First published in ITIJ 116, September 2010
The effect of travel – whether for work or leisure, and whether on a short or long-term basis – on the mental health of a person can often be quite surprising. Carrie Dunn looks at how travel insurers and IPMI providers can prepare for the unexpected
“The premise of insurance is to cover the risks that are not yet known. It’s very rare for insurance to cover pre-existing conditions, whether they’re physical or mental – so if you were to declare that you’d previously been treated for depression, there would probably be an exclusion on all mental health issues,” explains Matthew Aspon, head of international marketing at AXA PPP International. But others believe that it’s not necessary to take such a blanket approach to cover. Catherine O'Neill, service manager at Anxiety UK, states: "It shouldn’t be difficult for a person with any mental health issue to actually get travel insurance, but often buried away in the small print, policies include clauses that state that they can refuse to pay out a claim if they can prove a person's pre-existing mental illness contributed to them getting ill in the first place. This can often stem from a misunderstanding about mental health, where people think that a mental condition is with a person forever when in reality they tend to be episodic and a person can often have a mental condition, such as anxiety, and then never have it again."
But the act of travelling can, itself, spark anxieties and create mental health issues or lead to the resurgence of a previously diagnosed condition. As Dr Suzanne Black, a clinical psychologist, told delegates at a recent International Travel Insurance Conference (ITIC), an expatriate moving to an unfamiliar country is a foreigner in a strange land, and many travellers experience hyper vigilance and a heightening of the senses as they become accustomed to their new environment. “Those with existing psychiatric disorders will often find their symptoms are exacerbated or suddenly reappear and a sense of social isolation sets in,” she explained, continuing: “Psychiatric symptoms can appear for the first time, particularly in those aged between 17 and 23.”
Shaking off the stigma
When people look for travel insurance or IPMI cover, whether it's for work or leisure, they usually expect to tick boxes about physical conditions they have – asthma, diabetes, recent operations, that kind of thing. Mental health issues? That's another matter entirely. But it is important for insurers to ask questions on this subject and not just to determine whether the traveller has a pre-existing mental health issue and subsequently decline cover or issue a non-standard policy to take their illness into account.
consideration has to be given to the extent of the problem and how that could impact on the proposed journey
“I haven't actually been refused, but have been unable to easily purchase online policies as I always have to tick a box relating to my illness," says Sarah, a 38-year-old public sector manager. "This either means I have to call to speak to somebody and answer a lot of questions, and in some cases make declarations and give assurances about my current state of health, or sometimes get directed to further questions that are long, generic and often difficult to apply to an individual's circumstances. Again, this usually involves making assertions or assurances, or agreeing that any claims related to my illness would not be covered, or even paying higher premiums. It's not easy.” Maybe this is just the nature of the insurance game, or perhaps insurers might need to reassess how they approach the issue of mental health, especially given the commonality of such problems as depression and stress, which are often not covered by standard policies: the issue of public image and perception is a key topic for insurers, not to mention customer retention in these strained economic times.
"As many as one in six of the UK population has suffered from a mental health problem, and a quarter of these people seek professional treatment for this," explains Peter Hayman of specialist travel insurer PJ Hayman in the UK, "However, if an individual has a diagnosed mental health disorder, some travel insurers may refuse to cover them, even if the disorder is managed.” This creates additional hassle for companies looking to relocate their employees, especially now that the global workforce is so mobile. If a candidate is set to move to a different country but they've had a mental health issue at any stage, there may be a lot of paperwork to complete and to read.
Hayman adds: "In my view I don’t believe insurers do make it exceptionally hard for people with mental health issues to obtain insurance. Like other medical conditions, consideration has to be given to the extent of the problem and how that could impact on the proposed journey. Medical warranties on travel policies will inevitably differ but most no longer have an absolute exclusion for mental illness." Still, insurers also have to bear in mind that applicants often don't know they have to declare a ‘previous’ mental health problem – or may even be tempted to keep it secret so as to secure their policy.
Dr Sneh Khemka, medical director at Bupa International, agrees that the more common mental health problems such as anxiety and depression need special consideration of their own, and points out that these illnesses can have a detrimental effect on a person's overall wellbeing. "When people think of mental health conditions, they tend to think of the more serious psychiatric diseases such as schizophrenia," he says. "In fact, stress, anxiety and depression are by far the most common conditions. It is well established that these, on their own, can affect productivity and absenteeism; when combined with a physical health condition, they can make that condition much worse. Thus, mental health has a larger than expected impact on insurance premiums.” The amount people claim for psychiatric disorders is actually very low, he stated, but poor general mental health contributes heavily to the burden of disease, and therefore claiming patterns.
PJ Hayman deals with policies that offer comprehensive coverage to applicants with mental health problems at the more serious end of the scale, so their experience is slightly different to Dr Khemka's. "The most common we tend to see, given the fact that these are almost certainly likely to be declined elsewhere, are bipolar disorder, which was once called manic depression, and schizophrenia. Further down the scale are the anxiety-depression areas which typically will be picked up elsewhere," says Hayman. "There is a limited availability of bespoke cover for people with more serious mental health disorders. We've always adopted a pragmatic approach here relying, to a large extent, on the person's knowledge of their condition and recognising the fact that typically trips will be booked only a short time ahead when there is a window of opportunity or stability."
Furthermore, in Hayman's experience, claims on such travel policies don't generally happen mid-trip if the applicant is off on holiday. "Typically, claims that occur are for cancellation, for example a last-minute change in the condition rather than a relapse abroad necessitating repatriation.” His company doesn’t see many assistance cases for this type of risk as cancellation tends to be the option. Having said this, for those already travelling – or already abroad – he declares that there is a heightened repatriation risk should there be a marked deterioration in the condition: “These are invariably handled by the assistance company and do not in fact represent such a high risk as, for example, somebody with a heart condition.”
Companies looking to insure their employees either for travel or relocation need to be aware of their responsibilities should the individual need to make a claim. With so much to think about when moving abroad, even the calmest individual needs help and advice.
“In the wake of the global economic downturn and the resultant squeeze on budgets, indicators suggest that necessary levels of support have dropped down the corporate agenda," says Rachael Floyd, director of international employee healthcare specialist PMI Global. “This is certainly the case according to recent research conducted by our company, which highlighted the need for a greater duty of care amongst many employers that assign staff overseas. [The study] revealed that a third of UK companies fail to make regular contact with staff working overseas, with one in 10 leaving their expat employees completely in the dark over where to turn to for health advice abroad. A further 24 per cent do not provide any form of Employee Assistance Programme for psychological support while working overseas." Dr Khemka believes that companies who offer proper support to employees will benefit in the long run, as supporting staff in their management of stress, anxiety and depression will resultantly mean a decrease in claims, better management of insurance premiums, and ‘a more engaged, productive and motivated workforce’.
He also points out that travelling or relocating can be stressful for anyone, regardless of whether or not they have a history of mental health issues, and someone who is not usually a worrier can find themselves fretting when they’re settling in another country. Furthermore, as Dr Black explains, a new life abroad can also place a strain on family life, particularly on marriages when partners are forced to rely more heavily on each other and, in some cases, gender roles are reversed. Relocation can also cause children to become affected as well.
"The support that employers offer to a relocating employee can vary, but there are some essentials that should be supplied when considering relocation, especially abroad, says Dr Khemka. Bupa International’s 2009 survey of over 1,000 expats revealed that 42 per cent of people worry about finding accommodation – ‘so help in locating, securing and equipping a property is a must’, he says. This was closely followed by concerns about finding doctors, dentists and hospitals in a new country – 41 per cent of people worry about finding healthcare for themselves, and 25 per cent worry about finding healthcare for their families.
A health check is almost standard in many companies for employees at home and globally, and Floyd suggests that companies should be assessing their employees' psychological wellbeing just as much as their physical state. This, she thinks, will be especially helpful when someone is looking to relocate, highlighting any potential issues.
“An in-depth psychological assessment can flag up any potential stress points in advance and help predict how they will get on with colleagues in the new location," says Floyd, "Similarly, a wider medical health check to identify and address any potential medical problems before they go, giving employees reassurance and peace of mind before they go can prevent crises later on."
If a crisis does occur, Dr Khemka says that companies should not shy away from continuing to offer support and putting employees in touch with assistance if necessary. "The best an employer can do is ensure that their employee is covered in all eventualities through adequate insurance, so they are safe in the knowledge they can seek help from a professional when they need it. This is best backed up by access to occupational health services, whether in person or by phone, which can help manage someone’s wellbeing in the workplace over a long-term period."
companies who offer proper support to employees will benefit in the long run
Aspon of AXA PPP explains: “Many insurers now include access to all medical support abroad that a traveller is likely to need - whether that’s counselling, occupational health, or an optician. It’s not so much about the cost of the treatment; we try not to just offer direct claims reimbursement, but access to assistance. We have offices all over the world with a huge database of practitioners, so an individual can be put in touch with whatever they need – and most insurers now have a similar provision.” This is a particularly important issue, says Dr Black, who stresses the importance of selecting the right mental health practitioner for those requiring assistance while abroad. If possible, she says, it is best if both the clinician and the patient share a similar culture and background and speak the same language, as sessions where patient and clinician do not understand each other can be unproductive and increases the risk of misdiagnosis which, ultimately can affect the type of medication prescribed. Speaking at ITIC, Dr Black also urged health insurers to check the credentials of clinicians to ensure they meet local licensing requirements, and said it was insurers’ responsibility to ask for letters of recommendation and qualifications, as it is not unusual for practitioners to be working without the relevant visa or under a misleading title. She also says insurers should be aware of local standards of care and should ensure their clients are clear on what treatment they can receive abroad. They could also provide a list of dos and don’ts for clients with mental health problems before they leave the country, including advise to take with them written documentation of their condition in their native language and their new country of residence, prescriptions, and two months’ supply of relevant medication.