Who do you trust?

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First published in ITIJ 99, April 2009

drs

The recent publicity of the case concerning the McGrade family versus AmEx/ACE has served to bring to the fore some important industry issues. Dr Chris Peach, who spent 20 years working in the assistance industry, now works as a GP in the UK NHS and gives his take on the case

Ostensibly Mr McGrade from New Zealand took out insurance in good faith, having carefully researched the wording to ensure that he had full cover, and took out the policy through AmEx, underwritten by ACE Insurance Limited. Whilst travelling in France, he collapsed and was in a coma for 20 days before dying, running up a bill in excess of A$120,000. This was stated in the press as being due to a heart attack. ACE then declined cover. The assumption is that this was on the grounds of non-declaration of a pre-existing condition or exclusion from cover due to such a condition thanks to his previous medical history. The patient’s own GP has signed an affidavit stating that Mr McGrade had been investigated for chest pain and the conclusion or final diagnosis was that he had musculo-skeletal pain as a consequence of painting and decorating.

Devil is in the detail

It is perhaps important to stress at this point that ‘Chest Pain’ (the wording used in many insurance policy wordings) is a symptom and not a diagnosis. As such, unless it is qualified, it is a useless term owing to the enormous ambiguity it creates. Clearly the intention of this term when used in any insurance policy wording is to exclude conditions which are directly associated with ‘ischaemic heart disease’; ‘coronary atheroma’; or disease of the coronary arteries in general. These conditions make the possibility of ‘heart attacks’, or myocardial infarction to be precise, more likely. Incorrectly applying the term to exclude anyone with a history of chest pain would almost certainly exclude the whole population. Musculo-skeletal chest pain is an almost universal phenomenon with just about every human being having had some minor discomfort in their chest after over-using their pectoral muscles. Whether any sufferer chooses to have these symptoms investigated is down to personal preferences. Any insurer excluding cover on the basis of history of chest pain alone is, in my opinion, acting irresponsibly.

Many of the exclusions and terminology in the small print in some policies are difficult for the general public to understand. Policy wordings can be written in legal-speak jargon with phraseology so long that any normal human being would fall asleep before reaching the end.

"Any insurer excluding cover on the basis of history of chest pain alone is, in my opinion, acting irresponsibly"

In my view, once you have taken the money, you have a duty to provide the service on offer … any exclusions should have been clearly, openly and honestly ruled out in plain English. I have no sympathy for any ‘wrigglers’ (insurers trying to retrospectively deny cover).There is good evidence that the money they spend on ‘wriggling’ (Loss adjustment/claims handling departments) would be sufficient to settle all the claims that are investigated for one reason or another.

There are also many insurers that deal satisfactorily with exclusions prior to, or at the point of sale of, the policy and then appropriate cover thereafter. An example of this is MIA. Their spokesperson, Eileen Dalrymple-White elaborated as follows: “I can only speak for MIA's specialist travel insurance designed specifically for people with pre-existing illnesses called Clear2GoThe only input we ask the GP or Consultant for, is to place a written note on their medical records confirming that in their medical opinion they are medically fit to travel and endure the trip’.” A clear instruction that most consumers could accomplish without incident. Ms Dalrymple-White continued: “Most, if not all, physicians would not place a note on their patients’ records to this effect, if they did not believe that the trip would be in the best interest of the patients’ health, especially given how serious our clients medical histories are, many with a terminal prognosis. We have had some [doctors] tell the patient that they should not travel, some advising they could do a short-haul trip only and some adjusting dates to fit with medical treatment that will make the patient more able to cope. We have found that if we are all honest with each other and are striving for a common goal the health of the patient and their enjoyment of their trip there are no problems. We are not trying to catch the doctor out, we are wanting their input on the medical advisability of their patient travelling by the specified method to the specified destination. Together we work to achieve the safest holiday for the patient. To do this we often are able to get them to change their destination or method of transport."

Here is a common sense insurer who is open and honest and trusts the GP and Consultant to apply professionalism. With perhaps the inevitable rare exception, this trust is well placed. It also acknowledges that even with very serious medical conditions there are ‘windows of opportunity’, when travel to a sensible destination for a reasonable length of time is possible without risk to either the patient or the insurer.

dr2Vertical integration

A famous public health professor once made the statement “The NHS would work perfectly if only the patients would stay away.”  Most doctors have never read this statement and would not take much notice of it if they did. It seems however that a sub-section of the insurance world did read it and took it so seriously that they bought the intellectual property rights there and then.

At this stage it would be a good grounding point to remind ourselves exactly where the industry evolved from, and why people buy travel insurance in general, and medical assistance in particular, which may give us an insight as to why the ACE/AMEX case has provoke such controversy.

Obtaining access to satisfactory medical advice and treatment in one’s own country can be difficult enough. Add in a foreign country, and question marks over who pays the bill, which languages are spoken, what the local facilities can reasonably be expected to offer and the complexity becomes even greater. It is perhaps because of this that insurers started to retain the services of assistance companies back in the 1960s when tourist numbers were beginning to escalate. These companies were initially independent services retaining professionals – including doctors – to advise on how best to help the travelling public. One thing always came first in the formative days of assistance and that was that the patient’s healthcare interests, which prevailed over all other considerations. As an independent professional, the assistance company doctor was able to collaborate effectively without conflict or compromise with both the treating doctor and the patients GP and conflict rarely if ever arose and if it did it was easily resolved.

Because most assistance organisations were independent mutual organisations they retained professional autonomy and with it integrity and credibility. There was a clear separation between ‘commissioning’ of the service and the ‘provision’ of that service.

Sadly those days did not last. The bills for assistance company services were inevitably picked up by the travel insurers who had sold medical cover to the sick traveller. As such they quickly realised that therein lay the possibility to control costs and increase profitability. This can create an inherent conflict of interest when a commissioning organisation is also the service provider organisation.

This approach was compounded by the ‘short-termism’ of the 1990s, when a lack of vision and the longer term consequences led insurers into a repetitive cycle of under cutting on price to buy market share. Arguably, rather than achieving the intended benefit of profitability in subsequent years of business, this approach resulted in the public abandoning any brand loyalty they had previously and testing the market for the best value. The end result was an industry that was under priced and having to sacrifice quality for survival by cutting costs. This was a far cry from earlier criticisms that cartels of big insurers were keeping prices up. With the wisdom of hindsight, the latter was a far safer and more sensible approach. 

The travel insurance industry was (and still is), in my opinion, woefully lacking in any form of effective regulation. The complexity of its operational structure and the opportunities for conflicting advice, make it almost impossible for self regulation, let alone state-enforced regulation.

So when the cards are down and there is conflict between the treating doctor and the assistance company doctor or patient’s own GP … and who exactly, do we trust?

McGrade vs AmEx/ACE

A medical officer employed by an insurance company either directly or indirectly will be under pressure to support the company line when a conflict arises. An independent autonomous professional, such as a GP, has no vested interest in doing anything other than putting the patients’ interests first. In cases like the ACE case the insurer may have assumed that the client lied or was not honest in their declarations. In my twenty years in this industry I personally only ever encountered two individuals stupid enough to deliberately defy policy wording and attempt to travel knowing that they were in breech of the terms of their insurance. The paranoia about false claimants usually involves ‘cognitively distorted arbitrary inferences’ (false assumptions) and perhaps ‘the benefit of the doubt’ principle would be better applied before restricting or denying assistance (aka claims).

"Because most assistance organisations were independent mutual organisations they retained professional autonomy and with it integrity and credibility."

AmEx is an organisation with a reputation to protect and one can only assume that their settlement of the outstanding liabilities on the credit card was a damage limitation exercise. The reasons for ACE’s continuing action or inaction in the face of a huge swelling of sympathy from the general public and the overwhelming bad press from the world’s media are open to speculation. There are still many unanswered questions about this case and time will be their ultimate judge. My prediction is that ACE will end up settling for the full amount out of court and will leave us all wondering why they bothered to take the stance they did in the first place.

Will they be able to compensate the family for the all the distress suffered?  I doubt it. As to which doctor you trust … My opinion is clear. I trust the independent professional – not the corporate slave.