Ian Youngman looks at the new products hitting the insurance market

 

Malpractice

Let us first dispense with a popular myth peddled by those keen to discourage medical travel, particularly from Western European countries, the United States and Canada, which is that you shouldn’t go abroad for treatment because the legal protection you may have at home will not be available in another country. This is in fact based on truth. In most countries, the concept of medical malpractice is not understood, let alone insured. On the other hand, US and UK patients don’t have great recourse at home when things go wrong either, despite headlines encouraging that misconception every time a high profile, and high value case occurs. In general, cases take several years to go to court and plaintiffs usually lose, unlike in other personal injury cases. The ability of a patient to sue a medical institution successfully is practically non-existent.

Problems generally arise when US agencies assist their clients in organising treatment abroad. There is no doubt that US agencies are more at risk than their foreign counterparts, as an American who feels they have suffered malpractice is more likely to succeed in suing a US agency in a US court, than trying their luck in India for instance, or Bulgaria. Agencies claim they are protected by terms and conditions but they are in the same position as travel agents, and there are many examples of successful claims against them. As a result, most travel agents have professional indemnity insurance, which in some countries is a legal requirement. There are no such requirements for medical travel agents despite the fact that for many, being taken to court is not a question of if, but when. And as every agency is acutely aware, even if a claim against them fails, the costs of a legal defence can be enormous.

Costs overrun

Although high profile US medical travel agencies have claimed that they will soon offer malpractice insurance products, they have been beaten to it by an insurer offering a product direct to the public. Barbados based AOS Assurance has launched Patient Medical Malpractice Insurance (PMMI). Unlike conventional malpractice insurance, it is not bought by the hospital. Individuals can buy it direct from the insurer and a group version has been developed for employers. Those concerned about the location and name can take comfort in the insurer being managed by top multinational broker Aon. Although targeted at US citizens, it is available worldwide.

This unique insurance is aimed at individuals wanting to protect themselves should medical malpractice occur while seeking healthcare services in a foreign country. It covers elective and non-elective procedures. It is not available for those being treated in their home country.

Like traditional travel insurance, the patient buys ‘first person’ insurance before travelling for the medical or surgical procedure. Should medical malpractice occur abroad, the claim is handled in accordance to the patient’s own home country standards and claims are paid in US currency. There are no lawyers or lawsuits involved and claims are said to be settled 80 per cent faster than the traditional litigation environment.

The industry alleges, though has never proved, that many individuals do not choose foreign medical travel because they fear that if medical malpractice occurs abroad, there is little recourse available to the patient in a foreign country. This is an important development that will provide necessary insurance, not presently available anywhere else in the world, for medical travellers.

The insurer will only cover JCI approved hospitals and the premium depends on the procedure and amount of cover selected. The customer can choose to insure for between $100,000 and $1 million. For cover of $1 million, the premium for an angioplasty operation would be £573.75, or for breast augmentation $225.

This is not a policy that allows customers to sue hospitals, neither is it a protection for hospitals. Customers cannot make wild allegations, as all claims are subject to rigorous checks, including needing written proof of loss. What the insurance does cover is damages for wage loss, cost of repair, out of pocket expenses, rehabilitation, disfigurement, loss of reproductive capacity and death.

There is an insurance on offer outside the US called ‘cost overrun cover’. In general, quotes for treatment are based on average length of stay. If complications arise, most but not all hospitals, will bear the extra costs themselves. What they will not cover is the extra travel, the hotel costs of the patient and other people travelling with them. This policy would cover such an eventuality, but among hundreds of medical travel agencies only a tiny handful offer cost overrun insurance.

Direct Healthcare International's Surgery Protection Insurance is one such agency. They offer optional insurance which covers cost overruns resulting from unexpected overstays in hospitals which are beyond the control of the patient. This includes physiotherapy, travel and hotel bills for a relative. In South Africa, Surgeon and Safari offers BeautySure Cosmetic Surgery Insurance to insure against unexpected costs up to a defined limit. The premium is dependentupon the cost of the surgical procedure, Body Mass Index (BMI) and whether you are a smoker. BeautySure is underwritten by New National Assurance Company Limited.

Travel

Travel insurance can be a worrying problem. An increasing number of agencies recommend patients take out travel insurance. Some even offer to arrange cover. The position of most US, UK and European insurers seems to be that they wish medical travel would go away and they have reacted by adding a policy exclusion on going abroad for any kind of treatment. On a few travel policies the exclusion only applies to the medical expenses and cancellation covers, so you can be covered for baggage and money sections, but still charged the full price as if cover applied to the exclude sections - making the policy very poor value. Travel insurance is not aimed at medical travellers, and restrictions such as exclusions on pre-existing conditions, cosmetic surgery and dentistry, means that there is no cover under the policy. Yet few insurance, travel or medical agents point this out.

In insurance terms, whether someone is going overseas for treatment is a material fact and if not disclosed when applying for a policy, could invalidate any claim. Those who are honest and say why they are going abroad, may assume they have full cover, when they have not, simply because nobody tells them otherwise. When pressed as to why the insurance industry was ignoring a huge new sector, US insurance bodies said it was a matter for insurers, while UK trade association ABI, waffled and wiggled, suggesting that insurers would pay for baggage cover but not cancellation, medical expenses or other sections. Only the quiet settling of claims that were excluded and blind luck has so far pre-empted the sort of media outcry that arose against travel insurers refusing cover for (or asking for exorbitant premiums from) travellers unfortunate enough to be old or to have a medical condition.

Travel insurance policies for medical travellers were briefly introduced in the UK, but once underwriters realized the size of the industry, they panicked and withdrew cover. Yet there is an urgent need for specialist travel policies for medical travellers. They would never cover every risk connected to the treatment, but there is no reason why other sectors cannot be covered. It can be argued that medical travellers are a better risk than most, as they are travelling to a location where they will get medical care and rest. (The corollary to this is that while you would insure a car, you wouldn’t insure it specifically for a trip into a garage.) What is needed are brave underwriters and marketers who will offer travel cover to medical travellers. UK insurer, Bupa, is planning on looking at the market, but not until 2009. In the US, United Group Programs says it will soon launch travel cover that includes medical travel.

International and expatriate insurances

Some medical travel websites suggest that many international insurance companies will cover medical travel. This is wrong. International insurance policies for expatriates cover the insured either for a specific country, a select range of countries, or worldwide. These policies are designed to cover people from one country who are working in another country or living there as an expatriate. Most cover treatment in the person’s country of residence, treatment elsewhere, if that is a better medical solution, emergency treatment almost anywhere and repatriation to their home country. When these policies were designed the phenomenon of medical travel was unknown. There is a huge difference between covering unexpected treatment overseas and covering deliberately sought treatment. (For example, a liver transplant in Asia when you are an expat in Europe but originally from the US) Policies that appear to give the option of treatment in any country often exclude cosmetic, dental and most elective treatments. Policies also often limit treatment to approved overseas hospitals.

Peter Rousseau, business development director of specialist international insurer InterGlobal says, “Policies are not designed to cover medical travellers. Where an expatriate is overseas, they may want or need to get treatment in a country other than where they live. Many policies will not allow this. If they have to travel to another country as they can only get treatment overseas, then we will pay for the costs of travel and treatment. Unlike most, we have no restrictions on which hospital they can use. Also if a customer chooses to go to another country for treatment then it is almost inevitable that the cost will be lower, so it makes sense for us to pay those costs, even though the customer then has to pay their own travel costs. Most competitors will not cover either travel cost”.

Private medical insurance

In the UK, USA and Europe, standard private medical insurance bought by individuals only covers treatment in the country where the customer lives. Worldwide cover is an illusion, as it is restricted to emergency treatment only. Insurers show no inclination to extend policies to cover wider overseas treatment. A minority of UK dental insurance policies allow non-emergency treatment in other countries. Some UK medical insurers will grant requests for overseas treatment, but they will not pay travel costs and exclude what most UK travellers go overseas for which is namely cosmetic surgery, fertility treatment and dentistry. One of the few policies which does allow customers to get treatment anywhere in the world only covers listed treatments, few of which are the sort of thing that people go overseas for.

Some insurers will allow limited overseas treatment. A Bupa spokesperson explains: "Sometimes Bupa customers will seek treatment abroad where it is not available in the UK. In these cases we meet the equivalent UK costs of the treatment.” In the UK almost all medical procedures are available privately, so the extension is less generous than it sounds.

Vivas Health is the only Irish health insurance provider that will cover overseas treatment for the equivalent amount that they would have been covered had they received the treatment in Ireland. Although this applies to personal and corporate policies, it does not pay travel costs.

Increasingly popular in the US are health plans and mini-med plans. Consumer directed health plans seem to fit well with medical travel, but even at low prices, medical and travel costs can quickly erode any tax benefit. Mini-medical plans which are designed only to cover major medical expenses may be a better fit, but high excesses take away a lot of the advantages of going overseas.

Health insurers and employers have started to ask how medical travel can fit in with insurance, but there are many obstacles. Hospitals and agencies seem puzzled why insurers and businesses do not rush to them, but the countries and clinics popular with self-pay individuals may not be right for corporate cover. For them, proximity, local infrastructure, quality and capacity may be more important considerations. Making overseas treatment compulsory for all employees or customers would be the only way massive savings would be possible, yet an employer or insurer can only encourage the use of overseas providers, they cannot compel. As savings would go to the employer or insurer, even voluntary travel will be met with suspicion and questions as to why the individual should agree. The consensus is that the individual must share some of the benefits such as extra pay for vacation time which they can enjoy overseas. If a patient died or had complications, lawyers would sue the employer and insurer in the US, as chances of success would be much higher than suing a hospital overseas. US tax authority IRS could also tax any incentives, financial or in-kind.

On corporate insurance, a vital aspect will be quality control. Insurers are only prepared to work with internationally accredited hospitals. There are increasing signs that US insurers and employers will limit approval to JCI accredited hospitals. As most insurers use an approved provider network at home, logic dictates that this would simply be expanded to an international one. Aetna Global Benefits provide health benefits for the employees of US companies who live and work overseas, maintaining relationships with a community of hospitals (700 facilities in over 100 countries), and thereby establishing relationships with a number of international hospital facilities accredited by JCI.

Aetna confirms that unless specifically excluded in the plan design, and provided that the plan offers out-of-network benefits, and the procedure is a covered medical benefit under the individual’s plan, elective surgical procedures performed overseas are eligible for coverage. This is fine for larger businesses, but most smaller businesses and individuals would not have out of network benefits overseas.

Ann Dougan, marketing director of CIGNA HealthCare (European arm of US health insurance giant CIGNA) says, “We need to explore additional claims. Cost control measures and utilising a network of hospitals outside of the UK may be one solution. We would need to ensure that we could negotiate appropriate rates with overseas providers. As CIGNA is a global healthcare provider we’re in a good position to explore international networks such as those already utilised by our expatriate healthcare scheme. In terms of the future, we can’t rule out overseas treatment settings for UK healthcare plan members, as long as we can find the right way to balance patient care against healthcare scheme costs”.

A spokesperson for Aetna in the US says, “Medical travel may be one option to control medical costs for certain employers and Aetna is willing to explore that with them.  We believe certain accredited overseas facilities may become an attractive option. Our position is one of cautious exploration. We will follow the lead of the JCI and assess the medical management requirements necessary to ensure there is a seamless coordination of care between physicians in the US and those treating our members overseas”.

Insurers from the US and Europe are touring Asia to talk to major hospital groups. Most meetings are kept secret but Wockhardt Hospitals at Mumbai and Bangalore have confirmed visits to check out the processes followed, infrastructure and key clinicians. Pradeep Thukral, head of International Marketing at Wockhardt Hospitals says, “Some insurance companies are soon going to allow their beneficiaries to get reimbursement for cost of treatment at approved Indian hospitals against their local cover, which will save the beneficiaries the co-payment costs. Also these insurance companies are looking at launching differentiated products where for specific procedures it would be mandated from the beginning that the patient would be sent overseas for surgery. We are also getting a number of queries from employers in the US who are planning to send their employees for surgery abroad to reduce medical costs and may in future offer incentives to their employees for agreeing to go abroad for treatment”. So far it is all talk and no action.

Jonathan Edelheit of United Group Programs argues that although medical travel is a real solution for the US healthcare crisis, insurers are not going to rush forward.   “Insurance companies in the US have no incentive to send people overseas. They would alienate their US based PPO networks, who have given the US insurers deep discounts. These PPO network providers will backlash and insurers cannot afford to lose them. Insurers cannot give any real incentive to most insured US citizens to go overseas. If you are US insured and have a $500 deductible, why spend $1,000-$2,000 on an airfare, then pay for a hotel overseas when your local hospital will only cost you $500? International hospitals are excited and speaking to major US insurers, but they don't realise the average American has no incentive if they have a major medical policy with low deductibles and low out of pocket expenses.”

Many agencies and hospitals are keen to get a slice of insured and employer paid business. Big business likes to deal with big business. So we will see international UK, US and European insurers dealing with the larger international hospitals. Many already have a business connection on emergency treatment for travellers and expatriates. The noise from medical travel agencies is that they will be part of such deals. The reality is that, on group business, hospitals and insurers will either cut them out completely or relegate them to subcontractors providing travel services.

Even the biggest agencies are small fish, with no experience of cutthroat negotiation with big insurer sharks. In many countries travel agents and tour operators are regulated by strict requirements on bonding and special professional liability cover. Few medical travel agents have either, but as many arrange travel and accommodation, as well as medical procedures, regulators could soon argue that they too should be regulated. The lack of regulation, absence of bonds and professional indemnity insurance and general newness is why many insurers prefer dealing with established regulated travel agencies

New ideas

United Group Programs is not an insurer but an administrator of self-funded medical plans. Jonathan Edelheit explains what they are doing: “We have two plans where we will assign benefits to specific JCI accredited hospitals. One for clients enrolled in our mini-medical/limited medical plans, which are low cost health care. The other is for employers who have self-funded major medical plans.  We believe everyone should be given an option to go overseas.”

Blue Cross/Blue Shield of California are pioneering medical travel for members of such plans across the US. After discussions with medical travel agencies, the insurer felt it better to ignore them, set up its own medical travel subsidiary Companion Global Healthcare and use experienced travel agent World Access for travel services. The aim is to set up a network of approved international hospitals. At present the only one used by BlueCross/BlueShield of South Carolina and BlueChoice HealthPlan of South Carolina is Bumrungrad International Hospital. To overcome the problem of continuing care when returned home, the company offers patients a pre-paid aftercare package at Doctors Care facilities in the US.

In California, Salud con Health Net - a range of products from Health Net of California - provides access to affordable, quality health care for Latinos and their families in California and across the border in Mexico, both for individuals and HMOs.

Will tomorrow ever come?

Agencies and outsourcers around the globe are actively marketing the idea of overseas treatment to businesses, either self-insured or insured. So far there is more talk than action. There is a gap in the market for some kind of insurance product that would allow you to have acute medical treatment in the US and at the same time, have the more expensive procedures carried out abroad. Ultimately a more complete product could also offer an insurance to get a ticket back to where surgery took place should complications occur.

Many hospitals and agencies have been talking up the potential of insured medical travel, seeing it as a big potential earner. Many comments from these sources have been doing the rounds of websites, magazines and other media for the last three years. Announcements of major deals are always 'soon'. There is no rush for health insurers or employers to offer medical travel. There are many problems of accreditation, control, employee persuasion and taxation for insurers to solve. There are suggestions that European insurers, not so encumbered with malpractice concerns, are quietly doing deals with Asian hospitals to send existing customers there, but not looking to promote the concept or offer special policies.

Wherever they are based, insurers will do direct deals with large accredited hospitals, ignoring small clinics and medical travel agencies. Alternative and specialist health plans and insurers will fill some gaps with innovation. But the overwhelming majority of medical travel business will remain self-pay.

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McKinsey's got it wrong

Articles, 26 May, 2009

A recent report on the industry makes some serious errors

Will the boss pick up the bill?

Articles, 26 May, 2009

Can businesses insurers break into the medical tourism market

The hottest American destinations

Articles, 15 May, 2009

One country serves travelling American medical care more than any other. America

Where do Americans go abroad?

Articles, 12 May, 2009

Just as we don't know how many Americans travel for care, we have no figures as to where

How many American medical tourists?

Articles, 10 May, 2009

There are wide variations in the American medical tourist estimates. We examine a few

Americans travelling abroad for care

Articles, 10 May, 2009

Do we have any idea how many Americans would travel abroad for treatment?

Delivering destinations

Articles, 28 April, 2009

Not every government is active in attracting medical travellers

Offering a premium service

Articles, 10 September, 2008

IMTJ looks at the new insurance products coming to market

South Korea: medical tourism report

Articles, 01 June, 2008

Ian Youngman is producing a new set of country specific reports, first up, South Korea

Truth in statistics

Articles, 01 June, 2008

Ian Youngman talks on his work: Medical Tourism 2008: the World-wide Business Guide

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