Travel risks, insurance and the older patient

More and more older people are travelling abroad each year and many are going to exotic and far distant venues. They dominate the cruise market and venture to parts of the world where health hazards are high and care facilities are limited¹. However, older people are at high risk of trauma or ill health while abroad² making the need for travel insurance essential.

International travel without health insurance protection is foolhardy and may be life threatening. Yet many older people, in ignorance of the potential risks, globe trot without an insurance package. Also a high number purchase inadequate cover, fail to read the small print in the policy or void the policy by concealing current infirmity. This then means that the adverse impact of a health emergency while the traveller is abroad, especially in developing countries and remote places, may have more dire and immediate consequences than exposure to infection.

Role of healthcare practitioners in travel plans

In the UK, nurses and doctors are prominent in pre-travel healthcare³ and health professionals can play a role by discussing with patients their travel health insurance needs before they venture abroad and remind them of the pitfalls of restrictions and exclusions that may negate their policy. Although a number of doctors will not perceive it within their role to advise on travel health insurance, this advice may prove to be of greater health benefit to the ill or injured traveller than any recommendations on vaccines and prophylaxis.

Once fitness for travel has been determined, the health practitioner could draw attention to the need for adequate insurance. Highlighting policy details such as:

Emergency aid
Evacuation to hospital
Treatment
Repatriation
The need to read the policy small print to check for exclusions
Terms for pre-existing illness.

Good health insurance protection is imperative for this age group but restrictions on cover and the recent withdrawal of current E111 provisions can make the organisation of emergency aid a demanding exercise (see Table 1). Most people over 65 years now find they have to submit to a lengthy scrutiny of previous and current health status and medications before a policy can be purchased and that it includes certain exclusions.

Also, the number of insurers catering for elderly people has fallen dramatically. An online search a year ago would have provided many sources but few are now displayed and they prove selective (Table 2). As a result, some elderly travellers may now find that they cannot find adequate insurance cover or can only do so at considerable added cost. In addition, annual cover has been largely withdrawn for the very old. More than one in four of the annual policies examined in a recent survey by Help the Aged will not cover the 9.4 million people in the UK aged 65 years and over. For people aged over 75 years the situation is even worse, with almost 70 per cent of policies refusing cover to this age group.

Also, patients who have travelled extensively despite past history of cancer and major cardiac problems now could find themselves with a swinging premium loading, if they can acquire protection at all.

Table 1. Changes to E111 entitlement

From this month the old E111 forms will no longer be valid. Instead travellers need to apply for a new European Health Insurance Card (EHIC), which entitles them to reduced-cost, sometimes free, medical treatment that becomes necessary while in a European Economic Area (EEA).

It is normally valid for three to five years and covers any medical treatment that becomes necessary during a trip, because of either illness or an accident. It only gives access to state-provided medical treatment but this might not cover all the things patients would expect to get free of charge from the NHS in the UK. The EHIC also covers any treatment needed for a chronic disease or pre-existing illness. Travellers are still advised to take out comprehensive private insurance for visits to all countries, regardless of whether they are covered by the EHIC.

Pre-existing conditions and exclusions

An insurance company is entitled to refuse a claim for any pre-existing condition, but a number of previously declared medical conditions can be accepted with an extra premium. Some illnesses though, such as heart disease or cancer, are likely to be excluded from standard policies. If someone fails to declare a pre-existing condition and then has a claim linked to that condition then the insurance company is unlikely to reimburse this claim. Even if the claim is not linked to the condition, some insurers may still refuse it on the grounds of not having a full opportunity to assess the risk. They might have produced a contract with different terms if they had known about the condition.

The insured must also advise the insurer if health changes occur prior to departure as this could impact on cover provided. In addition, few people realise that inebriation at the time of medical mishap may also negate a later insurance claim.

Estimates suggest that four million Britons go overseas without insurance in a typical year and few people arrange cover for trips of less than five days. Some likely costs for treatment abroad are listed below4:

A holidaymaker who suffers a heart attack in Greece could face hospital bills of £6,000 to £7,000
Repatriation by air ambulance from Spain could cost £10,000
In the US, treatment for an arm fracture can cost towards £4,000
Some clinics, particularly in the US, will only perform operations if they are sure a patient is insured, or can meet the bill

Repatriation by air ambulance from Florida to Britain, costs about £30,000 with a similar fee for heart surgery there.

The Association of British Insurers urges travellers to carry insurance documents at all times, so that doctors treating them will know they are insured. The Foreign Office has also warned holidaymakers to be better prepared when taking breaks abroad. They also recommend carrying proof of insurance cover with emergency contact and medical assistance numbers for insurance companies.

Table 2. Travel insurance for the older patient

Some insurance companies currently do not have age limits but premiums go up with age.

Annual worldwide policies:

Age Concern 0845 601 2234, www.ageconcern.co.uk
Help the Aged 0800 413 180, www.helptheaged.org.uk
American Express 0845 028 7573, www.americanexpress.co.uk
Saga Insurance 0800 056 5464, www.saga.co.uk.

Worldwide, single-trip policies:

Churchill 0800 026 4050, www.churchill.com
Marks & Spencer 0800 068 3918, www.marksandspencer.com
The Post Office 0800 169 9999, www.postoffice.co.uk
RIAS 0800 552 100, www.rias.co.uk
Trailfinders 0845 050 5868, www.trailfinders.com.

Case studies

Case one

A 70 year old man was recently repatriated from a Turkish tourist resort. He had developed chest pain 17 days previously and was hospitalised. While in hospital, he was submitted to angiography and this was followed by triple by-pass surgery. His travel insurance enabled him to benefit from prompt insurance company attention, immediate medical and surgical intervention and speedy repatriation with a medical escort. A similarly aged patient in the next bed had been admitted at the same time with an almost identical history. However, he had failed to purchase emergency protection and wrongly assumed reciprocal EU arrangements existed for emergency medical and nursing support. This patient had electrocardiography, which had shown myocardial infarction and a consultant confirmed the need for cardiac surgery. However, this was too expensive for him to consider. Denied access to a flight by the airline, he was contemplating a long road and rail transfer back to the UK to join the local waiting list for surgical intervention.

Case two

An elderly gentleman had a myocardial infarction on a ship cruising off Greenland and had to be helicoptered to hospital in mainland Europe. The bill was expected to be £30,000 and he left behind a disabled wife who had to be disembarked at the first port of call and flown home at additional cost. The insurance covered his care but not his wife’s care.

Case three

A woman tourist collapsed at the entrance to the Oregon State Legislative building in the US. An on-looker phoned the emergency service and a fire-truck arrived within minutes. The paramedic crew ascertained she was still living, their second check was to seek and find her insurance document. She was promptly placed on a trolley and sped off to a private unit, examined and warded within an hour. In the absence of insurance she would have been taken to the local state hospital with a very lengthy wait for attention with admission likely to be problematic.

Conclusion

Elderly people indulging in international travel should give as much consideration to the acquisition of adequate and appropriate private insurance protection as they do to holiday location, accommodation and travel arrangements.

Dr Ian McIntosh, GP

References

McIntosh I. Sea Travel in the Elderly. Chapter 6. Travel and Health; Quay Books. Mark Allan Pub 1992. Dinton Somerset
McIntosh I. Travellers at Risk. Chapter 11. Travellers Health Ed. R. Dawood 2002 Oxford Univ. Press
McIntosh I. Editorial. Brit Travel Health Assoc 2002; 5
McIntosh I. Ensure travellers insure for emergency travel health care. Travelwise 2005; 22: 6

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