First published in ITIJ 129, October 2011
Travel insurers are geared up to deal with physical trauma and its after effects. But could they do more to help clients who suffer post-traumatic stress after falling victim to violent crime while on holiday? The European Commission and consumer advocacy groups seem to think they could, but some travel insurance providers disagree. So how far should the insurance industry’s responsibility to a client extend after the insured returns home? Robin Gauldie investigates the issue
Post traumatic stress disorder (PTSD) was first described as a psychiatric condition relatively recently – in 1980. Patients typically experience feelings of grief, depression, anxiety, guilt and anger, ‘flashbacks’ to the traumatic event, avoidance and numbing behaviour, such as increased use of alcohol, painkillers or anti-depressants and a range of physical symptoms connected to hyperarousal. “Such events can have devastating physical, emotional and financial consequences for victims and their families,” said a European Commission (EC) statement in May 2011, when the EC announced proposals for a range of measures to ensure a minimum level of rights, support and protection for victims of crime across the European Union (EU), no matter where they come from or live: “When [traumatic events] happen abroad, different cultures, languages and laws can create substantial problems,” it included.
EC vice-president Viviane Reding says the proposals will ensure that the EU puts victims first by making sure they can rely on minimum rights and support in any member country. And few will argue that better provision is a good idea: even in the best performing EU countries, only 38 per cent of victims of serious crime who wanted support actually got it. “There is a lot of help for those who are accused of an offence, but somewhere along the way we lose the victims,” Reding has said.
How far should a travel insurer’s contractual, legal and moral responsibility to clients extend after the client returns home?
Where the sufferers are victims of events such as the tsunami that struck holiday destinations in Thailand, Indonesia, Sri Lanka and India in 2004, or the nightclub terrorist bombings that injured 240 people and killed 202 in Bali in 2002, their plight is often highlighted by the media. But for individual travellers who are subjected to ‘everyday’ criminal violence – ranging from robbery to sexual assault or a racially motivated attack, the safety net provided by the public and private sector when they return home may be less effective.
Fear and helplessness
“Trauma is a dangerous experience that does not only expose people to threat to life or limb; it also pierces strong psychological defences to produce a state of fear, helplessness or horror,” notes Professor Gordon Turnbull, of Capio Nightingale Hospitals in the UK. And trauma, he says, ‘has been discovered to be much more prevalent than was generally assumed’. According to Prof. Turnbull, professionals trained to deliberately seek out danger – such as police officers, fire fighters, paramedics and military personnel – may be pre-selected for emotional toughness and their experience may ‘harden’ their capacity to absorb trauma. But even they cannot be prepared for every emergency, and some events will prove to be beyond their usual experience. How much worse, then, is the impact on ‘civilian’ holidaymakers who are exposed to violent crime?
The EC is proposing to reinforce existing national measures with EU-wide minimum standards, so that any victim can rely on the same basic level of rights, whatever their nationality and in whichever of the 27 EU countries the crime takes place. In addition, there are measures that specifically benefit people who become victims of crime while abroad, ensuring – among other measures – that victims receive sufficient information in a form and language they understand. So the EU looks set to recognise that this is an issue that must be tackled. But is the travel insurance industry keeping pace with proposed government action in Europe and elsewhere? How far should a travel insurer’s contractual, legal and moral responsibility to clients extend after the client returns home?
At the moment, the EC appears to have no plans to create an over-arching, pan-European framework that might involve travel insurers, leaving each EU nation to choose how best to provide treatment – whether through the state, non-profit organisations, or the private sector. “The Commission proposal obliges member states to provide such services to victims [and] their family members, free of charge and in accordance with their needs,” notes Mina Andreeva, a spokesperson for Vice-President Reding. “However, the Commission proposal does not say exactly how member states have to comply with these obligations. In some member states, victim support services are mainly provided by non-profit organisations, whereas state authorities or agencies deal with these questions in other member states. The possible intervention of travel insurers therefore depends on the characteristics and the quality of the national systems with which they would compete.”
Prof. Gordon Turnbull points out that while 70 per cent of trauma reactions resolve within one month of the incident without going on to become PTSD, symptoms must be present for a least a month before PTSD can be diagnosed. Sometimes, no symptoms appear to begin with after exposure to trauma and then present after six months – a relatively rare condition called delayed-onset PTSD. “Restoring feelings of safety and control as quickly as possible is most important of all,” he states. “Nothing much else can happen until this is achieved.”
Policies will not provide cover for people that develop disorders some time after an incident abroad
Commenting in an issue of ITIJ’s Assistance and Repatriations Supplement, July 2008, Mandy Rutter, head of Crisiscall® Services at AXA-ICAS, noted the need to include trauma counselling within travel insurance policies. She noted that while immediate ‘psychological first aid’ is an important concept for the travel insurance and assistance industry, a longer-term approach may also be required. In 2005 in the UK, she notes, the National Institute for Health and Clinical Evidence (NICE) produced guidelines on the treatment of people who had suffered trauma and crisis. The NICE guidelines suggested that a single debriefing session focussing on the crisis was not advisable, as it had the potential to cause distress rather than to help the person.
The numbers of travellers who become crime victims while travelling abroad on holiday or on business are relatively low. The UK Foreign and Commonwealth Office reported that it dealt with 685 incidents of violent crime involving British travellers in 2010, including 178 rapes and sexual assaults and 276 ‘general’ assaults. While figures from the US State Department are less comprehensive, they indicate that more than 5,000 US citizens required medical evacuation between 2003 and 2008.
However, one emerging area of concern could be violence against foreign students visiting or studying Australia, where a recent report by the Australian Institute of Criminology highlights an apparent surge in attacks on Indian students, from 11 such incidents in 2008 to 103 in 2010. Australia issues more than 300,000 international student visas each year.
“There was nothing in the original findings that lends support to the view that Indian students have been singled out primarily for racial reasons,” said AIC director Adam Tomison. The report notes that student expats, unlike mainstream holidaymakers, often have low-paid, part-time jobs in the accommodation, food services and retail sectors and live in low-cost rented accommodation in high-crime, inner city areas and therefore face multiple risk factors that increase ‘their probability of victimisation irrespective of their racial appearance’.
So the number of clients who might be expected to develop some form of PTSD is relatively low, and providing them with longer-term counselling and treatment would appear to be a relatively low cost for travel insurers. So, to what extent do they provide such cover?
Frank Brehany, consumer director at the UK pressure group HolidayTravelWatch, says the effect of violent crime on holidaymakers is ‘very often profound’. “We do not detect that any client so assisted by an insurer receives any ‘after-service’, for example legal assistance, help with reference to criminal injury compensation schemes in the EU, medical help or counselling,” he claims. “I’m not sure if this is a case of ‘washing their hands’ or simply a failure to understand or define the extent of a service that is required in these rare circumstances. It seems to me that if what we are told is correct, the insurance companies are missing an important marketing opportunity.”
In the UK, some travel insurers, including Direct Line, refer clients to the national charity Victim Support for help and counselling. “Most people suffer in silence, but you needn’t – just sharing your thoughts can help,” says Direct Line’s web site. But isn’t this simply passing the buck from travel insurers to voluntary organisations?
the number of clients who might be expected to develop some form of PTSD may be quite low, and providing them with longer-term counselling and treatment would appear to be a relatively low cost for travel insurers
Generally, insurers apparently see no reason to make a special case for PTSD sufferers over victims of other conditions, which develop long after their return home. “Travel insurance policies cover situations where people need emergency medical treatment while abroad. However, policies typically exclude the cost of treatment when people return to the UK and also issues that are not directly connected to the original condition that was suffered. As a result, as a general rule, policies will not provide cover for people that develop disorders sometime after an incident abroad.” says Mike Powell, insight analyst for general insurance at the UK insurer Defaqto.
In Britain, the Criminal Injuries Compensation Scheme (CIPS) covers ‘compensation for special expenses’ for victims of violent crime in the UK. This does not cover the cost of private medical treatment for PTSD that may result from incidents while abroad, although as an ‘assisting authority’, CIPS can help British residents to claim compensation through similar schemes from the country where the incident occurred, on country by country basis. In the US, according to the US State Department, all US states have victim compensation programmes, and many offer benefits to residents who are victims of violent crime overseas. Programmes include financial assistance to pay for medical costs, funeral expenses, lost income or loss of support.
In a climate in which the Association of British Insurers (ABI) has recently called for curbs on the selling-on of client details by insurance companies to ‘ambulance-chasing’ lawyers, the European Commission’s latest stance on this issue could open a can of worms for insurers. The ABI believes the business of passing on client details to lawyers is now worth as much as £3 billion per year, and has got out of hand. But if the ‘no-win, no-fee’ sector scents new opportunities in seeking compensation for PSTD under new European guidelines, things could get messy.
I asked Prof. Turnbull if he felt that travel insurance companies could, and should, offer better cover for the (relatively tiny) number of clients who develop post traumatic stress disorder. His response: “Yes, definitely, because PTSD is recognised as a psychological injury in both medicine and law.”
But medical opinion may be swinging away from the ‘touchy-feely’ approach. Dr Suzanna Rose, of the UK National Health Service’s West Berkshire Traumatic Stress Service, psychologist Simon Wessely of King’s College in London and Jon Bisson of the University of Wales, in a study reported in the New Scientist magazine in July 2011, said victims of traumatic incidents should be asked a month after the event to see if they were still experiencing anxiety, depression or panic attacks. But they concluded that only about one in five people might need psychological help, and that many people get better over time or by talking to those close to them. For most, the old-fashioned ‘stiff upper lip’ may be the best cure – but for the minority, travel insurers could perhaps do more, with minimum impact on their bottom line.