Taking the plunge
When does ‘worldwide’ emergency cover exclude the place you happen to be when you need help urgently? A Bristol couple found out when they ran into trouble on a Caribbean diving holiday, as David Kernek reports
First published in ITIJ 114, July 2010
When does ‘worldwide’ emergency cover exclude the place you happen to be when you need help urgently? A Bristol couple found out when they ran into trouble on a Caribbean diving holiday, as David Kernek reports
The case
Mary-Jane Haigh’s New Year sailing and scuba diving holiday in the Caribbean had been problem-free which, after 20 years exploring the wonders of the deep and with some 1,500 dives to her credit, was what she could reasonably expect. But, to be on the safe side, Mary-Jane and her husband Mike – veterans of dives in Papua New Guinea, the Galapagos Islands, the Maldives, Sudan and South Africa – had bought a Fortis Insurance travel policy that covered experienced divers up to depths of 40 metres, and promised ‘a 24-hour worldwide emergency service’.
The Haighs checked into a beach hut on Virgin Gorda, an eight square-mile island in the British Virgin Islands (BVI) group for a few days of rest before flying back home to the UK, but when boredom set in they went on a resort dive – something they normally avoided.
“It was a textbook dive,” said Mrs Haigh. “We dived to 28.5 metres for 45 minutes in warm, clear water – easy! Being careful, I took 11 minutes to come up from ten metres. It was nothing exciting; nothing to write home about.”
After that dive, Mrs Haigh felt a sharp but brief pain between her shoulders, which she attributed to having pulled sails, ropes and anchors during the previous week’s sailing. After a later, second dive, Mrs Haigh felt very cold. Again, she wasn’t concerned, since this was not unusual. Back at the hut, however, a hot shower failed to warm her. Even when she realised that evening that she’d lost her appetite, she didn’t suspect she had a serious problem.
Dr Lucas Fischer points to the UK, US, Thailand, Red Sea, Caribbean, Mexico and Australia as the regions with the most developed emergency networks for scuba divers
Mrs Haigh’s condition had taken a marked turn for the worse by the time she woke the following morning. “I woke feeling really out of sorts,” she said. “Walking was not easy; I had a general numbness in my legs. When I stood up I felt sick and dizzy.”
These are the symptoms, but far from the only ones, of decompression illness (DCI), widely known as ‘the bends’ – a serious condition that requires urgent medical treatment. In some cases it can cause paralysis and, rarely, death. Because diving is an unregulated leisure activity, it is impossible to count the number of dives made outside organised clubs and resorts – there are no precise DCI statistics, but the widely agreed estimate is that there is one case of DCI in every 7,400 dives, with one death per 76,900. A Japanese study in 2000 estimated that every hour of recreational diving is 36 to 62 times riskier driving a car.
The Haighs made their first call to Assistance International (AI), the service used by Fortis to handle medical emergencies, at 9.25 am; they were told that a medical assessment would be arranged. AI asked Global Exel, its agents in the region, to arrange for a local doctor to see Mrs Haigh at her hotel.
When it became clear that Global Exel was unable to make arrangements on Virgin Gorda, AI contacted Coris, a Miami-based assistance service, which set up an appointment at a clinic near the Haighs’ hotel. By this time, however, Mrs Haigh’s symptoms had deteriorated and she was unable to walk.
At 4.30 pm, almost nine hours after Mr Haigh’s first call for help, Coris advised the couple to get a boat to the main BVI island, Tortola. But the last boat had gone by then and, anyway, Tortola has no recompression chamber. Alternatively, Coris told the Haighs, call 911, a suggestion endorsed by AI, whose advisor, says Mrs Haigh, added that he did not ‘really know what more to suggest’.
Mr Haigh contacted a doctor in the UK whose view was that Mrs Haigh was probably suffering from DCI and needed to be taken urgently to a recompression chamber. The BVI has no such chambers, so Mr Haigh arranged a 15-minute helicopter transfer to the US Virgin Islands, which has one. He was asked for an up-front payment of $1,500 in cash for the flight and proof that he could pay for the hyperbaric chamber treatment. The cost of her six-hour recompression chamber treatment plus a stay in an intensive care room was $20,000, costs which Fortis did pay. The payment for the helicopter was later reimbursed by Fortis.
Mrs Haigh attributes her current health problems, such as poor balance, a damaged spinal cord and other life-changing disabilities, to the delay in receiving medical assistance.
“I was extremely angry that my condition had not been dealt with in a more professional manner; effectively they had left me for dead,” said Mrs Haigh. “I was clearly suffering from DCI, and at the end of the day I’d been offered no assistance whatsoever. If I hadn’t got to the recompression chamber when I did, I could possibly be in a wheelchair now.” She continued: “AI tried to insist that the BVI were too remote; that we had taken the word ‘worldwide’ too literally. But I’m not aware of any other meaning. As for the BVI being too remote, it’s visited each year by 2.2 million visitors.”
Mrs Haigh’s claim for compensation for the long-term health impact of the delay was not considered by the Financial Services Ombudsman, who, in his review of the case, said no medical evidence had been provided. He did, however, find that ‘the level of service provided by Fortis and its agents fell well below the level that Mr and Mrs Haigh were entitled to expect at an extremely worrying time’. His award of £5,000 (which has been paid by Fortis) was compensation for ‘the exceptionally poor level of service provided and the inevitable distress and inconvenience that Mr and Mrs Haigh suffered in consequence’.
The consequences
At London Hyperbaric Medicine (LHM), a specialist health unit complete with a recompression chamber and based at Whipps Cross University Hospital in East London, Dr Lucas Fischer points to the UK, US, Thailand, Red Sea, Caribbean, Mexico and Australia as the regions with the most developed emergency networks for scuba divers.
“Egypt and Thailand,” he said, “have infrastructure to treat patients in time, and medical treatment that's at Western standards. They know they have tourists who will pay for it, or that their insurance companies will.”
Dr Fischer's advice to people booking diving holidays is to research the locations of the nearest recompression chambers, and to find out if they are in, or close to, hospitals.
“If you manage to survive the first six to 12 hours, you are very likely to survive the DCI injury,” Fischer continued. “Ninety-five per cent of divers with injuries recover with no problems. But while not all of the rest are fatal, they [the patient] can be left with long term damage such as paralysis or stroke-like symptoms.” He added: “When accidents are fatal, death comes very quickly; it’s so serious and untreatable that the proximity of a chamber would be irrelevant.”
Fischer’s colleague Lee Griffiths, a medical technologist at the LHM, was a dive teacher for five years in Thailand, where he also supervised a recompression chamber and set up the country's Injured Diver Evacuation Service, which uses boats and helicopters. He has written a diver’s guide to decompression sickness.
Griffiths is reluctant to pinpoint regions with the weakest emergency networks, but warned: “The more remote and off-the-beaten-track, the trickier it is. The islands in the South Pacific would be an example.” He continued: “One of the problems is with novices who turn up in resorts and go diving with their fingers crossed. They take a lot for granted: tennis or golf yesterday; diving today.”
Many divers, he said, have insurance, but don't read the small print. Griffiths recommends the specialist policies available from the Divers Alert Network and Divemasters, which work closely with assistance companies that specialise in diving emergencies, saying: “The problem with non-specialist assistance companies is that they can take 12 hours, sometimes longer, to confirm that payment will be made for medical treatment and evacuation by air or sea. But it’s in those 12 hours that decisions must be made about the injury and treatment.”
A Japanese study in 2000 estimated that every hour of recreational diving is 36 to 62 times riskier driving a car
“Call handlers,” he added, “may not be trained properly, so they might be unwilling to take decisions that will cost big money. When that happens, the tendency will be to put those emergency calls at the end of the list.
“The non-specialist call handler might be told about a tingle in the fingers, but six hours later the diver can’t walk. Generally speaking,” he concluded, “the more insurance you have, the better – a regular travel policy and specialist scuba diving policy.”
Griffiths’s advice to diving novices is:
- Make sure you are fit to dive
- Get insurance cover that’s tailored for scuba divers
- Go to a reputable club or school with instructors who have recognised qualifications
- Ask the club/school what their emergency plan is
LHM has a 24-hour advice service for British divers in trouble anywhere in the world. “Our advice will be not to fly,” said Dr Fischer, “but if they ignore that advice and fly home to the UK, we'll arrange treatment at the LHM free of charge as an National Health Service benefit.’
Dominic Gibbings is a fully qualified dive instructor (who also trains instructors) in the Egyptian Red Sea resort of Dahab, where there are two hyperbaric chambers. He has seen only four cases of DCI in seven years working on Thailand and Egypt. He said: “The hospital here isn’t good now, but a new one will be opened later this year. Dahab had lots of dive fatalities in the mid 1990s, but it is much better now.” He continued: “Because of the problems in the 90s, dive safety standards here are now extremely good; there are lots of highly qualified European instructors.
If there’s a diver with a suspected DCI problem at Dahab, we have them on the back of a flatbed truck and inside the nearest recompression chamber within 30 minutes.”
Regarding travel insurance policies, Gibbings’s advice is: “Let the buyer beware. Some insurance policies cover divers only for stabilisation in the event of a decompression problem, not for treatment, so that means that in serious cases you’re not covered for the transport you need to get to a hospital or the treatment you need when you get there.”
He continued: “My understanding is that adventure sport holiday insurance – the type you get for skiing – deals adequately with diving, but this type of policy insures divers only to 30 metres. About 10 per cent of divers take courses allowing dives to 40 metres, at which point they should get proper diver insurance from organisations such as DAN and Divemaster.”
The assistance side
The case above is not a common occurrence, however, and the industry would agree that the vast majority of scuba divers who call their assistance company for help are dealt with in a timely and safe manner.
CEGA, a UK-based global assistance company handles more than 20,000 medical emergencies annually and is the assistance company for Divemaster. It has more than 60 international assistance co-ordinators running a network that includes UK and foreign legal and medical experts, remote healthcare specialists trained in handling overseas emergencies and more than 50 linguists covering 29 languages.
CEGA had 28 emergencies in 2009 involving divers with dive-specific insurance policies – although not all of them were DCI emergencies.
“It’s about one every fortnight,” said Juan Pena-Nunez, technical operations manager. “That’s a fairly low level, because most divers understand their responsibilities. They’re qualified divers; they do their research – they find out where the chambers are – they’re medically fit to dive and they dive within their limits. They use the vast amount of information that diving clubs around the world share through their websites and web forums.”
“We work not only with insurance companies that provide general travel policies,” said Dr Tim Hammond, CEGA’s chief medical officer, “but also with those who have policies specifically to cover divers, so our call handlers are trained and ready to handle DCI problems appropriately and to arrange to get the right medical care to divers as soon as possible.”
Symptoms are not always clear, so the company takes each case on its individual merits.”
He continued: “The general recommendation is that divers should be assessed first in a hospital, where doctors can diagnose the problem and see what treatment is needed. If transport by land or sea is needed, then we provide that. Flights can also be arranged, but if cabin pressures in the plane or helicopter are not set at sea level, a diver suffering from decompression could end up being ten times worse off.”
“In very remote spots,” warned Mr Pena-Nunez, “medical aid might be provided only when clinics and hospitals unimpressed by foreign insurance policies have seen the colour of a diver’s money or their credit cards. They see a foreigner who looks wealthy, and then only money talks. In those circumstances, we use our contacts and agents to negotiate on the diver’s behalf and guarantee payment, but if that doesn’t work, people will have to pay. That happens, though, in a very small number of cases.”
“Let the buyer beware. Some insurance policies cover divers only for stabilisation in the event of a decompression problem, not for treatment, so that means that in serious cases you’re not covered for the transport you need to get to a hospital or the treatment you need when you get there.”
Asking Cega about the level of training call handlers undergo when they join the company, Simon West, marketing and quality services manager, said that the company has a team of people whose expertise lies in diving have access to Cega’s own list of hyperbaric chambers around the world, so they can always tell a caller where the nearest help is. In the company’s experience, most of the callers are experienced divers who have already found the chamber and undergone treatment. If a call comes in where the policyholder is unsure what their symptoms mean, Cega has medically qualified staff on hand for immediate advice.
CONNEX Assistance Middle East provides emergency help in the Middle East and North Africa, with offices in Egypt, the United Arab Emirates and Sudan. In Egypt, there are six recompression chambers in the dive resorts along the Red Sea holiday coast, with a further two chambers in Cairo and Alexandria.
“We handle an average of 48 cases of decompression illness a year,” says Lara Helmi, the company's international network director. “Our 24-hour alarm centres have teams of multi-lingual call handlers and in-house doctors with years of experience,” she says. “We currently have more than 2,000 medical providers around Egypt. When a call is received, arrangements are made immediately to handle the case.
“To identify DCI symptoms immediately,” she told the ITIJ, “call handlers, helped by a medical team, ask a set of questions about patient's dive history, time underwater, dives within the last week, depths reached, and about his or her symptoms. At any sign of DCI, we dispatch a rescue team immediately to transport the patient to the closest hyperbaric chamber. We are continuously updated on the patient's condition, and we report to the insurance company or patient’s relatives until they are in the clear.”
For diving injuries at sea, CONNEX has contracts with all of the search and rescue teams along Egypt’s Red Sea coast. The teams have marine doctors and high speed marine ambulances. She says dive centres such as Sharm El Sheikh and Hurghada are well equipped to handle small to medium cases, while more complex ones are usually taken by road or air to Cairo.
“With some of the richest coral reefs in the world,” Ms Helm says, “diving in the Red Sea is a great experience, and when divers are properly trained and equipped, it’s for the most part a problem-free and exciting pastime.”
From its headquarters in Sydney, Customer Care (CC) provides an emergency medical assistance service covering not only Australia but also New Zealand, New Guinea, East Timor, Indonesia and the numerous islands in the South Pacific, the Malay Archipelago and three of the world’s most popular diving countries – Fiji, Vanuatu and Tahiti.
CC estimates that it gets ten to 12 DCI cases a year.
“In addition to our own team of medical specialists,” says Chris Jones, CC’s research and procedures co-ordinator, “we are able to call on the services of a variety of suitably qualified medical specialists in all the major health disciplines, including hyperbaric medicine. All staff members are trained in the initial identification of alert medical conditions, including diving illnesses, and staff are rostered to ensure a good mix of skills at any given time,” he says. “Initial calls are taken by assistance co-ordinators, who are trained to obtain preliminary information, insurance details and contact details, and to identify and escalate all alert conditions. Every medical case is escalated to a registered nurse for initial review.”
“Our call handlers are trained and ready to handle DCI problems appropriately and to arrange to get the right medical care to divers as soon as possible.”
Information call handlers need from divemasters or instructors includes details about the dive – including the depth, rate of ascent, gases used – and the diver in trouble. Were drugs or alcohol taken before the dive? Had there been signs of fever, dizziness, nausea, or muscle strain? What first aid or medical treatment has been given?
If DCI is suspected, people on site are advised to get the diver to a recompression chamber if one is nearby or, if it isn’t, to the nearest local clinic.
Working with the chamber services run by the Diving Emergency Service and Hyperbaric Health (which has 46 chambers worldwide), CC’s medical staff decide whether recompression is needed, pinpoint the location of the closest safe facility and arrange patient transport.
“There are hyperbaric chambers available in many of the locations that attract sport divers,” says Mr Jones, “but often they are poorly managed or the general infrastructure in the region is lacking; the area might have frequent power failures. One of our tasks is to identify not just the nearest chamber, but the nearest safe chamber. The insurer is notified and confirmation of financial cover is established.”
Mondial Assistance provides emergency services in Mexico where, says its USA communications director Daniel Durazo, it has had no DCI cases.
“Every call we receive for assistance is different, depending on the customer’s needs, their location and available treatment facilities and resources, Should we receive a call to help a customer with DCI, we will marshal the needed resources to insure the customer receives the best care possible as well as emergency transportation as needed.”
ITIJ asked Fortis for a comment, to which a spokesman responded: "We are sympathetic to the circumstances in which Mrs Haigh found herself. Following a review of the claim, we can confirm that the level of service provided on this occasion was not to our usual high standard and we have apologised to Mrs Haigh."
Conclusion
The DCI statistics provided by assistance companies such as CEGA, Customer Care and CONNEX suggest that relatively few divers run into decompression problems, and that even fewer suffer serious injuries and death. Clearly, there are plenty of assistance companies that take their responsibilities for training their call handlers properly very seriously, but insurers and their assistance agents that see comprehensive training for call handlers as a non-essential cost are risking not only their own reputations but also the lives of customers who are entitled to expect the comprehensive cover for which they have paid.