A level playing field

ITIJ 200, September 2017
Are European and British insurers offering very different travel insurance products when it comes to limits and exclusions on private healthcare?
Last month in ITIJ, we covered the story of British travellers with insurance who expect their cover to provide treatment in private hospitals in Europe. However, there are many variations within travel insurance policies, one of which is that some – many, in fact – exclude treatment for private healthcare. The Allianza de Sanidad Privada de Espana (ASPE) – Alliance for Private Healthcare in Spain – alleges that these exclusions are only seen in British travel insurance policies. ITIJ contacted several different insurance companies from around Europe to see what the consensus was.
European viewpoint
Dea Banse, head of brand communication and press office for Germany-based Europäische Reiseversicherung AG (ERV), told ITIJ: “As a matter of principle, our clients are at liberty to select any hospital abroad. However, in the event of the price-performance ratio being disproportionate, ERV reserves the right to draw attention to the obligation of mitigating any loss and, in the interest of the community of policyholders, to work towards the situation in which the prices do not exceed the bounds of what is customary.” 
So German customers of ERV can opt to attend the hospital of their choosing – within reasonable bounds. However, ERV has a UK arm, and the policies sold in the UK do contain an exclusion for private healthcare in Europe. ITIJ checked the standard leisure policy details and found that private healthcare is specifically excluded, unless first approved by the assistance company. So why the difference? Sabine Muth of ERV in Germany said: “Mostly there are calculatory and regulatory differences between country policies, as in this case between Germany and UK.”
Onwards to the Netherlands, where Charles Koks, network manager for ANWB Assistance, said that while there are no insurers it represents that would deny life-saving treatment for a patient in a private hospital, patients are moved to public facilities where possible once they are stable, and if a client calls the assistance company before heading to hospital, they will be directed towards a public institution.
Is it fair on patients to make them sign paperwork when they are ill/injured and in need of urgent medical care
The exclusions in British travel insurance policies have been put in place primarily as a cost control measure, so customers are not overcharged for treatment that they could have received for free or at a much lower cost in a public hospital. Koks agreed that charges seen in some private facilities are in excess of what is usual and customary: “Some hospitals are charging twice or triple the price for the same treatment in the Netherlands. We have placed these private hospitals on a blacklist. My opinion is that the EHIC is a perfect system and we steer on this document, our insurers expect us to do so as well.”
For Spanish patients on holiday in other European countries, Lola Martinez of Intermundial Seguros confirmed that the company’s insurance policies do not contain any exclusions related to private hospital care. “We always choose the most convenient hospital or medical centre according to our client’s situation,” she explained. “If the hospital where our client has been referred recommends him/her a treatment which is higher than the maximum limit of his/her travel insurance policy, the client will decide if they want to remain in that hospital (in that case, we only pay the amount included in the policy and the client will pay the rest) or want to be moved to another one cheaper (when possible).”
It seems that while British insurers are the only ones currently writing specific exclusions for private healthcare into their travel insurance policies, there is a general agreement that if a hospital is thought to be charging excessively for the services provided, the patient will be moved to a suitable public facility. Alternatively, cost containment measures such as negotiating discounts and appropriate examination of the bills will take place.
Cost recovery
The high cost of private healthcare in tourist resorts is not an unfamiliar lament from travel insurance providers – hence the inclusion of the clause excluding treatment given by private facilities – and in the case of private care not being covered under the policy, what is the patient to do? Well, more often than not, they have already given their credit card details to the hospital, explained 
an ASPE spokesperson: “When any patient that is not a regular client enters the hospital, they are always asked by the hospital to sign a document recognising the debt and for a credit card or a deposit in case their insurance company does not cover medical expenses. Hospitals always try to be paid by the patients before leaving the hospital because claiming the amount of an invoice in a foreign country, especially the UK, involves very high expenses.”
Is it fair on patients to make them sign paperwork such as this when they are ill/injured and in need of urgent medical care? One could argue that most people will sign anything at this point, just to get in to see a doctor. So when an insurer then refuses to pay a bill that it considers not to be a fair reflection of the treatment provided, this can leave the patient, the hospital and the insurer in a difficult position.
The ASPE spokesperson went on to say: “Companies know that it is often not worth complaining about and encourage patients to leave the hospital quickly and not pay the bill, since if the amount of the invoice is not high, the expenses to claim in the UK are higher than the amount we can recover. If a patient decides to leave without paying, the hospital cannot stop him. The hospital has to claim the debt, which is a slow and expensive process.”
Protracted legal proceedings between insurers and hospitals are not uncommon in the travel insurance world. Disagreements between medical professionals over what constitutes ‘necessary’ care, and where the line between usual treatment and overtreatment lies, are fairly regular occurences. As mentioned in last month’s ITIJ, insurers are also concerned that in some cases, the private clinics are not the right places for an insured to go when they are injured – the clinics may not have the necessary equipment or expertise to treat the injuries or illness being presented – and this is why customers are sometimes urged to leave a private clinic and attend a better-equipped public hospital.
The high cost of private healthcare in tourist resorts is not an unfamiliar lament from travel insurance providers
When an insurer – even one that does have private healthcare exclusions in its policies – decides that its client has acted reasonably and urgently needed the care the private hospital has provided, most will then engage in cost containment practices to limit their expenses. This can be as simple as making sure that all the treatment provided falls within the scope of the illness, or agreeing with the hospital in advance that there will be a discount on treatment given as a high number of clients will most likely attend the clinic over the course of, say, a year. Simple negotiation, said the ASPE spokesperson, is not going to work: “The rates are not negotiable, since they are free in Spain and each centre applies their rates to the companies. In the case of travel assistance companies, hospitals usually have a single rate for all these companies, and make special agreements with some of them depending normally on the volume of business, ability to refer patients directly and prompt payment of the bills.” Volume discounts, then, do exist, as do prompt payment discounts.
Where next?
Private hospitals are, almost without a doubt, going to charge higher rates than public facilities. Carrying out appropriate cost containment on medical cases in Spain is always going to happen, and whether or not refusing to pay a bill is ‘appropriate’ very much depends on who you talk to. Tensions are going to keep simmering in this debate, and with a conference session on this matter planned for ITIC Global in Barcelona this November, this is not the end of the story. ■

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