It goes without saying that some countries or regions of the world are, generally, more difficult in which to provide assistance – especially countries that are the location of recurring conflict. Sasha Gainullin offers his experience on how best to manage assistance provision when local resources are limited and logistics extremely challenging
It is easy to imagine certain countries that could be considered assistance ‘black holes’. Take Pakistan for example: there are numerous travel advisories against visiting parts of the country, so anyone brave enough to risk getting caught up in the violence and political activity occurring in these restricted areas would be doing so at their own peril. But what about travel to Punjab or Islamabad – to visit relatives, attend to business, or visit the World Heritage Site of Taxila? Visitors to these parts of the country would be covered by their travel insurance, but if illness or accident strikes or the traveller finds themself inadvertently caught up in conflict, can their assistance provider deliver what’s expected in terms of client and insurer expectations? Pakistan is in many ways a developed country, but healthcare standards vary, cultural and language barriers are an issue, and there is a lack of dedicated emergency air ambulance provision – all of which make this a difficult place to deliver efficient and appropriate healthcare. At the same time, assistance companies helping clients in the country need to make billing or payment arrangements and organise repatriations with hospitals unfamiliar with dealing with assistance companies or relaying information to foreign assistance company medical directors. So, is assistance provision in countries such as this beyond the reach of many of the assistance companies who market themselves as having a ‘global reach’? And can those ‘international’ assistance companies offering ‘worldwide’ assistance really be effective or efficient enough in their care delivery to meet insurer and customer expectations in such places? And just what can companies specialising in remote or conflict zone assistance provide that others aren’t as able to?
Understanding global reach
The term ‘worldwide policy’ has become a marketing norm in the travel insurance industry, but may mislead the buyer into believing they are purchasing a policy with truly worldwide assistance capabilities, when in actual fact there are a number of factors that could drastically limit such worldwide assistance provision. Let’s be realistic, there are some places in the world that cannot be easily reached because of their remoteness, lack of communication infrastructure, or other known dangers.
Most underwriters of travel insurance plans that contain international medical assistance provision use policy language to manage their liability by excluding coverage for travel into parts of the world deemed too dangerous; for example, they will exclude cover for travel to areas named by certain governmental travel advisories as ‘places to avoid’ due to current risks associated with that region. By relying on these authoritative sources, underwriters are able to exclude themselves from any obligation to respond to medical events or to pay claims in countries from Algeria to Yemen, as specified in their policy wording. Policy terms and conditions should, thus, reflect and make clear any limitations that could affect the company’s ability to respond to emergencies in remote or otherwise restricted areas.
assistance companies helping clients in the country need to make billing or payment arrangements and organise repatriations with hospitals unfamiliar with dealing with assistance companies
However, there is an element of personal responsibility that goes beyond ‘buyer beware, read the fine print’ and speaks to common sense expectations of what an assistance company can provide. But there must be a balance between honest disclosure by the insurer and an assumption of personal risk by the insured.
At the same time, an assistance company that claims to be able to respond in extreme circumstances must have a proper structure to support its activities. The best companies have employees posted in and around the locations where their clients are located. No such specialist assistance company can post employees in all of these locations, so they must have the ability to get there, either by proxy or in-person, within 24 hours. Having a network of regional managers who liaise with preapproved local operatives is an effective way to cover the company’s geographic assistance obligations.
Once the injured party makes contact, the assistance organisation is obligated to deliver on the promises in the travel insurance policy. The best way to accomplish this is through employees who are properly trained – from the call centre all the way through to the dispatching of qualified personnel to the location where the individual is situated. This goes for mainstream as well as specialist assistance providers, but it is especially important for assistance providers working in hazardous areas to ensure they have well trained staff in situ who also have good local knowledge. Many assistance companies are very good at delivering benefits in areas that have adequate infrastructure, but lack the ability to respond in other areas because they do not have qualified, trained personnel inside ‘black hole’ locations to the extent that certain specialist assistance providers do.
Black hole situations
Even assistance companies with offices in troubled countries or specialist assistance providers with experience of working in war zones can face scenarios that could be considered ‘assistance black holes’. These usually happen in geographical regions that could be deemed more generally as ‘assistance black holes’ or they could occur in larger-scale disaster situations.
Let’s look at an example. This is an actual case study, although details have been changed to protect patient privacy:
On a beautiful spring day somewhere in the Middle East, a bus load of Indian contract workers swerved to avoid a car. The bus rolled over, killing one person, and injuring 10 others. Ambulances arrived quickly, taking the crash victims to neighbouring public hospitals and private clinics. The owner of the business, Mr Singh, couldn’t locate all of his employees, as the ambulances had scattered to different locations. Even if the telephones had been working, Mr Singh couldn’t communicate with the ambulance companies because he didn’t speak Arabic.
One of his employees is dead, the rest are injured or missing, the phones are out, and Mr Singh doesn’t speak the language: his case represents an assistance black hole.
Black holes abound when delivering emergency medical assistance in remote and dangerous places. Language barriers are often the first obstacle, while locally available medical care may not be adequate to treat a patient’s condition; and poor infrastructure can cause transportation bottlenecks. Patients can get stuck in the wrong medical setting because of administrative delays and cumbersome bureaucracy with regards to their travel documents. Telephone and Wi-Fi deserts, along with unreliable electricity sources, can shut down communications. The insurance policy may exclude payment for the specific cause of the medical condition or death. Credit cards are not widely accepted in some areas, and getting cash to settle medical bills can be problematic: banks are often closed without notice and wire transfers can take weeks. The local and cultural norms of healthcare delivery may dictate treatments that are not in the best interest of the patient, while the absence of an adequate follow-up and treatment plan after discharge may compromise the patient’s full recovery. These challenges can’t be eliminated, but facing them directly and in person can provide surprisingly efficient solutions.
The best way to prevent black holes from swallowing an assistance case is through the training and placement of knowledgeable and empowered employees along each step of the process. This begins with the first call and continues until the patient is fully recovered. Most assistance companies use local subcontractors in these out-of-the-way locations and, as a result, their services tend to be uneven or inadequate in extreme situations, as specialist – as well as local – knowledge is often key to streamlined and effective case management. Because of the necessary attention to detail for each case, there are only a handful of specialist (often low-profile) – assistance companies adequately covering these regions.
When a medical event occurs, the first point of contact is usually the assistance company’s call centre. Injured and anxious in a foreign land, the client needs information, comfort and solutions. Too often, the call centre is staffed with powerless, linguistically challenged, untrained people who merely take messages. “May I have a phone number where you can be reached? Someone will get back to you shortly,” is too often the response received on that first call to an assistance company. Customers need to talk to well-trained people capable of assessing the caller’s level of need and providing immediate information and reliable solutions – even for the most remote or challenging regions. Delayed response times, lack of immediate medical care, clumsy handling of travel documents and poor follow-ups waste time and compromise patient outcomes. These challenges can turn into black holes, but they don’t have to.
In the field
Having experienced, locally knowledgeable health professionals in place before a medical event occurs is key. Assistance companies that subcontract patient care to outside organisations are often playing on-call roulette by relying on third parties to manage their cases. The best approach is to employ workers directly, train them professionally, and place them in the call centres and the communities where their clients live and work. By empowering employees both operationally and financially, they can make real-time, life-saving decisions in the immediate best interest of the patient. They should be expected and encouraged to comfort, advise and intervene bedside, and ensure the patient’s follow-up plan upon discharge is thorough enough to assure enhanced medical outcomes.
When a medical event occurs, the first point of contact is usually the assistance company’s call centre
These field agents have a keen understanding of where deficits in medical services exist in their region, and who the best medical providers are. They act as minders, finders, helpers and fixers by navigating the local landscape. First, they make contact with the patient, and provide a personal assessment. Based on local experience, they find cash – where necessary – and arrange for transport. Agents help patients wade through foreign bureaucracies and cryptic travel documents. Fixers expedite and fine tune the logistics, setting up and weaving together financial and information systems. These local professionals bridge potential black holes that could adversely impact a patient’s eventual recovery.
Furthermore, field agents know how to get to the hospital. They know when the power usually goes out, for how long, and what to do about it. For local agents, power cuts, Internet blackouts, and water issues are not catastrophes, they are part of daily life. Agents prepare accordingly, with portable generators, car chargers, batteries, bottled water, and extra phones. Because most medical providers in remote and dangerous places often don’t accept credit cards, bank wires, or cheques, good field agents have guarantee of payment arrangements already set up at hospitals and clinics. They know where to get cash day and night and can personally front the cash in emergencies. Not only are the local agents savvy on the ground, they also understand their customers’ language and cultural needs. This level of care can’t be phoned in. Local knowledge can literally fill black holes and save lives.
Let’s have a look at how Mr Singh’s situation panned out:
Mr Singh contacted the assistance company and told them of his situation. Based on the location of the accident, the regional office identified several possible medical facilities, and started dispatching agents to investigate. As the telephones were down, agents personally visited all the local hospitals and clinics. Within three hours, all 10 victims were found, assessed, and some were moved to alternative medical settings. The injuries included a crushed pelvis, broken femurs, head traumas, and minor cuts and bruises. The agents paid the medical bills of the previously discharged patients, who, thanks to a prearranged billing system, could get on with the business of getting better, and confirmed the financial arrangements for those needing further care. The family of the deceased were notified, and the remains prepared for repatriation.
Meanwhile, other field agents got busy collating and translating official police documents about the crash, and all the medical records into Mr Singh’s language. Once the cause of the accident was determined, they updated the translation.
Field agents continued following up on the crash victims. Medical training made a difference for one patient, whose doctor would not address his pain. The medically trained agent had the patient assigned to a different doctor, who started him on a new treatment regimen and he began to recover more rapidly. A few months later, most of Mr Singh’s employees were back at work, and the rest were making excellent progress.
When mainstream international assistance companies utilise subcontractors to deliver services in areas of the world that are either too remote or are complicated by conflict, they might use one company for transportation, another company to deliver medical services, and yet another to review and transmit medical claim information back to the home office. In this scenario, the chain of accountability has many links and many opportunities to fail. Using an assistance company with a centralised command and control structure that specialises in delivering medical and other assistance services in remote and dangerous places should be considered.
most medical providers in remote and dangerous places often don’t accept credit cards
Specialised field experts don’t come easily, however. Educated, multilingual, polite yet firm, and cool under pressure, such specialist assistance providers strike a balance between business and compassion that makes all sides happy, while smoothly navigating multiple borders and cultures. If mainstream international assistance companies choose to offer their services in dangerous places, they should look to work with experts that have experience in meeting the unique challenges found in such places.
The local agents are the heroes in Mr Singh’s story – as they are in so many other cases – and are the key to meeting client and insurer expectations in areas that are traditionally more difficult or challenging in which to deliver assistance. Call centre workers can talk to on-call doctors, but it takes first-hand observation to make sure patients are getting the most appropriate care in the most timely manner – agents with medical backgrounds who are qualified to make educated, on-the-ground assessments and recommendations for patients are invaluable. Without knowledge of local bureaucracy, police reports and medical records can be unobtainable. Without extensive linguistic skills, a local understanding of healthcare delivery and how it is paid, injured parties can face treatment and discharge delays. Dedicated local agents with these key skills, local security knowledge and an ‘insider’s’ ability to get the job done, make the difference between black holes and successful outcomes.