Infections, injections and insurance exemptions
With increased global mobility has come the increased spread of infectious diseases. Tatum Anderson evaluates what travel insurers can do to ensure their clients are educated about the potential and real health risks inherent in their intended destinations, and to check that policyholders are taking the necessary precautions to ensure their travels are healthy
With increased global mobility has come the increased spread of infectious diseases. Tatum Anderson evaluates what travel insurers can do to ensure their clients are educated about the potential and real health risks inherent in their intended destinations, and to check that policyholders are taking the necessary precautions to ensure their travels are healthy
In February 2003, a doctor from southern China who had been treating patients with an unrecognised respiratory illness travelled to a family wedding in Hong Kong. His journey ended up killing 774 people in 29 countries. Unwittingly, he had spread SARS to 10 other travellers staying in the same hotel. They boarded airplanes to other parts of Asia, North America, and Europe, spreading the disease to over 8,000 people.
The threat of another pandemic is ever present. Take Middle East respiratory syndrome coronavirus (MERS-CoV), which was first reported in 2012 and has affected 136 people in nine countries to date, with 58 fatalities. But the disease has no known origin.
As recently as April this year, the World Health Organization (WHO) announced that another avian influenza A (H7N9), a type of flu usually seen in birds, had been found in a number of people in China. It is the first time this virus has been seen in people and the new virus has resulted in severe respiratory illness and, in some cases, death.
As such, the world takes seriously the surveillance of new and previously unknown diseases. They are particularly mindful of the fact that travelling can exacerbate outbreaks. Indeed, travellers have been at the centre of infectious diseases outbreaks for centuries. From plagues during the Middle Ages that swept Europe and Asia, to the movement of smallpox to the Americas by European explorers (while the explorers brought syphilis back to Europe). Today, air travel helps things move a lot faster. Given that more than 900 million international journeys are taken every year, it’s obvious that global travel on this scale exposes many people to a range of health risks. Needless to say, this threat is of paramount importance to travel insurers.
Modern traffic routes
A type of influenza A (H1N1) that caused the first pandemic of the 21st Century was aided by travellers. Air traffic patterns revealed a very strong correlation between the volume of air travel from Mexico to other countries, where the disease was eventually identified in the early stages of the pandemic. Two months later, the WHO officially designated the disease as a pandemic.
That’s why some travel insurers exclude medical cover for people who travel to areas that are known to be rife with particular infectious diseases. Greg Lawson, head of retail for UK-based Columbus Direct, explains that that most, if not all, policies will carry a general exclusion about travelling to countries or regions where the Foreign and Commonwealth Office (FCO) has issued a recommendation that travel should be restricted for health, safety and security reasons. They may also do the same when the WHO issues travel restrictions too.
He says: “Where an outbreak is widely reported, then insurers will log when the advice not to travel to those regions/countries was first given and how long those travel restrictions are in place and any claims, regardless of whether it is related to the infectious disease, could be declined.”
The FCO and WHO release information regularly on the emergence of infectious diseases, and issue recommendations for travel restrictions. How insurers underwrite policies to cover travellers when advice is more nuanced is far more complex. For instance, authorities may not advise that travel be suspended completely, but they might recommend that authorities screen incoming visitors at airports, or that travellers use particular vaccines or prophylaxis before they travel to the area. The ability of a customer to make an eligible claim on their travel policy could be dependent on whether or not they followed the advice about obtaining a vaccine or taking anti-malaria pills, for example.
Risky business
There are also plenty of diseases that do not cause pandemics, but are still very risky to travellers (and those living within the country). Dr Hervé Raffin, CEO of France-based Medic’Air, which manages medical cases and flies patients on commercial and air ambulance flights, says dengue fever and malaria are posing particular risks at the moment. He explained: “Dengue because the number of cases is increasing, malaria because the diagnosis is more difficult.” He also sees drug-resistant tuberculosis and viruses that include Lassa, Marburg, Ebola and hantavirus as major potential threats, which are also highly contagious for medical teams who do not have specific training and equipment.
In addition, some travellers might visit areas that increase the likelihood that they could contract particular diseases. They might visit live poultry markets, for instance, or bat caves – several highly fatal diseases have been linked to bats, including rabies and histoplasmosis.
Some insurers say there are no specific exclusions for situations like this because they would be quite tricky to assess, according to Stephen Howard of Infinity Insurance Solutions, who said: “This would be impossible for an insurer to monitor, especially on backpacker/gap year policies where the traveller is visiting many different places. It would be almost impossible for travel insurers to be able to monitor infectious diseases around the world.” That said, most policies will contain some small print on general exclusions related to exposure to needless risk. Insurers might therefore look to apply this exclusion if they felt the customer had been aware there was a possibility of becoming infected and had acted recklessly. It makes sense that policies take into account the fact that travellers might embark on their journeys without taking the proper precautions. Unlike coronavirus and avian fl u, which have no known vaccines, there are plenty of diseases for which there are appropriate vaccines and prophylaxis. Of course, before travellers can enter some countries, there must be proof of inoculation in order to obtain a visa and so gain entry to the country. That is true of yellow fever, for instance. Entrance to countries such as Tanzania is impossible without a certificate. But there are no checks for whether or not a traveller is carrying malaria tablets.
Howard says: “If the customer has failed to take the relevant precautions that have been publicised, then the insurer could exclude cover for any claims arising out of a medical condition contracted by this failure.” Greg Lawson of Columbus Direct says not all policies detail the health precautions that a traveller must take in order for their coverage to be valid, but pointed out that they probably should. He says: “If they [insurance policies] don’t currently [stipulate that a vaccine must be taken], it is more likely to be due to oversight than a conscious decision to provide cover even when vaccinations have not been taken.”
This gap in insurance cover is perhaps surprising, given that so many tourists do not take the appropriate prophylaxis. Travel medicine experts say this is a particular problem with diseases such as malaria. There is no vaccine for this killer disease, which is endemic in many parts of Africa and Asia, but there is prophylaxis in the form of tablets. Despite this, the International Association for Medical Assistance to Travellers (IAMAT) says it regularly comes across travellers that take advantage of last-minute travel deals and head off on holiday without proper medication. Some travellers also say the cost of anti-malarial medication and travel health consultations can be prohibitive. The UK National Travel Health Network and Centre (NaTHNaC) says many travellers who are visiting friends and family in malaria endemic areas believe they are still immune to malaria because they lived in the region or had it as a child. Other travellers prefer to take natural remedies that are not scientifi cally proven to prevent malaria.
Usually, however, the excuse offered by travellers is that they do not have the time to research if malaria is a risk at their destination, or can’t book a doctor or travel health clinic appointment in time. Indeed John Widdrington, specialist registrar in infectious diseases at the UK’s James Cook University Hospital, drew attention to a cluster of cases of imported malaria in travellers returning from the Gambia in December 2010 in the British Medical Journal. He said: “The use of Internet websites to make late holiday bookings is increasingly common and can make organisation of medical advice and malaria chemoprophylaxis more diffi cult.” Widdrington and his colleagues recommended more information about malaria prophylaxis on travel booking websites.
A question of responsibility
But some travel medicine experts believe the travel insurance industry should include more information within policies too. Dr Charlie Easmon, medical director of Your Excellent Health Service, and a travel medicine expert, says insurers are particularly lax in covering travellers under different circumstances. He believes they should give clear protective advice within policies, because if it were readily available, more travellers would take the correct precautions and be less likely to require medical attention. He says: “Some of us think if they did [include preventive information and advice in policies] it would increase compliance. A signifi cant percentage of people do not get vaccinated or if going to malaria areas, do not get the prophylaxis and advice that they need.” While some insurers have suggested that it is too diffi cult for travel insurance companies to keep track of diseases everywhere, Easmon is of the opinion that industry meetings such as the International Travel and Health Insurance Conference (ITIC) are extremely helpful for those wanting to gather information on what’s going on with different diseases around the world.
Similarly, travel insurers could get far more information about diseases that might affect travellers if they chose the right sources of information, suggests Dr Dipti Patel, joint director of NaTHNaC. This agency issues alerts on outbreaks that specifi cally apply to travellers from the UK, although there are equivalent services in other countries, including the US, such as the Centers for Disease Control and Prevention’s travel health alerts.
The NaTHNaC alerts differ from the WHO recommendations, explains Patel, because they look solely at risks to travellers. The WHO is good at surveillance of outbreaks, she says, but its alerts are largely aimed at a wider audience that include doctors, politicians and national authorities that are worried about diseases coming in through their borders. She added: “There is a lot of information out there and a lot of sites just report outbreaks, but what we do is produce context for it,” she says. “We are analysing whether this is a significant risk for travellers and we don’t act on unverified sources.” This approach means that the organisation can decide more accurately the risks of a disease that has relatively few cases but in popular tourist areas, compared with an endemic outbreak in areas that travellers rarely travel to.
For instance, the polio virus has been discovered recently in Somalia, and in Israel’s sewage system. Both are a cause for concern amongst national authorities, but context is everything when it comes to travellers, says Patel. That’s because Israel is a popular summer stopover for long-stay travellers, who head for the beaches or a kibbutz experience while on a global backpacking tour. In contrast, Somalia is not a popular area for travellers, but outbreaks there are still relevant to travellers because of the countries surrounding it: “It’s important to know because it’s near the Kenya,” she explains, “but we wouldn’t issue lots of reports on it.”
NaTNHaC says most of this information is consumed by travellers and doctors, but says it is surprised by the lack of interest from the travel insurance industry. “We have a few insurers in our stakeholder group, but we don’t have an overarching body that we work with,” she says.
There may, however, be a limit on just how much policies can reflect the true risks to travellers. One of the world’s most pre-eminent infectious disease specialists, Professor David L. Heymann, chair of the UK Health Protection Agency, and Head of the Centre on Global Health Security at Chatham House, says it can get rather complicated to state exactly what the most important risks are because travellers go to different places for different reasons. Those going abroad for sex tourism are more at risk of penicillin resistance – gonorrhoea or HIV, for instance. Travellers are more likely to contract diarrhoeal diseases if they intend to sample lots of street food in certain countries. “It really depends on what they do and where they go and the specific pathogens where they are going,” he says. “You can’t just say what the most important risks are. It depends on where the person is going.”
Keep it real
It’s certainly a mammoth task to expect travel insurers to know about every outbreak that could potentially affect a traveller’s health, but it could be argued that perhaps the industry could take more notice of the sources of information that are out there, and engage more with organisations such as NaTHNaC to better inform their policyholders about the risks of travelling to a certain place. Just as an example, it recently released health information sheets with advice for Hajj and Umrah travellers that detail the vaccinations required and current health concerns in the region, such as MERS-CoV. Insurers selling policies to pilgrims could very easily point their clients in the direction of NaTHNaC’s website by linking to it from their own online portal.
As an industry, it is recognised that the vast majority of people do not read their travel insurance policies, so including a requirement that stipulates a person must take the necessary vaccinations and/or prophylaxis or their claim will be rejected could easily land the insurer in hot water with the ombudsman. While the travel and health insurance industry would say it is reckless for a traveller to go to, say, East Africa without malaria medication, for the general public, many would not even consider the fact that their policy might be void if they don’t head official pre-travel advice. When it comes to treating customers fairly, the ombudsman has shown, on more than one occasion, to err on the side of what ‘a reasonable person’ would consider fair, not what the industry considers to be fair. The defence of ‘it was clearly stated in the policy wording’ sometimes isn’t sufficient to defend claim rejections in the eyes of the ombudsman. The industry must balance its right to reject claims from reckless travellers with a realistic approach to giving them as much information as possible that will enable the client to look after themselves better.