The ITIJ team have been reporting live from ITIC Global in Barcelona this week (November 2023) sharing the discussions that took place at the conference. Read all reports
Darren Saunders, Managing Director, Payingtoomuch.com, Staysure Group
Saunders began by defining what a mental health disorder is, followed by the statistics that one in eight people live with such a condition.
In conjunction with travel insurance, he noted that ‘pre-existing medical conditions (PEMC) travel insurance cover for mental health conditions was an automatic exclusion across travel insurance policies until around 10 years ago’. However, despite being fully claimable now, Saunders clarified that mental health conditions must be declared as a PEMC and substantiated by a medical expert.
For underwriters, mental health cover is written in the same way as other PEMC. They will use claims history to determine risk, but difficulties remain, explained Saunders. Firstly, because of the block exclusion of cover until 10 years ago, which means that this dataset is still being built. Also, many customers don’t declare their mental health condition as they don’t view it as a PEMC. Finally, the social stigma of mental health conditions continues, despite increasing awareness.
Advancements in screening for pre-existing mental health conditions is assisting the travel insurance industry, for both insurers and customers, said Saunders. The Verisk Black Box screening tool has found that mental health declarations account for 11.4–13.8 per cent of the top 20 declared conditions, yet the risk score for travellers with mental health conditions is up to 2.5 – Saunders highlighted scoring for other conditions can go up to 70.
He further explained the challenges insurers are facing:
- Airline repatriation – airlines are reluctant to carry unstable passengers
- In-network mental health facilities – hospitals cater for physical rather than mental health
- Understanding of local mental health facilities and quality control
- Management and ongoing treatment are lengthy and specialised
- Impact of physical conditions on mental conditions – can delay other treatment or repatriations.
To conclude, Saunders said that travel insurance coverage for people with mental health conditions has significantly improved over the past decade but there is still room to develop. This will come with better underwriting skills, tools, datasets and understanding of mental health conditions, which will then benefit the needs of those customers. As Saunders summarised: “If we stand still, we go backwards.”
Susan Yates, Head of Americas Region, Falck Global Assistance
Yates brought the perspective of the assistance services side, including healthcare services and medical transportation.
She explained that incidences of mental health cases in the assistance industry can vary depending on the clients themselves – whether they are students, expats or digital nomads – and the nature of the insurance coverage – any exclusions for mental health or pre-existing medical conditions.
Yates highlighted that eight per cent of Falck’s global assistance cases related to mental health, with one per cent of them being severe enough to need hospitalisation and potential repatriation. She said the company usually sees cases related to:
- Stress, anxiety, and/or isolation
- Substance abuse
- Lack of medication compliance
- Lack of access to appropriate mental health services – waiting times, language issues
- Post-traumatic stress disorder (PTSD) from witnessing tragic events.
Yates then presented a severe mental health case study from Brazil. The patient had witnessed an incident where a child was killed. This patient had also stopped taking their prescribed medication for bipolar II disorder. They went into a manic state and were involuntarily hospitalised and would not provide information on their medication or sign a HIPAA release. Falck contacted the patient’s emergency contact, their sister, for more information, but she didn’t know the medication details; their brother, however, was able to provide the information. Once the patient was stabilised, arrangements for repatriation were discussed but the patient refused to be transported. The brother also had power of attorney and authorised Falck to repatriate. The patient was transported with their brother and a specifically chosen escort to offer support during the repatriation and was re-hospitalised at home.
This case shows how bystanders can often be overlooked in emergency situations. Yates explained that Falck and others are launching programmes to support bystanders on-scene and in the following weeks via online or local resources. She also explained the learnings from this case, such as involuntary hospitalisation and legal/privacy challenges, which differ from country to country.
She ended her presentation by explaining considerations transporters need to make and her recommendations regarding assistance and medical health cases.
Dr Adrian Hyzler, Chief Medical Officer, Crisis24
To begin, Hyzler highlighted three types of travel: business, student, and digital nomads. He acknowledged the similarities and differences between these groups, in connection with mental health. The five shared challenges were:
- Limited access to mental health resources
- Language barriers to seeking help
- Cultural stigma around discussing mental health
- Lack of routine in accessing mental health support
- Balancing work demands with personal wellbeing.
He also explained some of the support mechanisms assistance companies put in place for travellers who experience mental health conditions pre-, during, or post-travel. These were pre-travel assessments; a 24-hour helpline; psychologist support; psychiatrist support; planned counselling; and repatriation or evacuation.
Hyzler then presented three case studies. In one of them, he explained the relatively new phenomenon of cannabis withdrawal in international students. With recreational cannabis becoming legal in many US states and countries worldwide, students could be experiencing withdrawal when travelling abroad to study in destinations where it is banned. If they had been using cannabis to manage their mental health, this withdrawal could lead to anxiety or angry behaviour – both seen in this patient. Crisis24 organised a telemedicine psychotherapist for the patient.
Hyzler then focused on how travellers can manage mental health. Firstly, insurance – he advised that pre-existing medical conditions need to be declared and, if necessary, travellers should check with their doctor that they are happy for them to travel.
Next was medication, explaining that forgotten, lost, stolen or confiscated medication may be difficult to replace when abroad.
Changes in time zones and subsequent jet lag can also disrupt mental health. Hyzler’s advice was to work out the time difference and write out a schedule to take medication.
Also, monitoring your mental health throughout a trip is key, and, if needed, take a break, or seek help and advice.
To close his presentation, Hyzler explained why, despite some difficulties that could happen during travel, it is good for mental health. He said it is ‘enriching your life and enhancing your happiness’. He defined travel as ‘a chance to collect, reflect and reinvent’.
Dr Thomas Buchsein, Associate Medical Director, FAI Aviation Group
Coming from an aeromedical perspective, Buchsein explained that the focus on mental health is ‘all about behaviour’. This is the case for transports on commercial airlines, where the focus is not on the patient, but the other passengers onboard. He highlighted that both the patient and escorts ‘always have an audience’, so managing behaviour can be complex.
In terms of regulations, he highlighted the International Air Transport Association’s (IATA) Medical Manual and the MEDIF form. In the former, Buchsein noted this section: “Medical clearance is required by the airline if the passenger… is likely to be a hazard or cause discomfort to other passengers because of the physical or behavioural condition.” And in MEDIF, section 16 asks if ‘there is a possibility that the patient will become agitated during flight’. Both regulations put the onus on how the behaviour of the patient affects other passengers.
Buchsein then explained that if it is not unlikely that a patient will be disruptive on a flight then they can’t take a commercial flight. But he said that, in any case, two medical escorts at least are required, with one being a doctor.
Air ambulance aircraft could then be considered, but they aren’t without limitation either. Usually there is no cockpit door, leaving the pilot and technology exposed to the patient, and sometimes the toilet has an emergency exit and/or access door to the baggage compartment, he said, which raises the issue of whether the patient can go to the toilet alone.
However, considerations don’t begin with the aircraft; there are legal considerations to be aware of from the start. To force transportation, it must be considered whether the patient could be a hazard to themselves or others and if they are in a safe place. If so, in many countries, it is not legal to force them into a transport. If they have been incapacitated or their legal capacity limit been reached due to power of attorney, the patient could be forced to be transported, explained Buchsein.