Travel Insurance and Health

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COMMON QUESTIONS

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Travel Insurance and Health Peter A. Leggat,Judith C a m e , and Uyeporn Kedjarune advisers.Although only 4% of general practitioners (GPs) in a late 1980’sstudy in the United l n g d o m would advise a traveler going to Turkey about travel insurance,+more recent studies have shown about 60% of GPs in New Zealand’ and 39% of travel clinics worldwide” usually advised travelers concerning travel insurance. In addition, 54% of GPs in New Zealand usually also advised travelers about finding medical assistance abroad, but only 19% of GPs recommended travel insurance companies as a source of medical assistance while traveling.’

Travel insurance normally underwrites travel, niedical, and dental expenses incurred by travelers abroad and arranges aeromedical evacuation of travelers under conhtions specified by the travel insurance policy. Because of the costs of medical and dental treatment abroad and the high cost associated with aeromedical evacuation, all travelers should be advised of the need for comprehensive travel insurance and be advised to read their policies carefully to see what is covered and to check for any exclusions. In particular, those travelers who have known preexisting conditions, who are working overseas, or who are going to undertake any form of hazardous recreational pursuit may need to obtain a special travel insurance policy, which may attract a higher premium. Conservatively,it is estimated that between 30-50% of travelers become ill or injured whilst traveling.’ Relative estimated monthly incidence rates of various health problems have been compiled elsewhere.2 The risk of severe injury is thought to be greater for people when traveling a b r ~ a dThese . ~ risks should be covered by travel insurance to protect the traveler, however it is not known what proportion of travel agents or airlines give advice routinely on travel insurance. Travel insurance is the most important safety net for travelers in the event of misadventure, and should be reinforced by travel health

Why Do I Need Travel Insurance? Travelers are not usually covered abroad by their health insurance, workers’ compensation and third party and other personal liability policies. Few countries provide reciprocal medical and dental arrangements or free health care to travelers and few countries provide a full range of readily accessible health care services, including aeromedical evacuation. Travel insurance for international journeys generally cover, amongst other things, the expenses of your travel, medical treatment, or even evacuation in the event of misadventure or ill health. Most importantly, the travel insurer can assist in organizing, coordinating and, in some cases, financially guaranteeing a traveler’s medical care and keeping relatives informed, which is especially important when the traveler is severely ill or injured and requiring aeromedical evacuation. Domestic travel should also be covered by taking out travel insurance. Like international travel, insurance for domestic travel arrangements, especially for discounted economy tickets with “no refund” or no rerouting conditions on purchase, should at least cover the traveler against unavoidable cancellation due to illness, subject to any excesses which may be imposed. Travel insurance therefore affords financial security for the traveler against what can be very costly claims for medical and related travel expenses in the event of misadventure, as well as even more costly aeroniedical evacuation, occasionally requiring such things as specialized aircraft, modifications to aircraft, medical and nursing escorts, and assistance with legal, customs and ininiigration procedures. One way of explaining the cost-effectiveness of travel insurance is to compare it pro-rata

PeterA. Leggat, FAFPffM, FACTM, FACFIRM: Associate Professor and Deputy Head, School of Public Health and Tropical Medicine, James Cook University,TownsviIle, Queensland, Australia; Judith Came: National Manager, Travel Insurance, MBF Services Pty Ltd, Adelaide Street, Brisbane, Queensland, Australia; Ureporn Kedjaru-, DDS, PhD, FACTM: Assistant Professor, Department of Oral Biology and Occlusion, Prince of Songkla University, HatYai, Songkhla,Thailand. Disc1aimer:The views expressed here are not necessarily those of MBF Services Pty Limited, Australia or of any other organization or person referred to in this paper. Reprint requests: Peter A. Leggat, Associate Professor, Deputy Head, School of Public Health andTropical Medicine, James Cook University,Townsville Queensland 4811 Australia. JTravel M e d 1999; 6:243-248.

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with car insurance, both private and rental car insurance, and private health insurance,which will generally be very favorable for most travelers. The bottom line is that no one should travel uninsured.

Where Can I Obtain Travel Insurance? Travel insurance should be obtained well before leaving the country and application forms can be obtained &om travel agents,airlines,private health insurers,doctor’s offices, hostels, and other travel and tourism representatives. The travel insurance industry is a large dynamic industry with conipanies moving into and out of the industry quite regularly. Some consumer organizations may help provide travelers with independent advice on which travel insurance policy represents the best value, particularly in researched reviews that may appear in their publications.’ Travel insurance policies are generally avdable for individualjourneys or for frequent travelers as an annual policy, which should reduce the cost of the premium outlays and obviates the need for multiple travel insurance applications. Further information on travel insurance may also be available on the internet8 and general reviews of travel insurance have been published in recent years in travel maga z i n e ~Travel . ~ insurance for international travel should be taken out well before travel, and advice concerning travel insurance should be sought early by travelers, preferably at least 6-8 weeks before travel when the traveler is seeking travel health advice for their journey. It is important that travelers are advised to seek a travel insurer,which has international coverage for medical care and aeromedical evacuation, especially for the traveler’s destination.

What Level of Travel Insurance Should I Take Out? Ideally,travel insurance needs to be taken out at the top level available, which should cover as far as possible all medical,dental, and surgical costs (at least US$l ,500,000 or GBPl,O00,000, if possible);personal liability; costs of aeromedical evacuation;costs of additional expenses associated with medical treatment, including loss of income, travel rearrangements, transport of relatives, and daily allowance; plus usual travel insurance items, such as loss of baggage; and carriage of body or ashes after death.3 Travel insurance companies niay deny a traveler the right to purchase an inadequate travel insurance policy for a particular destination, for example, budget level coverage for the USA, to avoid being liable for claims arising from selling an inadequate product. The primary value of the health component in travel insurance is as a financial safety net. This is significant and can be demonstrated via hospital bills in the

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USA, the chartering ofjet ambulances to transfer from country to country, the stretcher home on a Boeing 747, and so on. Examples of huge medical expenses incurred by injured and ill travelers abroad occasionally appear in the popular press. Six figure accounts for hospitalization and treatment in the USA, for example, are not unknown for even short stays.

How Much Does it Cost? The cost of a travel insurance premium is factored against the levels of coverage and duration of time overseas, with the level5 of coverage becoming more strongly linked to destination. Discounted travel insurance policies will generally have exclusions or limitations and, whde policies with lower prenliuins for destinations such as Asia may be available, the cost of seeking private medical and dental care, needs to be taken into account. Travelers should be advised to compare the small cost of their travel insurance premium against their total travel expenses, which, in many cases, would be less than the combined cost of airport and departure taxes for their trip. For example, the costs of an international travel insurance premium for an 8 day, month-long, and 3 month holiday for a family with one insurer in Australia were A$SS,A$172, and A$331 respectively for budget coverage through to A$154, A$281, and A$503 respectively for top coverage. For singles, the costs for an %day, month-long, and 3 month holiday with the same insurer were A$46, AS93, and A96179 respectively for budget coverage and A$83, A$152, and A96272 respectively for top coverage.

What Doesn‘t My Travel Insurance Policy Cover? It is important that travelers don’t have unrealistic expectations of their travel insurance policies. Most travel insurers, especially for international travel insurance, will require a minimum processing period for applications and travelers should be advised accordingly. Excesses are also quite common these days on many aspects of claims with the various types of travel insurance policies available.Even the top level travel insurance policies usually do not cover travelers against such things as travel to war zones, self-inflicted injuries, unlawful acts, certain infectious diseases such as Acquired Inmune Deficiency Syndrome (AIDS) and sexually transmitted infections, pregnancy, and participation in professional sport. Those who are expecting to undertake any kind of hazardous pursuit should expect to pay a surcharge on their travel insurance premium, which may be assessed on a case by case basis by travel insurance companies. Some sporting organizations, such as those for divers, may recommend a travel insurance product. Some travel insurers may exclude pregnancy and any complications arising from pregnancy

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after 26 weeks, or they may restrict coverage even further or may give no coverage for pregnancy. It is important also for travelers, especially elderly travelers, to be made aware that travel insurance normally does not cover any known preexisting medical or dental problems. In these cases, it may be necessary for travelers to complete further documentation of these conditions and in some cases be clinically assessed by a doctor or insurance medical representative. It is possible that routine illnesses may also be excluded by the travel insurance policy. It is still important for these travelers to take out a travel insurance policy, since other conditions, not directly linked to their excluded preexisting condition, are likely to be covered. A common questions paper on health hazards and the elderly has been published elsewhere. '" For those travelers who may be uninsurable because of advanced age or advanced ill health, it is important that they are advised about destinations where they could travel safely, particularly where bilateral government health agreements exist and where the airlines are prepared to uplift the traveler. It is important to discuss the "worst case scenario" risk and the cost to them if it occurred. Travel insurance or emergency assistance policies, provided for domestic travel by agencies such as airlines,travel agents, and automobile associations, generally do not cover against medical expenses or aeromedical evacuation. However these expenses may be covered or the costs offset in other ways, for example through their private health insurance or by their employer. Some comprehensive household insurance policies may cover some personal effects and equipment while traveling, however the policy should be examined closely by the traveler. I t is important that travelers do not elect to decline third party or personal liability insurance from a car rental agency in the event that they are involved in an accident which was their fault, as many travel insurance policies do not include claims for damage to other persons or property arising from the traveler's operation of cars, boats,jet skis, aircraft, and other motorized devices.

Is 'Credit Card' Travel Insurance Enough? Some well-known charge and credit cards include travel insurance when payments for specified travel arrangements are made with the respective card. The traveler should not assume that this cover is sufficient and they should read the policy and the fine print well before the travel date to decide whether a standard travel insurance policy would better serve their needs. Since policies may not be issued with every travel charge made with these credit and charge cards, it is also important that travelers familiarize themselves with the relevant travel insurance documentation to determine their entitlements,

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preferably before they travel. Additional useful features may be provided by some travel insurance policies.

Does M y Travel Insurance Policy Cover M y Children? Although infants may be traveling at no charge and while they may not be old enough to have many personal belongings, it is important for children to be covered by travel insurance. Children are likely to suffer from some illness while traveling. If it is a severe illness,injury or major dental problem, then medical or dental assistance may be needed. Those traveling with children should ensure that their travel insurance policy, usually a family policy, covers their dependent children to a certain age limit while they are traveling. One parent or guardian traveling may be covered for one or more children, but travelers should be advised to check with their travel insurance company. A confnion questions paper on traveling with children has been published elsewhere."

Do I Need to Take M y Travel Insurance Card with Me? The travel insurance card is evidence of a traveler's current policy in travel insurance and the policy number to be quoted in emergencies, which may assist travelers in gaining access to medical, dental, and paramedical care in foreign countries. In addition, there is usually a 24-hour toll-fkee contact number on the card and instructions for travelers seeking emergency assistance. The travel insurance company will usually subcontract a t least some emergency assistance and aeromedical evacuation responsibilities to professional emergency assistance companies, however it is important for travelers to ensure that the travel insurance company wdl coordmate medical care and evacuation procedures with qualified medical staff. Travelers should take all their travel health documentation, including their travel insurance policy, with them in a waterproof plastic jacket, including their immunization record, travel insurance card, and doctor's letter for any medications carried. While travel insurance companies may keep some details of medical history, including allergies, travelers should also consider special medical alert identification for particular allergies, blood group, or medical conditions, such as diabetes, which may take the form of a special bracelet or neck chain. Some travel clinics use special booklets, which can be used to write up immunizations and medications, as well as give general travel health advice. Travelers should also be advised to make copies of the travel insurance policy and other important documents and keep them separately from the originals, in the event that the originals are stolen or lost.

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It Can Wait Until I Get Back, Can’t It? Travelers should be advised to avoid traveling or working overseas with acute medical or dental problems, which could flare up while abroad. Known preexisting illnesses, injuries, and disabilities may require additional coverage. All preexisting illnesses should be fully documented, preferably in a doctor’s letter and also by means of emergency documentation, such as medical alert bracelets for some illnesses, such as severe diabetes and asthma,and allergies. Travel insurance companies may also store this type of medical information.

Should I Give the Travel Insurance Company M y Medical History? Many travel insurance companies and airlines will store some medical information about medical conditions and special diets of travelers. This information is usually supplied voluntarily by travelers. Information about medical conditions may include special travel requirements, current treatment, and allergies. If the traveler is likely to be consulting a medical practitioner overseas or where this is arranged, then a doctor’s letter detailing the relevant aspects of the past medical history along with current treatment should be carried by the traveler. Any traveler taking medications should be advised to carry these medications onboard the aircraft with them. Travelers should have sufficient medications with them for the entire journey. If medications are lost or stolen during travel, these should be replaced with medications of the same type and manufacturer if possible. A physician should be consulted abroad for the relevant prescription. Travelers should carry a copy of their doctor’s letter separately, detailing their medications, which will assist them in obtaining replacement medications. Travelers who require insulin or other injectable drugs should also carry a letter from their doctor explaining why they need to have syringes in their luggage. Ideally this can be summarized on the doctor’sletter covering all these medications. Some countries may have special requirements for the importation of large quantities of medications and relevant embassies should be contacted, if in any doubt.

Can M y Travel Insurance Help M e Find a Doctor? Travelers usually have access to a travel insurance or medical assistance representative, through a 24-hour emergency assistance number usually printed on the travel insurance card, which can advise travelers about finding medical assistance abroad. Apart from travel insurers, there are several possible sources for this information, including travel insurance companies, diplo-

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matic missions, corporate and professional medical networks and emergency medical services,or other sources, such as niajor hotels. Emergency assistance companies may have their own network of clinics. However medical assistance directories of professional organizations, including the Clinic Directory of the International Society of Travel Medicine,12and the Directory of the International Association for Medical Assistance to traveler^,'^ may also be used when advising travelers.

How Quickly Will I Be Flown Out in an Emergency? Aeromedical evacuation is a planned activity, which requires careful assessment and preparation of the patient. A little time spent prior to the evacuation will make the entire procedure much smoother and less prone to complications. Escorts need to be trained health professionals, who are familiar with equipment on aircraft used for aeromedical evacuation. Evacuation may be performed on a conventional commercial flight or on a specially outfitted aircraft, either a fixed wing aircraft or a helicopter. The latter are usually maintained by emergency services (air ambulance), the military, niultinational companies, and also by international travelers’ assistance organizations. Every evacuation should be carehlly considered since they are expensive both in terms of time and resources. International aeroniedical evacuations can cost up to US$50,000 or more. All travelers therefore should take out appropriate travel insurance which covers against this contingency,but should also use common sense to ensure that the need for aeromedical evacuation is kept to a minimum.

Does M y Travel Insurance Cover My Dental Bills? Dental treatment abroad is generally not free and, depending on the procedures required, can be quite expensive. Travel insurance generally provides some coverage against dental expenses incurred while overseas,in addition to other aspects of travel misadventure. However it is important for travelers to check that their travel insurance covers them for dental treatment as far as possible.Dental care does not tend to be as accessible in the public health systems of many developing countries, however private clinics may be found. There may be language barriers that need to be overcome. Before travel, it may be helpful to provide travelers with a recommendation for suitable dental treatment services at their destinations,particularly if they are prone to dental problems. Ideally, this recommendation should be given by their dentist, together with a letter outlining their dental history. If it is likely that dental treatment will be undertaken abroad, then hepatitis B vaccination should be discussed with the traveler. Recommendations concerning

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suitable dentists available for consultation while overseas may be obtained 6-om foreign missions, hotels, private hospitals, and travel medicine centers. In addition, travel insurance and other agencies often provide a service to assist travelers in finding dental care while overseas. A common questions paper on dental precautions for travelers has been published elsewhere.’‘

I’m Working Overseas for Awhile, Will Travel Insurance Cover Me? Employers who have a number of employees traveling abroad on business will often take out a group travel insurance policy. Sindar to credit card’insurance,it is necessary for employees to obtain and peruse the policy documentation for their travel insurance. In some cases, the employer may meet the shortfall in coverage of costs associated with misadventure whilst traveling, however this should be documented to the satisbction of the eniployee. For the business traveler, these costs may include those of a replacement colleague who may have to take on the assignment of the ill or injured worker. Those about to undertake independent consulting work abroad for an employer may not be covered by an employer’s travel or workers’ compensation insurance policy. Prospective consultants should be advised to consider these aspects before finalizing any contract. If the employee is in any doubt concerning coverage, they should be advised to take out appropriate additional travel insurance, whether or not the employer will cover this cost. Travel insurance is normally provided for shortterm travel only and even annual, frequent, or business traveler, travel insurance policies do not necessarily provide continuous coverage, particularly for international travel. Private insurers in the host country may provide longer term medical insurance. It is important for all longterm travelers or workers to be aware of the location of appropriate local medical services, especially those recommended by their employer. Workers, consultants, and other long-term travelers should be advised to determine the availability of aeromedical evacuation in the area they’re traveling to. These travelers should be advised to register with the local embassy or consulate.Workers, consultants,and other long term travelers should give embassy or consulate staff an itinerary and/or contact address.

How Do I Make a Claim? In serious medical cases, travelers are advised, where possible, to contact the travel insurance company as soon as possible. In some cases and in much the same way as is the practice in some major hotels, credit or charge cards may be requested by the medical or dental provider as

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a guarantee of payment, even if the traveler has a valid

travel insurance policy. In this way, credit and charge cards may be useful in medical emergencies occurring during travel. In less serious cases, or where the traveler has been unable to contact the insurer, travelers should be advised to request and keep original accounts, receipts and medical reports for any medical or dental treatment while overseas, in case these expenses can be claimed back from a travel insurance policy, an employer, a national health service, private health insurance fund, or written off against tax. Loss or theft of any medical or dental equipment, as with any of the travelers’ belongings, should be reported to the police, usually within 24 hours.

If I Have a Problem with M y Claim, What Can I Do? In most cases, problems with claims are most likely to be resolved by discussing the problem with an of& cia1 from the insurance company. If the traveler is not satisfied with the outcome, travel insurance companies or insurance industry associations may provide information about dispute resolution procedures in some countries. In Australia, this is provided for by the General Insurance Code of Practice.’ Dispute resolution procedures usually revolve around an internal system for resolving disputed claims in the first instance. An external system may also be available as a Claims Keview Panel, which may be funded by the insurance industry itself, as is the case in Australia, or by government, whose decisions may be binding in most instances. The most expensive option of dispute resolution would be to take the insurance company to court.

Is There Anything Else I Should Know? If travelers are unclear about any aspect of a travel insurance policy, they should be advised to check this with the travel agent or travel insurer. It is often better if this advice is sourced directly from the travel insurer. It is also important to advise travelers that travel insurance should not give them a false sense of security and to take every precaution against illness and injury.

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after travel to developing countries. J Infect Dis 1987; 156:84-91.

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ers’ advice for travelers to Turkey. J R Coll Gen Pract 1989; 39: 148-150.

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12. International Society of Travel Medicine. Clinic Directory. Stone Mountain, GA: ISTM, 1997.

from New Zea1and.J Travel Med 1998; 5:61-64. 6. Hill DK,Behrens R H . A survey of travel clinics throughout the world. J Travel Med 1996; 3:46-51.

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