a two-week trip to Florida; InsureCancer provided the policy for £600.Shastri urgered insurers not to decline applicants with cancer, but instead to advise that it is a complex area that they do not cover, and pass on the details of a specialist insurer such as InsureCancer. While declining can damage a brand image, referral such as this, if handled sensitively, will refl ect well on the company.Turning to the issue of ‘terminal prognosis’, Shastri stated that it is not compassionate to ask a customer if their cancer is terminal. He also commented that there is no standard defi nition of ‘terminal’ – in Norway, for example, physicians will only declare a patient’s condition to be terminal if the have no longer than 25 days to live.

Clockwise from top left; Benjamin Francis, Pradeep Dharmapalan, Krish Shastr and Frank Gillingham

18 TRAVEL INSURANCE

Major claims – treating repudiation fairly

Dick AtkinsLegal counsel – International Recoveries, LLC

Ian JonesHead of claims – First Assist

Daniel ScognamiglioSenior solicitor – Blake Lapthorn

This focus group covered some diverse topics, including the increase in fraudulent claims that has been seen in the last quarter, and how insurance companies and claims handlers are countering these dishonest claimants. Ian Jones described how his company has seen a signifi cant increase in false claims in the last four months, which he attributed to either the fi rm getting better at catching the fraudsters, or more people claiming as a result of the credit crunch and trying to recoup some of their holiday costs. There has been a marked increase in the number of cancellation claims in particular, with consumers heading to their doctor for an ‘unfi t to fl y’ note, which is extremely diffi cult for an insurer to argue with. Although the client could be put under surveillance to see if they are actually that ill, in most cases the cost of such action would be prohibitive, especially when compared with the usual cost of a travel claim. It was suggested that perhaps insurers could seek confi rmation of the illness claimed by the client and doctor from the client’s employer – if they are ill enough not to go on holiday, they are probably too ill to go to work as well. The insurer could also suggest further medical evaluation, which could deter the claimant from pursuing a false claim.Delegates present agreed that an increase in claims had been seen in the last four months, most of which had been cancellation claims. In order to catch more fraudsters, if a claim is fl agged as being high-risk, and therefore possibly fraudulent, there are companies that will speak to the claimant on behalf of the insurer, and through a series of questions and making the claimant repeat the course of events several times, can expose many false claimants. It was pointed out that traumatic events stay in people’s memories for longer, so a valid claimant would usually be able to repeat every detail of their ordeal several times without any changes, whereas a fraudster would become fl ustered, and perhaps say they need to go and check some information and will call back. At this point, many false claims will then be forgotten – the client knows they have been ‘rumbled’, and take the opportunity given to them to back down. Another way to protect against fraud is to make the client sign claim form – people are less likely to lie if they have to sign a form, as it turns a ‘white lie’ into

insurance fraud.Fraud does not just come from the clients. Hospitals in certain countries are recognised as regularly overcharging insurers – for the insurer, the best way to combat this is through good relationships with the medical provider, and ensuring they have on their staff a physician who can make an informed decision about whether or not the care given was appropriate. Other insurers put in their policy wording that they will pay ‘a reasonable and customary’ reimbursement rate to a hospital, and use this to protect themselves from overcharging hospitals and doctors.

Denying a claim on the grounds of the infl uence of drugs or drink can be extremely diffi cult to prove, as some hospitals will not give the results of a blood alcohol test to the insurer, as they know they won’t be paid for the care they have given if they do. For UK insurers, the clause stating that claims will be not paid arising from the client exposing themself to extreme risk is useful in this situation, as it is far easier to prove the client brought it on themselves, regardless of whether alcohol was involved or not.The issue of insurers denying claims related to moped or motorbike accidents is at the forefront of industry debate at the moment. Jones suggested that such cover be excluded altogether from travel insurance policies and instead offered as an option for a higher pemium, as First Assist has seen so many claims arising from moped accidents this year. However, blanket exclusion could give the industry a bad name, and not achieve a great deal other than bad publicity. Instead, it was suggested that the insurer or broker selling the policy should be explaining such issues in detail to the client, not leaving them hidden in the back of the small-print booklet that no one reads.The UK-based Travel Insurance Claims Committee has started to share the data of six large travel insurers in order to help combat fraudsters who repeatedly target travel insurers, and to identify trends in fraudulent claims. It is hoped that the results of the data sharing will be available by the end of this year.

people are less likely to lie if they have to sign a form, as it turns a ‘white lie’ into insurance fraud

Left to right; Ian Jones, Dick Atkins & Daniel Scognamiglio

TRAVEL INSURANCE 19

Martha TurnbullDirector of operations – Assured Assistance & Medical Claims, RBC Insurance

Martha Turnbull spoke on the state of the Canadian travel market and the knock-on effects changes to the marketplace are having on travel insurance sales channels. The Canadians are a nation of travellers, and 2008 has seen a 19-per-cent increase in the number of outbound tourists from the country. However, due to economic conditions, we can expect to see a decrease in capacity and consolidation in the tour operator market. The evolution of the travel industry is continuing, with more cruises than ever before, especially on Mediterranean and European river boats. All-inclusive holidays are also becoming more popular as travellers use the Internet to fi nd the best deals available, while also using the Web to research travel insurance.In terms of distribution channels, travel agents still have the lion’s share of the market with a 44-per-cent stake, while brokers, consumer associations, banks, credit cards, airlines, the Internet and employee benefi ts are all other ways in which Canadians can source travel insurance. Turnbull’s statistics showed that 43 per cent of Canadian travellers buy annual or single trip cover, the same percentage buy just medical cover, and 14 per cent purchase non-medical travel cover. Traditionally in Canada, there is no medical underwriting at the point of sale on travel insurance policies for those under the age of 60 and pre-existing conditions are excluded, while evacuation and repatriation are often included.The snowbirds of Canada are excellent travel insurance buyers, spending time researching policies to make sure they get the best cover possible for the lowest price. This group will still travel, regardless of the economic downturn, although their trips this year might be slightly shorter due to the decreasing value of the Canadian dollar. Regarding market changes, Turnbull said there has been particular growth in insurance that offers ‘cancel for any reason’ cover; an increase in the popularity of cruise holidays means travel agents are making more insurance sales; and an increase in the number of students travelling and working abroad has also prompted further sales of travel insurance.

Christine Panet-RaymondPartner – Avalon Actuarial

Christine Panet-Raymond explained the nature of distribution channels within the US travel insurance market, drawing interesting comparisons to the Canadian sector. Putting matters into context, she told how 64 million Americans made international trips in 2007 – 31 million overseas and 33 million popping over a border to Canada or Mexico, with 38 per cent of such trips being for leisure purposes. There is plenty of research done on the Internet by US travellers, she added, but when it comes to actually booking a trip, most are likely to use a travel agent or tour operator. Furthermore, awareness of travel insurance is an issue in the US, partly because two billion internal holidays are taken every year and most of these do not require the traveller to take out medical insurance as their private health

cover will take care of them through their network. The travellers most likely to purchase insurance are those heading outside the US and Canada, cruisers, graduates and groups. The key purchase drivers for these groups are the same: trip cancellation and interruption top the list, while medical evacuation comes second. US Travel Insurance Association fi gures show that the market is worth $1.3 billion annually, with 75 per cent of revenue stemming from trip cancellation and interruption cover – the main product

sold to the US market, usually with at least two other benefi ts added on, although again there is no medical underwriting. She confi rmed that the US market has witnessed a marked increase in ‘cancel for any reason’ cover and that it has

become a market expectation, despite the fact that the cover usually only offers partial reimbursement.Distribution of travel insurance in the US is mixed, with cruise lines and tour operators having a 37-per-cent share and travel agents 29 per cent, while the Internet only

catches nine per cent of sales, and credit cards and affi nity groups together have 17 per cent of the marketplace. The market share for travel agents and credit cards is down from recent years, while cruise lines, the Internet and airlines have all seen rises.Panet-Raymond predicted that due to the recession in the US, there will be less domestic travel, yet insurance penetration could increase as travellers feel in hard times that fi nancial and physical protection is more important. She noted that this could also prompt a rise in fraudulent cases, as has been seen already in the UK, but she forecast that the distribution channels present in the US market would largely remain the same for some years to come.

Steve NickersonManaging director – Preferential Travel Insurance

The distribution of travel insurance in the UK has changed a great deal in the past seven years, as travel agents’ share has diminished in response to the Internet fl ourishing. Meanwhile, online comparison websites have made consumers more savvy, while fi nancial institutions have been giving away travel policies in packaged bank accounts. However, due to the collapse of several airlines this summer, travel agents could well see a resurgence in business as consumers realise the protection that booking through an ABTA-bonded agent can give them. Further predicted to level the playing fi eld is the upcoming regulation of connected travel insurance sold by travel agents, which should improve their selling technique and claw back consumer confi dence.Steve Nickerson forecast that in the UK, direct distribution is the future, which will be driven by the competitive nature of the marketplace and the continuing popularity of the Internet. The strengths of the UK market, he said, include growing numbers of overseas travellers; an increased desire for exotic and different travel destinations; plenty of older travellers needing comprehensive cover; simple, low-cost travel insurance policies; and the increase in standards that will hopefully come as a result of regulation. However, all is not rosy as weaknesses are also present: the credit crunch is affecting people’s ability to travel; regulation will increase compliance costs, reducing margins; competition will continue to drive down prices; the proliferation of online comparison sites can lead in some cases to misunderstandings by consumers; and the market is also saturated with providers.Nickerson’s statistics showed that at the moment, the share between single trip and annual cover is fairly uneven, with more cheap, single trip policies being sold. However, he did predict that by 2010, sales would have evened out to a nearly 50-50 balance between the two types of policy. Factors affecting the future of the travel insurance market include regulation, an ageing population that needs to have its medical conditions covered, and online aggregator sites growing direct sales while at the same time driving down the premiums. In addition, it was predicted that IT will be used more frequently to design tailor-made policies with selective benefi ts. Although the UK economy is wobbling, Nickerson forecast that well-organised travel insurers should be fi ne – recessions are cyclic by their nature, so eventually we will come out of the gloomy times currently being experienced.

Distribution Panel Session

the US market has witnessed a marked increase in ‘cancel for any

reason’ cover

it was predicted that IT will be used more frequently to design tailor-made

policies with selective benefi ts

Martha Turnbull

Christine Panet-Raymond

Steve Nickerson

20 TRAVEL INSURANCE

Cost containment across Europe

Pablo GonzalaMedical director – MCI Spain

“Where do we come from, where are we, and where are we going?” asked Pablo Gonzala. These questions are fundamental to an analysis of any problems faced in the European cost containment market – a market that is growing with the expansion of the EU, which has allowed clinic groups to expand more easily into other countries. And the most popular countries for tourism – currently Spain, France and Turkey – are going to be more and more attractive to the growing cost containment industry.So, what kind of market have cost containers been operating in, and what is the current situation? The market was unregulated, but we are experiencing progressive market regulation, said Gonzala; we have seen high diversity in the prices demanded by providers around Europe and in suppliers’ profi les, but have moved towards greater provider specialisation, including EU-regulated clinics, even though outpatient centres are not yet fully regulated, and rates remain varied. Previously, continued Gonzala, private treatment was dominant, but there is now an increased percentage of national health service admissions; and where previously there were a high number of inpatient admissions that were not medically justifi ed, this situation is improving, even though we are still encountering problems concerning overtreatment. Furthermore, said Gonzala, direct deductions are now only generally made on the medical bills of unregulated suppliers; payment times have been improved; there is less obsession with discounts, even if they are still considered more important than the cost per claim; and tour operators have less infl uence on directional care. All in all, costs and savings have been normalised, but medical claims are still expensive.So, where is the market heading? In the future, predicts Gonzala, the market will be fully regulated, and both in and outpatient suppliers will be fully specialised, with clinic groups expanding their facilities across Europe. In addition, by reducing the infl uence of tour operators with regards to directional care, rates will become more normalised. Directional care will then be at the control of cost containers, and will be channelled through negotiations with clinics. Also, state health systems will be used much more frequently, making use of EHIC agreements: until recently in Spain, 95 per cent of inpatient admissions were to private clinics, but now tourist patients are increasingly being directed into the public health system. In the future, said Gonzala, inpatient admissions to private hospitals will only take place when medically necessary. Moreover, direct discounts will not be possible without the supplier’s permission, payment times will be optimised – helped by online GOPs, and pricing tools and price lists will be more transparent. Is this possible, and if so how will this be achieved? Yes it is, said Gonzala, and it can come about through a joint strategy between underwriters, assistance companies, cost

containers and loss adjusters. A key global concern will be process optimisation, with insurers capturing information in real time. Medical suppliers will be seen more as partners, and will have greater involvement in cost strategies, while systems will become more codifi ed and we will see better reporting tools, benchmarking and cost transparency.

Christiane BurnistonChairman and managing director – ChargeCare International

Christine Burniston set up ChargeCare 13 years ago to handle medical expenses in Europe, and said she’d learnt a great deal in that time, not least to avoid any form of complacency and to be responsive to the needs of the markets in which the company operates. ChargeCare has offi ces in Spain and Greece, so these are the markets she knows best. The presentation centred on Spain, however, where the company has managed to bring down the cost of medical expenses year after year, after infl ation. So, costs in Spain are stable, and this is despite medical infl ation, a shortage of doctors driving up hospital costs, and the overall improvement of Spanish medical facilities. Cost containment is, thus, a long-term process, whereby future trends and market infl uences have to be taken into account in order to keep costs on an even keel over time. Burniston also works directly with primary care doctors to help reduce the number of people admitted to hospital unnecessarily. This has helped to reduce the number

of inpatients in Spanish hospitals over recent years, and increase the number of people seen on an outpatient basis, saving a great deal of money. Burniston made the point, though, that when examining cost containment, the amount paid out ‘is the reality’: savings,

she said, do not necessarily equate to lower costs.An important part of cost containment, continued Burniston, is the streamlining of processes, and in new and emerging tourism markets, it is essential to be ruthless when establishing processes with local doctors and clinics. Such future challenges include: Bulgaria, Poland, Slovenia, Slovakia, Montenegro, and Dubai. Talking of a current issue in Spain, Burniston told delegates of the increasing number of European patients being sent to state hospitals by the growing number of companies offering third-party administration (TPA) services in the country. The problem is that the subsequent bills sent by these TPAs are relatively very high, and companies looking to make a recovery are often unable to obtain the necessary original hospital invoice required to do so, as the TPA will not allow access to it for obvious reasons.Burniston summarised by reinforcing the fact that cost containment, in the real world, must involve costs that are stable and sustainable, and that the cost containment process is long-term and must adapt to threats and opportunities in an ever-changing world.

Virginia Villanueva de PedroMedical director & network manager – Mapfre Asistencia

Virginia Villanueva started working with Mapfre just before the company began working in cost control in 1996, so speaks from experience when she says the best solution with regards to cost containment is to manage costs directly and without a mediator. Mapfre, like many assistance companies, obtains discounts for its clients in two main ways: through direct contacts with medical providers, and reviewing medical procedures case by case. The contracts with providers increase the providers’ presence in tourist hotspots and allows for reasonable prices through discounts given per case. Thus, the greater the volume, the bigger the discount. At the same time, reviewing procedures case by case means an assistance company can avoid unreasonable and uncustomary prices, check for best medical practice, and dispute any charges that do not correspond to the diagnoses given in the case. In medical cases where assistance companies are not involved in the management of the case, patient services are often sought by the hotel’s medical staff, but prices in such clinics are very high, said Villanueva, and the bill is often tailored to the patient’s nationality, with Brits and Germans paying the most. Hotel doctors are also known to alarm patients about a health problem in order to get them back into hospital or to admit them to hospital in the fi rst instance, as they have agreements with certain medical providers who give them a commission for steering patients their way. This steerage is also practised by hotel staff, tour operators and guides for the same reason. Another unfortunate, though not uncommon practice, is exaggerating the cost of treatment, while costs are also hiked by billing for medication and follow-up treatment. As a result of this situation, over 90 per cent of foreign patients treated in Spain are inpatients, where they fi nish their holiday, with the travel insurer picking up the large bill. It is essential, therefore, said Villanueva, that if an assistance company is not able to control the cost of a case itself, that it involves a TPA such as a cost control company to carry out the cost containment.Regarding medical costs, Villanueva explained how there is a vicious circle around the world, not just within Europe, whereby tourist clinics increase their prices, then pay commissions to those entities they ‘collaborate’ with who steer patients their way, and give legitimate discounts to cost control companies, further increasing their need to put up costs. Who pays these extra costs while the provider gets rich, she asked: the patient and the insurance

company. When the assistance company handles the cost containment, however, they can manage a case in real time, using local alarm centres to access the best and nearest providers. A good tool with which to establish the proper

price for a diagnosis, she added, is the medical prices scale provided by several countries to establish reasonable and customary pricing.

Pablo Gonzala

Virginia Villanueva de Pedro

Christiane Burniston

TRAVEL INSURANCE 21

Regulatory challenges and opportunities

Tom HudsonLegal counsel – Medex

Jill McCutcheonPartner – Blaney McMurty LLP

Daniel ScognamiglioSenior solicitor – Blake Lapthorn

During the panel session, the three lawyers covered several different pieces of legislation from an international angle, with Tom Hudson giving the viewpoint from the US, Jill McCutcheon delivering the Canadian verdict and Daniel Scognamiglio representing the UK. Issues covered during the session included the different laws concerning aviation medicine, and more specifi cally, the American Aviation Medical Assistance Act of 1998 (AMAA). The Act increased the requirement of medical equipment on planes, increased crew training to deal with medical emergencies and also put strict limits on the liabilities that can result from in-fl ight care given by a member of the cabin crew. The AMAA protects the ‘good Samaritan’ (a doctor who happens to be onboard a fl ight when there is a medical situation and can offer help): the same rules apply to medical escorts working for US assistance companies, whereas in the UK there is no similar legislation. For a UK airline, the decision to allow a good Samaritan to treat a passenger is the captain’s. In Canada, however, the good Samaritan is not protected by any law, but nonetheless doctors are expected to come forward to offer assistance in an emergency.Regarding regulation of the sale of travel insurance in Canada, McCutcheon explained the complex nature of the Part 13 Issue, which specifi es who can sell insurance and where, and prompted a battle between Canadian

banks and regulators. The banks lost and must now comply by the licensing rules. Confusion continues in the US, where there are different rules on selling insurance in almost every state, making it very diffi cult to operate nationally. The UStiA is making efforts to communicate with the National Association of Insurance Commissioners in order to clarify the rules where possible and to soften the regulatory regime. In the UK, come 1 January 2009, all sales of connected travel insurance will be regulated, and the Financial Services Authority will be investigating fi rms regularly to ensure new selling standards are being met by travel agents.The implications of the European Gender Directive are somewhat limited when it comes to discrimination in the UK, as its small print states that insurers may discriminate

on the ground of accurate actuarial and statistical data. However, pregnancy cover could become a problem if a claim is denied on those grounds, as there are consumer groups that are waiting to take a test case to court – however, this is probably the only way UK insurers will fi nd out where they really stand with regards to pregnancy cover. There is a similar state of affairs in Canada, where human rights laws state that an insurer may not unfairly discriminate – unless they have risk evidence to prove the need for the higher premium.An Equality Bill that is currently working its way through the

UK Parliament aims to eliminate all types of discrimination, in particular age discrimination, but again if statistics can be found that show the increased risk the insurer is taking then they can load the premium. In the US, the legal system allows for discrimination on ‘a rational basis’ – e.g. that it is dangerous to travel in the third trimester of a pregnancy and therefore such travel should not have to be covered. In Canada, insurers enjoy a lighter regulatory touch and can quote premiums based on risk without the worry of accusations of discrimination.Concerning litigation and travel insurers, McCutcheon explained that in Canada, most of the time a case will be settled by the insurer before it comes before a judge, as more often than not, the judge will side with the claimant. She has, however, seen an increase in the number of cases overall, suggesting that Canadians are becoming slightly more like their litigious US neighbours. Where relevant, US travellers tend to sue US companies, as often if an accident happens in a European country, it is very diffi cult to prosecute in that country. Again, the laws are different depending on which state the claimant is resident in – in some states, individuals are allowed to directly sue an insurer, whereas in others they are not. In the UK, the problem of an individual being able to sue a (UK-based) insurer, even if the accident in question occurred abroad, will soon stop, as regulation will be brought in in January to halt this practice. The Law Commission is also currently looking at insurance contract law in relation to non-disclosure and mis-representation.The panel also discussed the dangers of medical tourism, and the liabilities that can result from such practice. Making themselves and their businesses vulnerable are the foreign hospitals, foreign surgeons, the health insurer that offered the cover in the fi rst place for a lower premium, the employer who offered it as part of their employee benefi ts package and the health travel agents that are springing up all over the world.

Daniel Scognamiglio

Jill McCutcheon

Tom Hudson

For a UK airline, the decision to allow a good Samaritan to treat a passenger is the captain’s

Confusion continues in the US, where there are different rules on selling insurance in almost every state, making it very diffi cult to operate nationally

22 TRAVEL INSURANCE

Cost containment: what happens when you litigate?

Robert BlackwoodVP and general counsel – Global Excel Man-agement, Inc

Robert Blackwood spoke about dealing with diffi cult cost containment cases from a US perspective, and how to avoid litigation. Avoiding litigation, he said, was the goal, but what happens when it does occur? Most medical providers are reasonable and fair, he stated, but some try to get the patient on their side during the claims process. It is the larger cases that need the most attention, however, as 80 per cent of claims received are for up to $1,000, yet together they account for just 20 per cent of costs. Meanwhile, the one per cent of claims that are for anything over $20,000 account for 27 per cent of costs. Professional management is, thus, key in the handling of any cost containment case. Policy wording is critical, and can help you, as can your contracts and relationships, which should be meaningful and add value, said Blackwood. “Be transparent in your contracting,” he said. “Tell the provider you’re an international insurer, not a PPO.” And when managing a case, use appropriate data to support it. If facing a diffi cult case, however, the fi rst rule is to prioritise the patient. However, said Blackwood, ‘don’t leave the insurer in the lurch’: protect their rights too. Use competency fi les relating to third party data and monitor the case carefully, keeping a log of all calls made to the provider.Inevitably, issues will arise with some providers, who may refuse to co-operate or respond, or who may take an adversarial stance. Despite this, you don’t have to pay the high rate that the hospital is asking you to pay, and you can take a reasonable stand. There is a culture of litigation in the US, but just because some providers use lawyers to legitimise their billing, ‘litigation doesn’t mean you’re going to court’, said Blackwood. If you’ve documented a case properly, maintain reasonable communications and continue to negotiate, you can often agree on a fair price. Informed decisions are essential, however. Know at the outset what number you’re looking for, said Blackwood, and

document it, using outside data to back it up. The insurance community has a duty to rise up against unscrupulous providers, and should share data on such institutions. He concluded that through professional negotiations with providers, even if relationships start acrimoniously, such situations can be resolved, and good, long-term relationships can be forged.

Eric D. ShatanofCorporate VP of managed care & network development – Baptist Health

Provider-payer contracts are often 20 to 30 pages long and are very detailed, said Eric Shatanof, but at the end of the day, the provider has a list of key expectations for any such contract. The contract should outline all the terms of each party and amendments should only be by written mutual consent. The provider also expects to be paid accurately and within a defi ned number of days for all medically necessary covered services; where non-covered services are the responsibility of the member. And, fi nally, members/patients should have unrestricted access to choose any contracted provider for all services that the provider offers. Shatanof went on to explain how providers generally administer these contracts. The provider sets up an insurance plan code (IPC) to identify the payer, he explained, and all necessary staff are informed. The rates and terms of the contract are then loaded into the contract management system, which calculates the expected payment on each patient account. All patients, he said, whether domestic or international, are billed the same prices based on a standardised chargemaster. Finally, routine reports are generated to compare a payer’s actual and expected payment, and any variations or

underpayments are followed up by the hospital in the fi rst instance or by legal counsel if the matter remains unresolved. As patient out-of-pocket amounts continue to rise, patients want to know how much a service is going to cost prior to its delivery, so Baptist Health has set up a dedicated pricing offi ce, explained Shatanof, to provide pricing for self-pay patients and out-of-pocket estimates for insured patients, as well as to provide quotes on collect-up-front amounts for insurers. He concluded by giving some interesting quality indicators: with high quality care, initial costs may be higher but the overall cost may be lower; the Centers for Medicare and Medicaid recently began publishing quality data on US hospitals; and the Hospital Compare website is a useful tool for assessing quality markers such as process of care and outcome measures.

David T. DonahueAttorney – Brasher Law Firm

David Donahue’s company represents Tenet Healthcare, and in the last two years has seen an increasing number of cases involving travel insurance. Everybody wants to make money, he said, but this cannot be achieved by giving it away – either by the hospital receiving less money for treatment than they spent in giving it, or the insurer paying way over the odds for a procedure. There are, thus, appropriate and inappropriate ways of containing costs. Insurers sometimes feel that hospitals take advantage of them, said Donahue, but they should ask: is it reasonable to expect a discount? Hospitals, on the other hand, should ask: is it reasonable to bill rate card prices? Probably most importantly, we should ask: is it reasonable for travel insurers to expect to pay Medicare rates of reimbursement? When a price for a given

treatment cannot be agreed, however, litigation is a matter of last resort.Travel insurers should ask: what is a reasonable discount and how is this determined? The answer is through negotiation and disclosure, but if these don’t work, the result is litigation. Subsequently, the costs for the insurer and the hospital increase – the antithesis of cost containment! Donahue then gave three examples of the types of cases he’s dealt with in recent times, pointing out the underlying issues that have been brought up in each case, and exploring how the subject of fraud is touched upon in each. The fi rst of these cases related to the issue of silent PPOs, and whether usage of such a method to obtain a discount is problematic or tantamount to fraud. He pointed out that it could certainly amount to deferred liability, whereby a lawyer can re-open the relevant accounts two to three years down the line and pursue a fraudulent claim on behalf of the provider. Again, an antithesis to cost containment. The second case brought up the issue of insurers or cost containers sending cheques to providers marked ‘full and fi nal payment’, and later down the line being chased for extra payment. “Is this short-term gain for the insurer in return for long-term pain?” posed Donahue. If the hospital cashes the cheque, however, it could amount to ‘accord and satisfaction’; but did the hospital intend to accept the amount on the cheque? Thirdly, an example was given of an insurer sending verifi cation of coverage, but six months after discharge from hospital, denying the claim due to a pre-existing condition. Donohue said the questions raised in this situation are: has the hospital been deceived? Has the patient acted fraudulently? Does an insurer really need six months to diligently check the details of the case? All in all, travel insurers and providers generally both want to resolve any litigation matters reasonably and fairly, summarised Donahue. The key to cost containment, he said, quoting from ITIJ’s latest supplement on the topic, is to negotiate reasonable discounts in advance that cannot later be changed.

the one per cent of claims that are for anything over $20,000 account

for 27 per cent of costs

The key to cost containment … is to negotiate reasonable discounts in advance that cannot later be

changed

TRAVEL INSURANCE 23

Chaired by

Michael WeinlichPresident – EURAMI

The European Aero-Medical Institute (EURAMI) members meeting saw 19 members in attendance. Michael Weinlich began with an overview of EURAMI’s recent activity and current position: the Institute currently boasts 76 members from 26 countries around the world. There are 12 EURAMI-accredited air ambulance providers spread across nine countries on three continents: Luxemburg Air Rescue (LAR), DRF Luftrettung, REGA, Norsk Luftambulanse, Flight Ambulance International (FAI), the African Medical

and Research Foundation (AMREF), International Medical Services, Skyservice Lifeguard, American Care Air Ambulance, ADAC, Bangkok Airways/Bangkok Hospital, and Air Ambulance Professionals Inc. During the meeting, framed certifi cates were awarded to ADAC, Air Ambulance Professionals and Bangkok Airways/Bangkok Hospital to celebrate their recent accreditations.Weinlich advised the group that eight

further providers in four countries have registered with EURAMI and are currently working on accreditation standards. Six additional companies in four countries, have contacted the Institute to request information on the audit process and steps required for accreditation.In the period since 2006, EURAMI has moved its headquarters to Reutlingen, Germany, and supported the FlyMi online empty-leg auction tool, which includes an indication of the accreditation status of bidding providers. It has also had articles published in several industry journals, increased the number of audits being undertaken, and was honoured with an offi cial visit by Prince Faisal of Saudi Arabia.Looking to the future, EURAMI is moving from the current paper-based version 3.2 accreditation standards to Web-based version 4.0. Reaccreditation will be carried out for providers accredited three years ago, and will be at a lower price than the initial audit. In terms of marketing, steps will be taken to improve promotion of EURAMI, including enhancing the website and having exhibition stands at ITIC and the Waypoint AirMed & Rescue Airshow.The Institute also aims to develop better cash fl ow management in order to promote growth. Recruitment of members is targeted to be 10 per year, which will help provide a basis to spread news of the benefi ts of EURAMI accreditation and to better help accredited companies. Income for 2009 was predicted to be approximately €60,000, and a detailed breakdown of expenses was given, including costs of administration, website maintenance, travel expenses, fees of accreditation auditors and marketing costs. The fee for accreditation will increase by €500 in 2009 due to the increasing costs of carrying out overseas audits. A €1,200 membership fee will also be implemented for EURAMI-certifi ed providers. Auditor fees will be €1,000 for accreditation and €750 for reaccreditation.The existing governing board was dissolved, and those wishing to stand for election as board members were given

the chance to make brief statements on why they should be chosen. Supporting his candidacy, Andrew Lee of fl ight auction site Air Ambulance Connection stated that EURAMI should be the governing body of accreditation but lacks commercial ability and needs enhanced marketing in order to raise funds. However the Institute has, said Lee, the fl avour and feel to provide accreditation badly needed in the industry. The six board members elected were: Michael Weinlich, CEO, Med Con Team; Michael Braida, chief medical offi cer, AXA Assistance; Bettina Vadera, medical director – emergency services, AMREF; Olivier Seiler, medical director, REGA; and Volker Lemke, CSO, FAI rent-a-jet.Weinlich noted that Air Ambulance Connection had approached EURAMI to see if and how the organisations could work together; but despite the potential advantages – given that both undertake audits of air ambulance providers – the Institute has declined the offer in order to remain independent. Lee thanked the board for considering the proposal, and asked them to give an opinion as to whether members should also be able to act as a broker, as US accreditor CAMTS forbids this. Weinlich invited all present to give their opinions on this.Thomas Buchsein, medical director, FAI

rent-a-jet, asked whether the Institute has plans to accredit training courses such as Terry Martin’s Clinical Considerations in Aeromedical Transport (CCAT) in the UK. Weinlich said links could be set up with such courses, but EURAMI’s mission is accreditation of operators and so should not extend beyond operators’ own internal training courses for their own staff. He highlighted the diffi culty of establishing objective criteria to determine how to judge a training course, though if these could be

established then additions could be made to the audit process. Karen Chamberlain, director of clinical services, Air Ambulance Professionals, said there are publications in existence on the standards required for the medical transport of patients, and was tasked with taking this further.The next EURAMI open members meeting will take place at ITIC 2009.

EURAMI members meeting

Michael Weinlich

Eurami members

© ITIC / Photos by Santa Istvan Csaba

24

Finale DinnerThe 2008 ITIC gala dinner, incorporating the ITIJ Awards ceremony, was an evening to remember, with a fantastic line-up of entertainment and a tantalising menu, all provided in a beautiful white-themed setting. Before dinner commenced, attendees enjoyed champagne and canapés, and were visited by a group of real-life standing statues including a beautiful mermaid and a charming Egyptian pharaoh, getting the evening off to an interesting start.Throughout the meal, guests were treated to some to amazing entertainment acts, including the incredible flexibility and strength of The Golden Pyramid – a trio of gymnasts who wowed the audience with their moves.

ITIJ 2008 Awards Night

Next up on the entertainment bill was the Attraction Laser Theatre, who were, it is safe to say, the highlight of the evening. Starting off relatively calmly, the dancers soon had the audience gasping and laughing in amazement as they made seemingly impossible shapes and moves in their UV-costumes. The speed and dexterity of the troupe had the guests open-mouthed in admiration, and the length and volume of the applause afterwards reflected their appreciation for the performance…

25

Evening entertainment sponsored by Air Ambulance Connection

The Golden Pyramid

The Attraction Laser Theatre

© ITIC / Photos by Santa Istvan Csaba

26

PHN Award 2008International Private Healthcare Insurer of the Year AGB Goodhealth

Finalists:

InterGlobal and

Nordic Health Care

Presented by

Mandy Aitchison,

title editor of PHN

ITIJ INDUSTRY AWARDS 2008The ITIJ Awards ceremony was a glittering

occasion as always, and all eyes were on the podium for the announcement of this year’s

winners. Here, we have a round-up of all the fi nalists, and spotlight each of 2008’s winners in each category.

Before the Awards ceremony began, a mystery prize draw – sponsored by Air Ambulance Connection – was carried out, with one very lucky delegate winning a fabulous two-week holiday for two to Florida. Congratulations!

Next came a surprise announcement, with two special awards being given out – to Denise Clements and Sarah Watson of the Voyageur Group, for their 10-year tenure with the company – well done to them both!

And then started the evening proper – the presentation of the ITIJ Awards, led by ITIJ’s editor-in-chief Ian Cameron and ITIJ’s editor Sarah Watson. Th ey were helped out by representatives of those companies sponsoring each of the Awards: Steve Manton of M Consulting, Mandy Aitchison of PHN, Michael Braida of AXA Assistance, Barry Smith of Mondial, Michael Weinlich of EURAMI, Mark Jones of Air Ambulance Worldwide and Andy Lee of Air Ambulance Connection.

ITIJ thanks all of the Awards sponsors and extends a huge ‘congratulations’ to all this year’s winners.

27

Air Ambulance Connection is committed to creating an

organised global network in the air ambulance industry by

promoting a higher quality of providers, increasing productivity

to providers by expanding their opportunities, and in so doing

reducing costs and improving effi ciency for insurers and

their designated assistance companies. Its service can

assist you with private transports and repatriations,

commercial airline medical escorts, or organ

transplant transportation. In addition, its participating

preferred providers undergo an application process and can only

participate once they have been approved and credentialed.

Insurer/Underwriter of the Year

Europ Assistance

Finalists: Europeiska Reseforsakringar and PTI Co Ltd Presented by Andrew Lee

ITIJ Marketing Campaign of the Year

UnitedHealth International

Finalists: ADAC, MedSave and Raisbeck EngPresented by Steve Manton

sponsored byAir Ambulance Connection is committed to creating an

organised global network in the air ambulance industry by

promoting a higher quality of providers, increasing productivity

to providers by expanding their opportunities, and in so doing

reducing costs and improving effi ciency for insurers and

their designated assistance companies. Its service can

assist you with private transports and repatriations,

commercial airline medical escorts, or organ

transplant transportation. In addition, its participating

preferred providers undergo an application process and can only

participate once they have been approved and credentialed.

Budapest InterContinental Hotel

ITIJ INDUSTRY AWARDS 200814th November

M Consulting is an integrated marketing

communications fi rm operating throughout

the UK from bases in Birmingham and

London. The fi rm provides specialist

services to help fi nancial service

providers maximise their returns on

marketing investment.

ITIJ INDUSTRY AWARDS 2008M Consulting is an integrated marketing

communications fi rm operating throughout

the UK from bases in Birmingham and

London. The fi rm provides specialist

services to help fi nancial service

marketing investment.

sponsored by

© ITIC / Photos by Santa Istvan Csaba

28

Air Ambulance Provider of the Year

AirMed International LLC

Finalists: Life Flight Int. Inc. and SkyServicePresented by Michael Weinlich

Cost Containment Company of the Year

Euro-Center

Finalists: ChargeCare International and Global ExcelPresented by Michael Braida

sponsored byITIJ INDUSTRY AWARDS 2008

AXA Assistance is one of the largest assistance

generalists in the world. With an extensive network of

over 30 offi ces worldwide, it possesses the

global capability, expertise and experience to

provide a comprehensive range of services to

meet the needs of its clients and their customers

both in the UK and throughout the world. In the UK, AXA

Assistance operates as a B2B organisation and works in

partnership with a wide range of blue-chip companies,

providing world-class services and insured solutions to

their customers 24 hours a day, 365 days a year.

The European AeroMedical Institute (EURAMI)

is primarily involved in the medical aspect of air

rescue, and its main aims are to: promote air rescue

everywhere in Europe, harmonise and generalise

the European and international experience of

and insight into air rescue, facilitate and develop

the practical work of its members, and improve

and increase the results of this work in order to

guarantee a high level of air rescue in all countries

inside and outside the EU as a part of the process of

European unifi cation in the area of health services.

AXA Assistance is one of the largest assistance

generalists in the world. With an extensive network of

over 30 offi ces worldwide, it possesses the

meet the needs of its clients and their customers

both in the UK and throughout the world. In the UK, AXA

Assistance operates as a B2B organisation and works in

partnership with a wide range of blue-chip companies,

providing world-class services and insured solutions to

their customers 24 hours a day, 365 days a year.

sponsored by sponsored byITIJ INDUSTRY AWARDS 2008

The European AeroMedical Institute (EURAMI)

is primarily involved in the medical aspect of air

rescue, and its main aims are to: promote air rescue

everywhere in Europe, harmonise and generalise

the European and international experience of

and insight into air rescue, facilitate and develop

the practical work of its members, and improve

and increase the results of this work in order to

guarantee a high level of air rescue in all countries

inside and outside the EU as a part of the process of

European unifi cation in the area of health services.

© ITIC / Photos by Santa Istvan Csaba

29

Intermediary of the year

Columbus Direct

Finalists: InsureandGo and PreferentialPresented by Barry Smith

Assistance/Claims Handler of the Year

SOS International

Finalists: Europ Assistance and Fortis Insurance (UK)Presented by Mark Jones

Budapest InterContinental Hotel

sponsored bysponsored by

ITIJ INDUSTRY AWARDS 200814th November

Air Ambulance Worldwide, Inc. (AAWI) provides

fi xed wing air ambulance transportation services to

private individuals and family members, hospitals,

nursing homes, medical assistance companies,

cost containment companies and other providers of

medical care. AAWI provides a bed- to-bed service,

including ground transportation in both cities, an air

ambulance aircraft with specialised medical team,

as well as all coordination with the family.

Mondial UK is a leading provider of assistance

and travel insurance third party administration,

conducting business with or on behalf of major

companies. Mondial provides services to customers

24 hours a day, wherever they are all over the

world. Its Corporate and Travel division provides

all encompassing assistance, travel and health

services to insurance companies, fi nancial

institutions and other blue-chip organisations.

sponsored by

Air Ambulance Worldwide, Inc. (AAWI) provides

fi xed wing air ambulance transportation services to

private individuals and family members, hospitals,

nursing homes, medical assistance companies,

cost containment companies and other providers of

medical care. AAWI provides a bed- to-bed service,

sponsored byITIJ INDUSTRY AWARDS 2008

Mondial UK is a leading provider of assistance

and travel insurance third party administration,

conducting business with or on behalf of major

companies. Mondial provides services to customers

24 hours a day, wherever they are all over the

world. Its Corporate and Travel division provides

all encompassing assistance, travel and health

30

ITIC 2008 after-show party!

Following the glittering Awards ceremony, the party started in earnest, with plenty of action on the dancefloor, at the roulette tables and at the bar! The pictures say it all really…

© ITIC / Photos by Santa Istvan Csaba

CONFERENCE REVIEW 31