First published in ITIJ 103, August 2009
In May 2009, a letter was written by assistance company MIA Online to the Turkish Embassy in London. MIA’s complaint centred on disputes it was having with Turkish hospitals over their medical bills. One case involved a UK traveller with lung cancer who was admitted to hospital after feeling unwell. The man was detained for four days and a series of tests were run on him including ECG, X-rays and ultrasounds. The discharge notes advised oxygen on the flight home with a nurse escort even though the patient and his wife advised there was no need. The subsequent bill, which included removing wax from the patient’s ears, came to a staggering €5,107. A previous patient was also charged a huge amount for diagnosis of heart failure, MIA wrote. On returning home his GP could find no evidence of this. MIA asked the Turkish Embassy whether there was a Turkish body that regulated prices charged and where bills could be submitted for scrutiny, and also warned that holidaymakers would shun trips to Turkey if they were faced with losing a large part of their holiday unnecessarily detained in hospital and being faced with large bills.
Two months on and Eileen Dalrymple-White, corporate director of MIA, which provides specialist travel insurance for people with pre-existing medical illnesses, tells ITIJ that no reply has been received from the Turkish Embassy. What of the names the company ‘cc’d’ on its letter – including Conservative Party leader David Cameron and the Foreign and Commonwealth Office?
“We received a reply from Mary Heaton of the customer service centre for the Department of Health, thanking us for the letter,” says Dalrymple-White. Heaton responded with the following advice: “I am afraid that neither UK Government Ministers or Department of Health officials can intervene in this case. This is an issue which you will have to resolve with the Turkish Authorities.”
Dalrymple-White reacts: “We have not heard from the Turkish side nor have we heard from the opposition leaders in our own government. The dismissive governmental response that could have been written to a group of school children is really short-sighted.” She highlights Turkey’s attempts to join the European Union: “If they are successful there will be a reciprocal agreement between our countries. This does not mean that each country will pay for the treatment of a person from a member state, it means that they will treat people from a member state and recover the cost from the country of residence,” she states. “If we do not resolve this issue over inappropriate treatment and enhanced bills our National Health Service will be crippled. Even if the Government negotiated a set price, the difference in management of a case would still result in higher costs for us. The Turkish doctors are tending to over- investigate and over-treat.”
“Individuals will never win this battle on their own. It will help if every stakeholder, including the media, address this problem, collect data from other areas in the world and close ranks.”
So is this just a different method of treating patients, incompetence or exploitation of vulnerable people? “It is a pure revenue source,” responds Dalrymple-White. “If it were incompetence we would have had a few dead patients or indeed very ill ones.”
What should the Turkish Government and UK Government do to improve matters? “The Turkish Government could provide a body to oversee working practices within their hospitals and ensure that conservative emergency treatment is given. If this continues it could jeopardise tourist revenue and EU entry. The UK authorities could at least discuss the question with the appropriate people and at best ensure a fair working practice and costings ahead of negotiations for Turkey entering the EU.”
Dalrymple-White argues that such a move would fit with current UK Government concerns that holidaymakers are travelling abroad uninsured. “The Government is up in arms about this. This is because their consulates get landed with the responsibility for these people,” she says. “We are providing affordable insurance to try and combat this. In addition we are providing insurance to people who would not normally be able to obtain it. These hospitals and similar ones are making it untenable to do so.”
Is it just Turkey where MIA has experienced problems? “Yes it is. We are obviously aware of countries that are expensive but we can usually control costs. Turkey goes off the radar or doesn’t tell the truth so it is difficult to combat this,” Dalrymple-White states. “Even in the US we have a really good agent who works for us and gets great savings.”
As a result MIA says it is ‘most definitely’ removing cover from Turkey. “We have already declined a lot of requests from our clients,” Dalrymple-White says. “Turkey is a brick wall. They will not reduce by a penny. We have tried very hard but, even when shown evidence from UK consultants and GPs contradicting their findings, they will not budge. The only outstanding bills for anything we have are the Turkish hospital bills. We are sure that there are thousands of bills sitting around offices not paid. Perhaps if they agree to reduce bills and start being honest with treatment the industry could pull out all the Turkish bills and arrange payment at an agreed discount.”
In the meantime MIA continues its fight with the two hospitals concerned. “We have three cases at present,” explains Dalrymple-White. “We will continue to fight. We are very passionate about our product and helping people to have a ‘normal life’ given their medical history and most definitely about unfair or fraudulent practice.”
A lone problem?
Eric Grootmeijer, manager network and purchasing at Dutch company ANWB Assistance, has also experienced problems in Turkey. “We have been fighting the same battle as MIA Online for over 15 years now. We too sent a complaint letter to the Turkish ambassador in The Hague, which resulted, after a period of months, in a denial of the problem. We too challenged bills with preposterous amounts. We too were faced with our clients being held hostage by Turkish hospitals in order to obtain letters of guarantee.”
Grootmeijer goes further than MIA by stating that problems have been experienced in “every tourist emerging country”. He says: “Look at the Dominican Republic, Bulgaria, India, Mexico, Egypt and Indonesia and you’ll see the same phenomenon. What do these countries have in common? They are all relatively poor and see a huge, sometimes sudden, influx of rich Western Europeans. Restaurant and hotel owners, taxi drivers, shop keepers, they all prosper with the newly acquired industry. So is it a surprise that doctors and hospitals also want a piece of the pie? Of course not. Should we accept that? No.”
Grootmeijer says the solution is for assistance companies to ‘stand shoulder to shoulder together’. He says: “You must take a firm stand and choose a powerful agent in Turkey who shares your views on honest and reasonable pricing. It doesn’t happen overnight and we are not at our desired level yet, but these actions do lead to results.”
What Grootmeijer has not done and will not do is remove Turkey from coverage. “Travellers will still travel to Turkey. They will be forced to accept the consequences once they are admitted to a local hospital. Individuals will never win this battle on their own,” he explains. “It will help if every stakeholder, including the media, address this problem, collect data from other areas in the world and close ranks.”
But even this won’t completely eradicate the problem, argues Grootmeijer. “Since the beginning of mankind travellers have been the victims of highwaymen. Today’s highwaymen are sometimes called hospitals.”
Can we add airlines to that list? On 9 September 2008, a patient suffering from spinal injuries was due to fly home from Ercan, Turkey, via Istanbul to London on a stretcher with Turkish Airlines. The pilot of the aircraft, in an unprecedented step, demanded to see the patient’s confidential clinical record, declared them out of date and refused to board the stretcher, leaving the patient and escort stranded at Ercan Airport. This was despite Turkish Airlines themselves having confirmed both stretcher space on the aircraft and medical clearance for the patient. The escort claimed he saw no evidence that a facility for a stretcher had been made onboard, nor was there any proper lift facility present to transfer the patient onto the aircraft.
So what is the reaction from Turkey? ITIJ phoned and emailed the Turkish Embassy in London. The press office said it knew nothing about the MIA letter. After forwarding the letter on to the Embassy there was no response. ITIJ also tried two Turkish hospitals, one of which was involved in the MIA case, for comment on the issues raised by MIA and ANWB, again with no luck.
The abuse of travel insurance is spreading around the world. It is a growing sore.”
However, contact with Turkish Airlines regarding the case of the repatriated passenger last September proved more fruitful. Gokalp Yazir of the airline’s media relations team says the airline performed a ‘complete and full investigation’ into the incident.
“The sick passenger was asked for the doctor report. The companion of the sick passenger said that they couldn’t show the medical records to ground personnel and that they could only show them to the captain,” says Yazir. “They were escorted to the captain and he inspected the papers and explained that he was not able to allow the documents as they were old and out of date.” Yazir says Turkish Ailrines acted in ‘full conformity’ with International Air Transport Association rules and regulations.
“We are fully dedicated to customer satisfaction, including our sick passengers from the UK,” adds Yazir. “The UK holidaymaker in this case did not have the proper documents. Therefore our staff couldn’t provide that sick passenger with enough help. There is no other reason behind this and we work with the guidance that ‘our passengers are our bosses.”
Dr Mustafa Atac, chief executive of Turkish travel assistance firm Marm Assistance, has a different stance. “Many would prefer this issue to be swept under the carpet. The abuse of travel insurance is spreading around the world. It is a growing sore.” Regarding the Turkish Airlines case, Atac says: “It is probably the most hardline applier of EASA rules and regulations. They only read and implement the restriction lines and allow zero tolerance on passenger or patient air transport. There are courses and programs on educating and training the Turkish Civil Aviation Authority on certain flexibilities but I doubt they have participated in any of them. The insurance company should ask for a claim and compensation in this case.”
Overcharging of hospital bills in Turkey happens much more frequently. Atac says. “There is patient and insurance abuse. There is highway robbery. We have a so called medical system which is unquestioned. It is not challenged and is free to grab and run any opportunity using innocent travellers as a vehicle.”
We have a so called medical system which is unquestioned. It is not challenged and is free to grab and run any opportunity using innocent travellers as a vehicle.”
He adds: “Turkey and underdeveloped countries cannot develop a system to tackle this issue. Why expect the Turkish government to do anything if they have continuously failed for over 30 years?” Atac’s solution is akin to Grootmeijer’s and, indeed, Marm has acted as ANWB’s agent in Turkey. “How many of the stakeholders are willing to tackle this issue? Would they join in making a taskforce? How determined are they to stand together and fight the abusers or do they prefer to compromise with weak voices and quick settlements?” he asks. “As long as there are travel assistance and insurance companies who agree to pay high costs there will be little progress in fighting inflated bills.”
Turkey, it seems, has a long way to travel.