The life aquatic

ITIJ 195, April 2016
Scuba divers are growing wrinklier – and not just because they spend a lot of time underwater. Could an ageing cohort of sub-aqua enthusiasts be a worry for insurers? Robin Gauldie dives in
Scuba diving, once seen as an extreme, high-risk sport, has become a mainstream holiday activity enjoyed by millions, with trial lessons given for free to beginners in many resorts as part of all inclusive holidays. And as the number of divers grows, they are also getting older and more adventurous, travelling further in search of new underwater thrills, and diving deeper once they get there. 
Despite the risks associated with such activities, some of the world's busiest dive spots are close to mainstream holiday resorts, so access to specialist emergency medical facilities such as hyperbaric chambers is relatively easy. The Cayman Islands, for example, has two hospitals with specialist services including hyperbaric chambers, while several resort islands in the widely scattered Maldives have their own clinics with chambers. 
But scuba's frontiers are always expanding, which presents challenges for travel insurers and assistance companies. Related claims can also be costly for insurers. “Dive-related medical costs can be very expensive,” Richard Warburton, chief operating officer at Australian insurer 1Cover Travel Insurance, told ITIJ. “Many great dive sites tend to be in remote locations, far from emergency medical help and often in developing countries. One of our first ever claims was a diver who got ‘the bends’ [decompression sickness] while diving off South America. Not only did we cover the cost of the decompression tank but we also arranged transport via boat and land to the nearest hospital. Diving claims such as these end up being tens of thousands of dollars.”
The numbers seem to indicate that scuba is a relatively well-regulated and low-risk activity
Bubbling up
Sport diving has been one of the fastest-growing holiday activities of recent decades. Self-contained underwater breathing apparatus (scuba) was pioneered by French diver Jacques-Yves Cousteau, who in 1953 coined the name ‘aqua-lung’ for his new toy. Cousteau's pioneering films of undersea adventure popularised scuba diving, but until the 1980s it was a pastime for serious enthusiasts only – not least because insurers treated it as a high-risk activity, so specialist policies were not universally available and premiums were high.
Since then, scuba has gone global, with destinations from Belize to the Cayman Islands, the Maldives and Australia building entire tourism industries on underwater wonders like the Great Barrier Reef.
Founded in 1966, the Professional Association of Diving Instructors (PADI) has done more than any other organisation to popularise scuba diving. Providing a worldwide framework for training and certification, PADI’s 6,300 dive centres have trained more than 24 million divers, and its certification system is recognised by insurers worldwide. 
PADI is also a player in insurance. In partnership with the Divers Alert Network (DAN) in North America and German insurer Aqua Med in Europe, the Middle East and Africa, it offers tailor-made all-round travel and specialist scuba cover for all levels of PADI-certified diver.
Trial dives or beginners' diving courses are part of the holiday experience for hundreds of thousands of holidaymakers every year. After completing their first level of certification, many are happy to remain as 'open water' divers, who are allowed to dive to depths of no more than 18 metres. In response to scuba's massive increase in popularity, some mainstream travel insurers now include some level of cover for scuba diving within their standard policies.
“Our approach,” says Steve Scott, head of business development at TIFGroup, “is that for new or novice divers, the standard range of products that we offer includes scuba diving (not solo) to 30 metres. This is considered the normal depth for new and novice divers, as it does not require a mixture of gas and air. For this level of diving, the policy would include any emergency medical expenses incurred as a result of an accident while diving.”

Just when you thought it was safe…
Even relatively easy-going dives are not without risk, and accidents can occur. This reporter, with around 80 dives logged as an open-water diver, has directly experienced or observed five potentially serious incidents, all close to shore, in shallow water, and even in a pool. Two involved boatmen failing to keep track of divers in order to locate them on surfacing, one involved the failure of an instructor’s breathing equipment and subsequent rescue of the instructor by an experienced member of the group, using the standard 'buddy breathing' air-sharing technique, and two involved a diver or instructor simply forgetting to turn on the air supply before entering the water.
The numbers seem to indicate that scuba is a relatively well-regulated and low-risk activity, however. DAN, which monitors dive incidents worldwide and also offers its own specialist insurance policies for divers, received notification of 561 deaths globally involving recreational scuba diving between 2010 and 2013, and in its 2016 Annual Diving Report, the organisation said it received reports of 50 recreational diver fatalities occurring in the US in 2014. The US Sport and Fitness Industry Association estimates that some three million American divers make an average of 10 dives each per year. Fifty deaths out of 30 million dives doesn't seem like bad odds.
In Australia, the Royal Lifesaving Society estimates the mortality rate among divers and snorkellers at less than 0.6 per 100,000 dives, although the average annual number of deaths of scuba divers and snorkellers almost doubled between the 1980s and the first decade of this century as the number of divers increased.
Destinations from Belize to the Cayman Islands, the Maldives and Australia have built entire tourism industries on underwater wonders like the Great Barrier Reef
Scuba and snorkelling incidents account for nine per cent of water activity-based claims under policies issued by Australian insurer 1Cover Travel Insurance, according to Richard Warburton. “The fact that scuba diving is covered under our policies is a popular reason many people choose 1Cover,” he says. “However, to be covered, the person must hold an open water diving licence recognised in Australia, or be diving under PADI-licensed instruction, and they must only dive to the depth they are licensed to.”
Many insurers, however, prefer to err on the side of caution by excluding even entry-level diving from their standard policies, classing it as an extreme sport. UK-based tour operator Thomas Cook, one of the world's largest holiday companies, unequivocally states that its clients need specialist cover for scuba diving. “Thomas Cook rates dives to no more than 20-metre depths, accompanied by an accredited instructor, as a 'low-risk' activity,” Marc Heley, a spokesperson for the company, told ITIJ. “Our own water sports travel insurance, underwritten by White Horse Insurance Ireland (a TC subsidiary), offers specialist cover as an add-on at no extra cost for such dives. Cover for dives to 30-metre depths, rated 'medium risk', and to 50 metres, rated 'slightly higher risk', can be covered for an additional premium. For both these categories, medical excess is increased, personal accident cover is reduced by 50 per cent from the standard policy level, and personal liability is excluded.” Meanwhile, medical cover for all three categories is increased to £10 million and a hospital benefit of up to £1,200 is added for insureds hospitalised during a scuba diving trip.
How deep is your love (for diving)
While what might be called ‘entry level’ holiday diving has never been more popular, experienced divers with a taste for adventure seem determined to plunge to ever-greater depths, using an array of new techniques and equipment, including air and gas mixtures such as nitrox (a breathing gas with a higher oxygen content than normal air) and trimix (a mixture of oxygen, helium and nitrogen). Such techniques require more complex skills and insurers understandably rate them as more hazardous.
But the biggest risks to divers are more mundane. As scuba diving has matured into a mainstream leisure activity, participants have matured too. In its Scuba Diving Participation Report 2014, the US Sports and Fitness Industry Association said that 22 per cent of ‘core participants’ in scuba diving (i.e. those making eight or more dives a year) are over 54 years old.
That may pose challenges for insurers. As the average age of recreational divers increases, cardiovascular disease has become second only to drowning as a cause of fatalities and disabling injuries among the diving population, with some sources indicating that it could soon be the biggest contributing factor. “With regards to age, the policy is ‘age rated’ so the premium takes into account a customer’s age at date of booking,” says Steve Scott. “The policy also includes the need for customers to declare any medical conditions, and if a more specialist policy is required, we would recommend the purchase of a specific scuba niche product which is aimed at the scuba enthusiast.”
the overall incidence rate of snorkelling deaths is very small
Some voices in the scuba community are beginning to ask whether scuba operators and insurers should require older insureds not merely to declare existing medical conditions, but to undergo some form of medical examination. The deaths in Australian waters of three scuba divers and three snorkellers within one week in November 2016 prompted Graham Henderson, president of the Australian Underwater Federation, to call for more effective safety standards and mandatory medical tests for older divers.
Heart failure is also a cause of death when snorkelling, an activity that unlike scuba diving requires no special training and is covered by standard travel insurance policies. According to an Australian study, Snorkelling-related deaths in Australia, 1994–2006 by John M. Lippmann et al, most deaths among snorkellers were due to cardiac-related causes. That said, the overall incidence rate of snorkelling deaths is very small, with approximately five deaths per million snorkellers per year.
“There’s definitely a market for older divers,” says Richard Warburton. “People are living longer and staying active well into their retirement. Many older travellers also have the additional means required to partake in diving, a sport that tends to be quite costly. Research has shown that as the number of older divers rises, there has also been an increase in the number of scuba diving fatalities. Many of these have been due to cardiac arrest.”
Warburton emphasises that 1Cover's medical screening protocols are thorough, but that older divers need to be punctilious when providing medical information. “Typically, older travellers present with more pre-existing medical conditions, and this is something we need to be mindful of. We want to ensure people aren’t failing to declare any pre-existing medical conditions they may have. Many insurers deem scuba diving a high-risk activity, and as such, many policies don’t cover it. Others may cover it but not to the level more advanced recreational divers need. This is why research is so important.”
Unquestionably, better training, better equipment and decades of experience have made scuba diving a much safer activity now than in its pioneering days. It's still far from risk free, however, and divers need to be gently but frequently reminded that the biggest risk is over-confidence. That said, insurers, certification organisations, dive operators and divers themselves appear to have the sport adequately covered.