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ESSENTIAL READING FOR TRAVEL INSURANCE INDUSTRY PROFESSIONALS WWW.ITIJ.CO.UK APRIL 2011 • ISSUE 123

Let’s talk about sex

On 1 March, the European Court of Justice decided that insurers

pricing risk according to gender is incompatible with the fundamental

principles of European Union (EU) law in the ‘Test Achats’ case. The judgement is expected

to have a major impact on the European insurance market and will require all insurers to review a wide

range of policies to ensure gender-based pricing is removed. Mandy Aitchison reveals the details

The change in the law means that the use of separate actuarial tables for men and women in the calculation of premiums and

benefi ts will be outlawed. Particularly affected will be the motor, life and health insurance sectors of the market, where the gender of the

proposer is nearly always taken into account in the pricing of the policy.International legal fi rm Norton Rose LLP expressed its concern about

the knock-on effects of the law: “Following the logic of the Test Achats case, pricing based upon other areas of discrimination such as religion or belief, disability, age or sexual orientation could also be found to be incompatible with EU law.” In principle, continued the law fi rm, the decision that gender-based pricing is incompatible with EU law could have immediate and indeed retrospective effect as the legislation allowing the

discrimination becomes invalid. Policies made under the derogation will be incompatible with EU law. However, the Advocate General has

proposed that in order to avoid the consequences of immediate illegality, there should be a transitional period.

ITIJ spoke to Ashley Prebble and Noleen John, insurance lawyers at Norton Rose, about the decision and the likely fallout. John

is concerned about the length of time insurers will have to adapt: “Insurers will from December 2012 need to apply

unisex rates. This transitional period is less than that recommended by the Advocate General and means that insurers will need to review their policies and practices as soon as possible. It also seems likely, in view of the length of the transitional period, that insurers may need to use uncertainty premiums until they have suffi cient data in relation to the carrying on of business on this new basis. This could result in higher premiums or lower benefi ts for certain policyholders (female motorists and male annuitants).”Ashley Prebble said: “There is going to be

uncertainty in the insurance market for some time as a result of this decision. It is likely that the decision will require the European Commission to clarify the position with regards to other potential areas of discrimination, particularly age and disability, [which] might be done through Protocol, setting out exactly what insurers will be able to do in terms of differentiating the risks posed by different categories of policyholders.”Simon Sheaf, Grant Thornton’s general insurance actuarial practice leader, also commented on the possible effects of the change: “There is the potential for anti-selection for any insurers acting ahead of December 2012 and for all insurers over the change-over [period, which] will need to be addressed. This issue applies to a number of general insurance products, such as motor and personal accident, as well as to life and health products meaning that both the life and general insurance industries have major exercises to undertake.” Currently, the change in law is still open to challenge; however, Sheaf added: “The challenges to insurers will now be to fi nd any underlying risk identifi ers that sit behind gender differences and to move towards using these as rating factors by December 2012. Ironically, the new Solvency II capital regime creates higher capital requirements where risk factors have been ignored.” Nigel Cooke, Grant Thornton’s senior life actuary, says there is a greater concern that insurers should be focused on: “As a consequence of the judgement, all differential pricing that has occurred since the Gender Directive was implemented in 2004 may yet be challenged as a fundamental infringement of rights enshrined by the EU Treaty, despite the fact that the Directive permitted the differential and will continue to do so until late 2012. Whether this would be the fault of insurers, the regulators or the EU itself would then have to be considered.” For more information, see ITIJ’s News Analysis Gender Realignment on p.22

International Travel Insurance Journal

2 NEWS

IN THIS ISSUE

REGULARS

News continued 4

Editorial blog 6

Company brief 8

Travel matters 9

Insurance matters 10

Health matters 12

IPMI news 14

Cross-border care 16

Air ambulance news 18

Service directory 43

Grapevine 50

On the move 51

ITIJ CONTRIBUTORS

Published on behalf of: Voyageur Publishing & Events Ltd, Voyageur Buildings, 43 Colston Street, Bristol BS1 5AX, UK

The information contained in this publication has been published in good faith and every effort has been made to ensure its accuracy. Neither the publisher nor Voyageur Ltd can accept any responsibility for any error or misinterpretation. All liability for loss, disappointment, negligence or other damage caused by reliance on the information contained in this publication, or in the event of bankruptcy or liquidation or cessation of the trade of any company, individual or fi rm mentioned is hereby excluded.

Printed by Pensord Press, South Wales, United KingdomCopyright © Voyageur Publishing 2011. Materials in this publication may not be reproduced in any form without permission

INTERNATIONAL TRAVEL INSURANCE JOURNAL ISSN 1743-1522

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ITIJ TEAM

Gerry Bolger MHM, RN, is a freelance in-fl ight nurse and policy advisor on pressure ulcers at the Department of Health, England. He is also the programme director for the Quality in Caring work within the Chief Nursing Offi cer’s (CNO) Directorate at the Department of Health. He formerly led the Royal College of Nursing In-fl ight Nurses Association as their chair for eight years and has been involved in clarifying issues on medicine administration in that role.

David Ing is a freelance journalist covering mainly travel and tourism issues in Spain. He writes on air transport for a leading international news agency, as well as contributing special features to Newsweek and writing in-fl ight magazine articles and guidebooks.

Roger St Pierre is an avid traveller who has visited 119 countries and rising. He writes and broadcasts extensively on the tourism industry, motoring, cycling and music. He is also fascinated by how the global economy works. At 15, he already had fi ve regular newspaper columns covering sport but also happens to be a qualifi ed associate of the Chartered Insurance Institute and writes regularly on business and fi nancial matters for a number of prestigious publications.

Design: V Creative Design

News analysis: Genger realignment 22Rule changes in the European Union could have far-reaching effects for the insurance industry

Feature: UAE provider fraud 26The rise of fraudulent activities in the health insurance sector is examined

Feature: ITIC Miami Review 30A round up of the panel sessions that took place in Miami at the International Travel Insurance Conference

Assistance & Healthcare World Markets: Mauritius 38A dream holiday destination, but are the healthcare facilities up to standard?

FEATURES


4 NEWS

Only one third of Australians check government travel advisories before booking their overseas holidays, while 38 per cent seek no travel safety advice at all, according to research from Travel Insurance Direct.A survey undertaken by online company Travel Insurance Direct has found that although the Australian government’s Smartraveller website, operated by the Department of Foreign Affairs and Trade (DFAT), remains the most popular source of safety advice for Australian travellers, only 34 per cent of those surveyed said they checked the site before booking a holiday. Others said they sought safety advice via a combination of online search engines (23 per cent), friends and family (13 per cent) and from their insurers (five per cent), but 38 per cent sought no advice at all.Ian Jackson, general manager of Travel Insurance Direct, said that the company’s findings were of particular concern given recent events in Northern Africa and the Middle East. “Being fully aware of the risks of travelling is absolutely essential and the government’s advice on the Smartraveller website should always be considered carefully. It’s not only

important for your personal safety, it can also affect your insurance – if you choose to travel against DFAT advice then you might not be fully covered.” The survey found that those who travelled the longest were most likely to check the advice offered by the DFAT website. Forty per cent of those who were away for a month or more said they checked the site, compared to only 32 per cent of those who travelled for shorter time periods.Of some concern to travel insurers should be the revelation from the survey that up to 10 per cent of Australians have travelled without adequate travel insurance. “We found a strong awareness that the cost of travel insurance is small compared to the risks if something goes wrong, but it’s still concerning that a lot of Australians are venturing overseas completely unprotected.”

Online purchases rise

Business travel cover concernsSpecialist life, accident and special risks broker Strategic Broking is highlighting the potential risk to businesses that have employees working in high-risk areas around the world. As Matt Chilton from the company explained, standard business travel policies may not provide the cover needed in the exceptional conditions that are now occurring: “With organisations searching further afield for business opportunities, business travellers are likely to travel to higher-risk areas. Their employers, therefore, need to ensure they have the adequate protection and support, and with the recent unrest in a number of regions around the world, this is more crucial than ever.” He said that Strategic Broking has been working with a number of companies to provide comprehensive business travel policies that incorporate a variety of additional benefits. “Significant enhancements include vital cover for political evacuation of employees. This reimburses the costs involved in evacuating an insured traveller due to expulsion from, or political instability in, the country in which they are working. Additional cover is also provided for hijack, kidnap and evacuation following natural catastrophes as well as providing access to a range of assistance services.”

Medical claims show need for coverNew Zealand-based company Southern Cross Travel Insurance (SCTI) has highlighted the importance of travel insurance cover as it releases its claims figures for 2010, which show that one claim for medical care and repatriation from the US alone cost over NZ$1 million. That claim, and four others that amount to over $100,000 each, were all related to Kiwis becoming critically ill while overseas. Furthermore, the company’s statistics show that two other New Zealanders treated in the US filed claims costing $249,000 and $168,000. A $273,000-claim was made by a policyholder who fell ill in France, meanwhile, and another claimant who became unwell in Switzerland claimed for $136,000. SCTI said that more than half of its total claims costs of $15 million last year related to medical and evacuation expenses. The net premium revenue for the company was $34.7 million for the year to 31 December, with more than 100,000 policies being bought over the period.SCTI chief executive Craig Morrison said that the cost of travel insurance represented a tiny fraction of the potential cost of becoming ill or injured while overseas, even in countries with reciprocal health agreements such as the UK and Australia. “In the

US and Europe, medical costs can be astronomical – and that’s before you take into account the cost of evacuation. In many countries, if an accident or health problem strikes, you may also be left with a hefty bill for air, boat or ground ambulance travel.”

Research from UK-based company World First Travel Insurance has shown that more than 50 per cent of their past customers choose to buy their travel insurance policy online, directly from their chosen insurer. The research, which was carried out by independent company PFA Research, targeted more than 600 people throughout the UK who had previously insured with World First. The research was carried out to monitor trends in booking patterns after World First saw a steep rise in the number of online bookings it had received in a six-month period and wanted to establish if that was at the cost of other, more traditional methods of purchasing insurance.Respondents were asked how they usually bought travel insurance and were able to select up to two answers. In total, 63 per cent of those surveyed said they buy travel insurance online, and of those people, 51 per cent said they would buy it directly

through the website of their chosen insurer, rather than through a price comparison site. The second-most-popular way for people to buy travel insurance was over the phone, while the least popular methods were through an insurance broker, face-to-face with an insurer, and as part of a holiday package.Martin Rothwell, managing partner of World First, said: “We have noticed that more people are buying travel insurance online. With the improved online medical screening facilities now available, people are finding it even easier to provide all of their details via an online application.” He added: “It’s reassuring to see that only a small percentage of people are buying their insurance as part of a holiday package deal. This means that more people are taking out tailor-made packages, rather than a ‘one-size-fits-all’ policy that can have limited cover, especially for people who need medical travel insurance for pre-existing medical conditions.”

Aussies ignore warnings

www.itij.co.uk

NEWS 5

Cruise cover concerns

Japanese disaster coverage

John W. Cook, president of QuoteWright, an online travel insurance comparison service, has warned that most travel insurers will be classifying the tragic earthquake and tsunami in Japan as a natural disaster, and as such this will have a serious effect on coverage offered for trip cancellation and interruption insurance. He said: “Under those coverages some, but not all, companies include natural disasters, which cause your airline to cease operations, to be a covered event. Most of the plans limit coverage for natural disasters that make your destination uninhabitable.” The coverage offering for travel delay and missed connection is often clearer, he added, as these coverages are also ‘named peril’ benefits; however, the majority of plans include natural disaster as a covered event. “The bottom line,” he said, “is to read your plan carefully and don’t assume that there will or will not be coverage.”At the time of writing, concerns were rising about the increasing level of radiation being released into the air as a result of explosions at nuclear power plants in Japan. The General Insurance Association of Singapore has warned consumers that travel insurance policies sold in the city state do not cover fallouts from nuclear disasters. The cover provided by local insurers excludes any loss, damage, illness directly or indirectly arising from the existence or escape of nuclear, ionising radiation as well as contamination by radioactivity from nuclear fuel. Consumers were urged to check the terms and conditions attached to their travel insurance.The Australian government’s Department of Foreign Affairs and Trade has issued a formal warning not to travel within 20 km of the Fukushima Nuclear Power Plant in Japan, or the Miyagi Prefecture. It has also advised Australian travellers to ‘reconsider your need to travel’ to Tokyo and the prefectures of Chiba, Fukishima, Aomori, Iwate, Nagano, Niigata and Ibaraki. The US State Department has warned its citizens to avoid travelling to Japan altogether, while the UK’s Foreign and Commonwealth Office has advised British nationals that only essential travel should be undertaken to northeastern Japan.

Squaremouth, the online travel insurance comparison site, is recommending that travellers compare multiple cruise insurance policies before they rush into buying the cover offered by a cruise line. Chief executive Chris Harvey warned: “Purchasing the wrong travel insurance policy could result in a higher premium with lower benefits.” He added: “Travellers embarking on a cruise should be warned of the possible disadvantages of purchasing travel insurance through their cruise line,” as many cruise lines only offer one travel insurance option. In Harvey’s opinion, the insurance offered by cruise lines is usually inferior to third-party products and can be much more expensive as it could include large administration charges. Another reason for not buying from the cruise operator, according to Squaremouth,

is that third-party policies tend to have an allowance for the holder to cancel their holiday and receive a cash refund, whereas on most cruise line-sold policies, they only offer a cruise credit for part of the trip. Finally, Harvey believes that travellers shouldn’t consider the cruise line insurance as their sole option as many policies only offer cover up to $50,000 for medical evacuation. He said: “A single incident might require an airlift from the ship, transportation to multiple medical facilities and even a flight home. If a travel insurance policy does not provide enough coverage, the balance of such an expensive ordeal becomes the responsibility of the traveller.” Squaremouth recommends comparing policies that offer between $100,000 and $500,000 of medical evacuation coverage.


6 NEWS


Well, well, well … we live in turbulent times.The earthquakes and tsunamis of the Pacific region have once again wreaked havoc on the populations of Japan and, to a much lesser degree, New Zealand. The threat of a nuclear Armageddon has had most of us transfixed over the last month.And as the armed conflict and insurrection across the MENA countries continues, also dominating the news, you can’t help but wonder where we’ll be in a couple of months.The appalling loss of life, the economic damage and the shift in politics are all things that will affect us all in the coming months and years.… Fortunately for travel insurers, at least, it will have had little impact on claims. Egypt and Tunisia have both calmed down, and unless you count both tourists who were actually on vacation in Libya at the time of the revolt, or the mass exodus of English Language teachers from Japan, and of course the crack UK SAS team (with diplomats) who nipped over to have a quick chat with the Libyan rebels and got arrested (now they definitely could have done with the services of an assistance company) then there wasn’t a lot going on.Now, if you’re involved in expat insurance, you’ll have been a very busy bee over the last couple of months ...

Ian [email protected]

NEWSWIREFitch Ratings has revised UK travel bond insurer Travel & General Insurance Company plc’s rating outlook to Stable from Negative and affirmed its Insurer Financial Strength Rating as ‘BBB-’. The change in outlook and affirmation reflects the stabilisation of the organisation’s risk-adjusted capital assessment at the end of October last year.

UK consumer organisation Which? is to launch a challenge against the surcharges that many companies impose when customers pay with a debit or credit card. Low-cost airlines are among the companies prone to charging a fee per passenger, per leg of the journey, in spite of the fact that they only have to process one transaction.

The UK’s Financial Ombudsman Service saw 644 complaints about travel insurance in the third quarter of last year, a significant decrease from a year earlier. Nearly 40 per cent of the claims received in this period were resolved in favour of the consumer.

Post Office Travel Insurance is reminding those planning to take a holiday this year to ensure they are adequately covered by their travel insurance policy before they set off. It also reminded travellers of the convenience of annual cover, which can offer better value for money to some travellers.

Online insurer Chill Insurance is to create 100 new jobs in the next three years at its base in Dublin, Republic of Ireland, as it plans to increase online sales in various insurance products, including travel insurance.

A five-year-old boy died after being buried under snow that was being moved by a snowplough at the Spanish resort of Baqueira Beret in the Pyrenees. He spent 11 days in intensive care before he died.

Repat figures releasedIrish insurer Vhi Healthcare has released figures that show nearly 5,500 of its customers required emergency medical treatment while abroad throughout the course of 2010. The insurer’s statistics show that nearly 1,600 of these claims involved hospitalisations, and there were nearly 400 international repatriations. Regarding the geographical spread of the claimants, Vhi paid out €4.3 million for medical claims in the US; €3.5 million in Spain and €500,000 in Portugal. The top three reasons for the hospital visits were accidents, infectious diseases and cardiovascular problems. The most common claim under the company’s MultiTrip travel insurance policy was for cancellation or curtailment of a trip, which accounted for 41 per cent of claims, while a further 32 per cent of claims were for outpatient medical expenses, and 13 per cent was for the loss or theft of baggage.Declan Moran, director of marketing and business development for Vhi Healthcare, commented on the claims data: “The highest single claim we paid for involved the treatment of a baby who fell ill in the US and incurred medical bills of approximately €190,000. While we’re all facing financial challenges and cost is clearly an issue when shopping around, the value of a comprehensive travel insurance policy is clear to see.”In related news, the results of a recent survey carried out by Vhi has shown that the number of people with travel insurance has declined sharply over the last three years as the recession hit home. The survey, which was carried out in October last year, found that 32 per cent of those surveyed had travel insurance, compared to 42 per cent in the same survey from 2007.

Signposting support for older customersThe British Insurance Brokers’ Association (BIBA) has welcomed a new consultation paper from the UK Government Equalities Office, entitled Equality Act 2010: Ending age discrimination in services, public functions and associations. The paper outlines proposals where the government intends to encourage action to improve access to insurance products so that if a provider is unable to provide assistance to a person because of their age, it will be obliged to refer that person to a provider who can meet their needs or to a dedicated signposting service. BIBA believes that signposting will greatly benefit customers who are excluded from highly commoditised and web-based insurance offerings because they do not fit the standard risk model on age. The organisation says that signposting will be of particular benefit to car and travel insurance customers, as these are areas that have already been identified as where some people have difficulty finding affordable and adequate insurance.Graeme Trudgill, head of corporate affairs at BIBA, said: “There is a solution through insurance brokers who can arrange insurance cover on the more complex risks. Signposting will help consumers to find the protection they need, otherwise they run the risk of travelling uninsured.”Plans announced by the Equalities Office will make it unlawful to unfairly discriminate against someone because of their age when providing goods and services, although specific exemptions will allow companies to continue to offer beneficial services to certain age groups – for example, free bus travel to over-60s. However, the Equalities Office stated: “Providers of financial services, such as insurance companies, will still be allowed to use age when

assessing risk and deciding prices. However, the new law, which will take effect from April 2012, will mean they have to base such decisions on solid evidence rather than simply imposing a blanket ban. Insurers will also be asked to help people find an alternative provider if they are unable to provide cover for age-related reasons.”

Victory for airline passengersEUclaim, an organisation dedicated to airline consumer rights, has announced that the British Courts have clarified that there is no general stay of claims against airlines for compensation in cases of delays of more than three hours brought under EC Regulation 261/2004. The court ruled that an application to stay in a particular case is not tantamount to a general suspension of the Regulation. Airlines in the European Union had apparently been wrongly interpreting an order of the UK High Court in the judicial review case of TUI Travel plc, British Airways plc, easyJet Airline Company Limited and International Air Transport Association versus The Civil Aviation Authority (CAA) by stating that this case placed an automatic general stay on all delay cases, when this in fact is not the case. The effect of the ruling from the British court is that any passengers who may have a claim against airlines for compensation under the Regulation for a delay of more than three hours where ‘extraordinary circumstances’ do not exist, can proceed with their claim.Mike Rattenbury, solicitor and director of EUclaim UK, said: “We are happy that the courts in the UK have confirmed what we always knew – that delay claims against airlines have not been stayed generally. This means that the CAA, and airlines themselves, must continue to interpret the Regulation as imposing an obligation on air carriers to pay compensation in the event of a long delay.” He added: “If the airlines fail to comply, the CAA can invoke its powers of enforcement.” Hendrick Noorderhaven, chief executive of the consumer organisation, said: “It is vitally important that passengers who may have such claims now pursue them and bring them to the attention of the airlines as soon as possible. Although EUclaim is disappointed that it has taken many months to clarify the position, it now trusts that airlines will proceed to process compensation claims.”

Repatriation changesInsurers and assistance companies that have patients who require oxygen should be aware that there have been some recent changes from European airlines that could affect the provision of such services. From February, Iberia stopped offering oxygen on aircraft leaving from Tenerife South airport, Lanzarote, Santa Cruz de la Palma, San Sebastian and Pamplona. The shift in policy is due to restructuring and personnel changes at the above airports, and could be a temporary change; ITIJ will keep you up to date with changes as and when they occur.

Elsewhere in Europe, Greek airline Olympic Air has dropped its routes flying from Heathrow to Athens and Gatwick to Thessaloniki, which will seriously affect the number of flights available to assistance companies seeking to repatriate travellers from Greece to the UK. The only other airlines operating these routes are British Airways and Aegean, both of which are considered to be more expensive than Olympic Air. The move by Olympic Air comes following the European Union Competition Commission’s rejection of the proposed merger between Olympic and Aegean, even though the two airlines are expected to appeal against the decision.

www.itij.co.uk

NEWS 7

NEWSWIRE Ignore government advice at your perilAccess America reminds skiers of coverUK-based World First Travel Insurance is reminding travellers that they must observe Foreign and Commonwealth Office (FCO) travel advice as a condition of their travel insurance policy. Failure to comply with FCO advice will invalidate insurance policies, leaving customers vulnerable. Currently, the FCO advises against all travel to the Ivory Coast, Somalia, and Bahrain, as well as all but essential travel to Japan, Guinea, Haiti, Mauritania and Niger.Martin Rothwell, managing partner

of World First, said: “As travel insurance specialists, we rely on FCO advice in judging the risks and necessary actions to ensure we deliver the best possible service. If customers find themselves in a country or region when advice is issued not to travel there, they will be covered and we work hard to get them out as quickly as possible. If customers ignore FCO advice, for example, set off to Bahrain on holiday, we and all other travel insurers will not cover them.” He went on to urge anyone travelling to destinations where there is a perceived higher risk to use the FCO’s Locate service, which is designed to ensure that anyone travelling to foreign shores is accounted for and not forgotten should anything happen in the destination during their stay.

With the National Oceanic and Atmospheric Association predicting that the La Niña weather phenomenon will contribute to colder weather in the northern hemisphere, the promise of deep powder snow in ski resorts across the US and Canada has prompted Access America to warn travellers about the importance of ski and snowboard insurance. Daniel Durazo, director of communications for Access America, said: “Skiing is one of the best ways to enjoy the great snowfall we’ve experienced so far this year and travel insurance can provide greater peace of mind when vacationing on the slopes. A good tip for anyone planning a ski vacation is to make sure you have a travel insurance plan that offers medical assistance, including medical evacuation.” He added that skiers should note that extreme skiing, heli-skiing and skiing outside marked trails are excluded from coverage in most insurance policies, and skis and snowboards are eligible for lost, stolen or damaged baggage coverage only when they are checked in with a common carrier.

Emergency help for Goan touristsThe increasing number of tourists heading to Goa has brought with it an increase in the number of emergency incidents, prompting the Indian government to team up with a private company in order to offer a toll-free number that tourists can call for help 24 hours a day. State tourism director Swapnil Naik said the helpline would be dedicated to tourist-related concerns and address emergencies. He added: “We are looking forward to working on a public private partnership model to initiate and manage the functioning of this helpline. The centre too is working towards setting up a National Tourist Helpline.”Over the last few years, international reporting of incidents such as the 2008 murder and rape of British girl Scarlett Keeling, and the subsequent attempt to cover up the case by authorities, have affected the idyllic image of Goa represented in tourism literature. In light of such negative publicity, several initiatives to improve the safety of tourists heading to the area have been mooted that have the support of tourism industry stakeholders. Ralph de Souza, spokesperson for the Travel and Tourism Association of Goa, said: “The setting up of the tourist helpline is an excellent initiative put forward by the Goa Tourism Department, and the industry welcomes it wholeheartedly. While other emergency helplines like 100 and 108 (for medical emergencies) are extremely effective, an additional helpline meant solely for tourists is most welcome.”Other measures to make tourists feel more confident about travelling in Goa include the establishment of tourism assistance booths, which will be built in 14 areas that have high numbers of tourist visitors. Naik said: “The tourism department has also issued an expression of interest calling for quotations from interested parties to set up eco-friendly tourist assistance booths at 14 prominent places as well as to maintain them for the next five years. Manned by Tourist Police and the newly commissioned Tourist Security Force, the smart booths will act as a contact point for tourist information and assistance.”

Baga Beach, Goa

International Travel Insurance JournalInternational Travel Insurance Journal

8 COMPANYBRIEF

NEWSWIREUS-based International Services, Inc. has launched a new website dedicated to helping customers find suitable travel insurance cover, as well as offering them key information about the nature of travel insurance and what it covers.

Traveller safety e-learning course Travel Angel has won the Business Travel & Meetings Show Gold Innovation Award. The course has been developed using instructor-led training to reduce corporate traveller exposure to risk through education and awareness training.

Heath Lambert Insurance Services in the UK has extended its partnership with The Stroke Association to offer a new suite of travel insurance products for stroke survivors, their families and carers. Two levels of cover – platinum and gold – are available; both cover pre-existing medical conditions and disabilities.

Finnish travel organisers are planning to launch a joint liability insurance programme for travel agencies and tour operators, which could protect companies against potential losses caused by cancellations due to exceptional circumstances such as the April 2010 ash cloud.

Lloyd’s intermediary SportsCoverDirect has added new activities to its offering, including soap box racing and canoe polo competitions.

UK company World First Travel Insurance has teamed up with national independent charity Dreams Come True to help provide travel insurance to families with children who have pre-existing medical conditions. The charity fulfils the dreams of terminally or seriously ill children.

easyJet’s single and annual multi-trip travel insurance products have been awarded five stars by Defaqto, a UK financial research company. The policies are underwritten and administered by Mondial Assistance.

TravelBru, a travel website, has launched a travel insurance policy for its customers that can be bought before or during the person’s travels, and is easily extendable at any point during the trip. The insurance covers a range of adventure sports, including kitesurfing.

The Canadian National Union of Public and General Employees has announced that its members can now access travel insurance for individual or family coverage from MEDOC.

Ancile acquires Sun SelectionUK-based Ancile Insurance Group, the newly created consumer direct travel intermediary, has acquired specialist insurance brand Sun Selection. Supporting Ancile’s core business objective of operating multiple travel insurance brands in niche markets, Sun Selection becomes a trading style of the Ancile Insurance Group, which will invest in the growth and development of the brand and its products. Sun Selection’s current proposition includes travel insurance for those with pre-existing medical conditions, as well as pregnant and mature travellers, tapping into currently under-served niche markets.As part of the deal, the Sun Selection website will be re-launched later this year to provide a more user-friendly and intuitive online quote and purchasing process, while telephone support and customer service is provided by the Ancile call centre. Graham Linney, managing director of Ancile, said: “This is a key acquisition as Ancile aims to develop a robust portfolio of insurance brands. Sun Selection already has an established insurance offering, which is strong in the over-65s and impaired health markets, making it a perfect fit for the Ancile Insurance Group.”

Backpacker web service startsEntrepreneur and world traveller Matthew Coe has launched a new website that makes it easy for visitors to compare backpackers’ travel insurance online, allowing users to identify the most affordable and suitable options for their trip. The website, Leavingonajetplane.co.uk, is designed to help individuals compare the different policies available

on the market, and claims to offer comparisons that are ‘generally not available through other websites’. The website compares the top-five UK companies that offer backpackers’ insurance – Direct Travel, Downunder, Essential Travel, Endsleigh and World Nomads. Matthew Coe said the service doesn’t stop merely at comparison of policies: “We also offer a personalised service where users can email us their trip details, and we will manually search the providers for them, making sure that all the details of their trip will be covered.”

Co-operative offers ethical coverThe Co-operative has become the first major insurer in the UK to introduce ethically screened general insurance, meaning that customers can rest assured that no money they pay is invested in corporations that operate in areas with which they disagree. The company’s travel, car and home insurance premiums will no longer invest in businesses involved in activities that it considers to be unethical, which include the arms trade, fur and fossil fuel extraction.Financial services chief executive Neville Richardson said: “Our general insurance customers now know that the investments supporting their policies are ethically screened. We have long recognised that the provision of ethical finance is crucial to the pursuit of sustainable development. This is why our ethical policy now includes the £1 billion of assets that support our car, home and business insurance products so that our customers can be confident that their money will not be invested unethically.” He added: “Following the introduction of our bank’s Ethical Policy in 1992, we have withheld over £1 billion of loans from business activities that our customers say are unethical, while at the same time increasing our total commercial lending sixteen-fold to almost £9 billion. Our vision is to build a better society and our Ethical Operating Plan not only aligns with our vision, it stimulates and reinforces the unique benefit of the consumer co-operative model.”

Healix enhances service for AXAHealix’s medical risk assessment tools have now been fully integrated into AXA Direct’s online travel sales process, bringing customers a more streamlined buying experience. AXA customers with pre-existing medical conditions can now complete their quotation and buy travel cover quickly and easily online. AXA Direct has been using the risk assessment for a number of years through its call centre, but has recently fully integrated the tools into its online sales process as part of its strategy to improve the online customer experience.Roman Bryl, AXA Lifestyle Direct manager, explained: “Our partnership with Healix means we benefit from a system that is fully integrated into our new website, without any disruption to the customer experience. This upgrade is central to our commitment to helping our customers gain access

to the right level of cover for their individual needs.” Lara Suttie-Sims, client services manager for Healix Risk Rating, added: “Our Healix Black Box Two rating tool is flexible and easy to integrate into our clients’ existing systems and processes, bringing a new level of customer care to those with pre-existing conditions.”

Intakt Internet offers travel coverGerman company Intakt Internet Services, a provider of online services with products ranging from travel and tourism to hospitality, has announced the launch of its latest offering, which gives users the opportunity to tailor a travel insurance policy to their individual needs. Dr Toralf Kahlert, chief executive officer of the company, explained: “Many of our customers have indicated that they are interested in buying travel insurance for round trips and flights booked with us. Travel insurance products can be described as clear cut. Therefore, the presentation of the travel insurance offered focuses on providing the information rather than on the design of the website. Speeding up the web page loading was the highest priority.”

Partnership of providersUS-based Global Events Partners has announced an exclusive partnership with ASSIST-CARD and Forum Tel to offer meeting planners a cashless travel insurance policy and savings through mobile phone services for groups travelling internationally. “We are extremely pleased to add ASSIST-CARD and Forum Tel to the existing meeting services we already provide to meeting professionals,” said Chris White, chairman and chief executive of Global Events Partners. “With this initiative and these partners, we’ve created an integrated assurance solution unique to the meeting planning industry, providing peace of mind, security, constant contact and the lowest rates in country-to-country and in-country local calling and texting this year.” One of the key attributes to the service, he added, is that ASSIST-CARD is able to provide medical assistance overseas: “Many US residents do not realise that their primary health insurance does not cover them when travelling abroad. With ASSIST-CARD, not only will the policyholder be covered should they get sick or have an accident while travelling, but they will have their medical and dental services co-ordinated and paid for by ASSIST-CARD.”

WorldAware app launched by AonAon has launched WorldAware, an iPhone app for employees and clients that offers comprehensive travel safety advice to business travellers about the security situation in countries throughout the world. The application offers a range of functions, including detailed safety and travel information, an easy-to-use embassy locator and mapping using GPS technology, as well as cultural awareness hints and tips.WorldAware assesses the overall security threat in each country, categorising it as severe, high, medium, low or negligible. It also provides individual threat scores for street crime, civil unrest, regime instability, corruption, business espionage and armed conflict. The app allows users to ‘watch’ countries of interest, store personal travel information such as passport number and frequent flyer membership, and uses GPS technology to track where the user is – enabling it to give directions to the nearest embassy.

www.itij.co.uk

TRAVELMATTERS 9

The Global Business Travel Association (GBTA) has released the results of a survey of business travel professionals on their reactions to the ongoing crisis in the Middle East and North Africa. Of the 472 survey respondents, nearly all said they are concerned about the impact of rising oil prices on travel costs as a result of the ongoing political crises, with 45 per cent saying that they are very concerned. However, it seems that no price is too steep for some, as even with the growing worry over the price of oil, 63 per cent of travel professionals are either opposed to (25 per cent), or indifferent to (38 per cent) new government programmes that would financially assist airlines.According to the results of the survey, 49 per cent of travel managers said their company had already seen some negative impact from the political unrest that has gripped nations across the Middle East and North African regions, and 47 per cent reported that employees had experienced travel disruptions, including the need for evacuation. Of these, one in three have had to support between one and 50 employees facing disruption, and nearly one in 10 have provided service and support to over 100 employees.A number of tactics have reportedly been used by travel managers to keep their employees safe. Most commonly, a simple alternative transport arrangement has been made, but 12 per cent have used an external crisis management company. Overwhelmingly, travel managers who took part in the survey say that emergency contact information and worldwide tracking support are the most

common elements of strategic crisis management plans.Mike McCormick, executive director of the GBTA, commented on the results of the survey: “The global nature of the business travel industry can inevitably lead to travellers being in dangerous situations. Travel managers need to have a crisis plan ready to go at a moment’s notice to ensure they can help get employees out of frightening situations and return them to safety.” He added: “It is unwise for travel managers not to have a crisis plan on the books. To that end, GBTA’s risk committee is in the midst of developing a new ‘best practices’ playbook to advise our members in their own crisis scenario planning.”In related news, several international cruise lines have cut Bahrain from their list of Gulf destinations for the rest of the cruise season, following the protests that have taken place in the Kingdom. Italian company Costa Cruises has said that instead of stopping in Bahrain, its ships will instead dock for another night in Muscat, Oman. According to Seatrade, a shipping communications company, a 2,000-passenger ship brings average revenue of around Dh1 million (US$272,250) to each port of call. During the last cruise season, 150,000 tourists made port in Bahrain from cruise ships. The unrest in Bahrain also prompted the cancellation of the Formula One Grand Prix race, resulting in estimated losses of around $600 million with hotels missing out on the country’s biggest international event.

Concerns rise over Middle East security

Eastern promiseAbacus International, a provider of travel solutions and services in Asia, has predicted that the region will become the top travel destination in the world as soon as 2015. The company said that Asia is on course to become the largest region in terms of air transport, travel destination, business travel, utilisation of ancillary revenue models and mobile usage. New data has shown that the number of booking transactions for 2010 hit record levels, up 11 per cent on the figures from 2009, and even higher than pre-recession levels in 2007. Robert Bailey, president and chief executive of the company, said: “Asia today is an outstanding force in the travel industry. It has well weathered the storm of the past few years and emerged at an all-time high, well poised to take over as the leading travel region.” He added: “Despite rising fuel costs and the recent recession, the Asian travel industry has shown its resilience in its quick recovery and strong growth years in both 2009 and 2010. I foresee that 2011 will continue to be a high growth year for Asia, albeit at a slightly slower pace.”The predictions from Abacus International corroborate international arrival figures, which show a 13-per-cent rise year-on-year in Asia, which is notable, especially when it is compared to a worldwide average of seven per cent.

Focus on costEgencia, an Expedia Inc. company, has released the results of its 2011 Global Cost Avoidance Study, which uncovered numerous best practices and strategies that travel managers can use to circumvent and protect against the growing costs of corporate travel, whether from airlines or for accommodation. “As the Canadian travel market continues to shift, it is essential for corporations to employ policy enforcement and cost avoidance strategies to ensure their programmes are streamlined and optimised to endure any change or circumstance,” said Nikki Germany, managing director of Egencia in Canada. “We want our clients to be equipped with the most effective tactics and strategies, allowing them to maximise their budgets and minimise their costs.”The global survey of 348 travel executives revealed that 95 per cent of respondents view traveller compliance as important to extremely important to the success of their travel programme in 2011. A lack of compliance can mean missed opportunities for corporations to conserve funds, and can ultimately affect the bottom line. For example, respondents identified failure to book air travel far enough in advance (68 per cent) as the number one area where travellers tend not to comply. Respondents identified other areas of frequently breached compliance, including not booking with preferred carriers and booking more expensive hotel rooms.To encourage compliance amongst their travellers, 50 per cent of respondents proactively communicate their corporate travel policy as updates occur; with 16 per cent communicating quarterly, and 11 per cent yearly. Additionally, 77 per cent of respondents noted that they do not use incentives to keep their travellers compliant with their corporate travel policy.When respondents were asked how they promoted travel spend accountability within their company, 56 per cent noted that they establish a pre-trip approval system for approving or denying travel before booking, while 37 per cent identify rogue travellers and follow-up with them directly; 36 per cent provide department managers with a specific travel budget that they manage and own.

Fuel surcharges addedTourists from the UK are having even more financial pressure applied to them, thanks to two of the UK’s biggest holiday companies adding fuel surcharges to the price of holidays, which could potentially add as much as £160 to the price of a long-haul trip. Package holiday companies Thomson and Thomas Cook are adding supplements for customers of their charter airlines that range from £15 to £40 per person, depending on how long the flight is. Ian Ailles, chief executive of Thomas Cook UK and Ireland, said: “We’ve worked hard to keep the impact of the rising fuel costs on our holidaymakers to a minimum, but the fuel levy is an unavoidable result of the rising price of oil.” British Airways added the fuel charges to its own ticket prices in February as well, adding between £75 and £125 per person.Rochelle Turner, head of research at Which? Travel, a consumer organisation in the UK, said that the price hikes would prompt some families

to consider whether or not they can afford to go on holiday in 2011. She added: “It is a lot of money to find for just getting to your destination. With all the uncertainty surrounding Libya and whether the unrest could spread

to Saudi Arabia and other big oil producing countries, the price of oil could easily escalate further. People might find they won’t be able to travel anywhere, never mind just going on holiday.”

Tui teams with IntrepidTui Travel is joining forces with an Australian adventure travel specialist in an effort to take advantage of the fast-growing and lucrative trend for adrenaline-filled holidays. Tui has thus struck a deal with Intrepid Travel, with the result being a merged company 60-per-cent owned by Tui and 49-per-cent owned by Intrepid Travel. A spokeswoman for Tui said that while package holidays – the company’s main market – generate profit margins of between three and five per cent, by contrast adventure holidays bring profits of around 10 per cent.


10 INSURANCEMATTERS

According to Fitch Ratings in Sydney, the Christchurch earthquake will not impact the ratings of Australia’s major non-life insurers, with director John Birch saying: “Australia’s major non-life insurers, who dominate the New Zealand insurance market, can provide the vital support required, and have the financial strength to aid in the recovery.” Two catastrophe modelling firms have so far released preliminary estimates of insurance losses, with AIR Worldwide estimating losses of between NZ$5 billion and $11.5 billion (NZ$1=GB£0.46 or US$0.74), while EQECAT Inc.’s estimates range between US$1.5 billion and $4 billion. The initial estimates are wide given the preliminary stage of the disaster, but even at the bottom end of the range, insurers are aware that losses will be significant. However, despite the high level of insured losses, Fitch has said that it expects the financial impact on Australian insurers will be met by their earnings.The ratings agency continued: “Comprehensive reinsurance arrangements limit the impact of catastrophes, and are a feature of the Australian market due to requirements imposed under a robust risk-based regulatory regime. Specifically, insurers are required to hold capital against their net exposure (after reinsurance) to their largest catastrophic event, and included in this charge is the cost of reinstating this cover if not pre-paid. While this ensures good protection, it has resulted in significant reinstatement costs for insurers as they have replaced primary and back-up covers during an active catastrophe period.”The largest insurer in New Zealand is Insurance Australia Group (IAG), with around 35 per cent of the market. Operating on a calendar year basis, IAG’s main catastrophe reinsurance protection provides up to AU$4.1 billion of cover in excess of a $250-million deductible (Au$1=GB£0.63 or US$1.01). In addition, the programme includes a three-year cover, which reduces the group’s net retention further and varies dependent on the location and number of events incurred. With regards to New Zealand, these vertical covers, along with the group’s aggregate cover, have reduced the group’s net exposure to the most recent Christchurch earthquake to $40 million. Elsewhere, Suncorp Group Limited has about a 25-per-cent share of New Zealand’s non-life market. Its main catastrophe protection provides $5.6 billion of cover in excess of a $200-million deductible, and an additional cover reduces its net retention from a New Zealand event to NZ$60 million. Having renewed its reinsurance programme from

1 July 2010, Suncorp is further into its reinsurance programme than IAG, and following an extremely active eight-month period, has incurred AU$223 million of reinstatement premiums so far this year.The largest-listed insurer in Australia, QBE Insurance Group, has a market share in New Zealand of around 15 per cent. Fitch Ratings said of the firm: “As a global insurer operating in 46 countries, Fitch believes QBE has effectively managed its aggregate exposure through geographic and product diversification in addition to its comprehensive reinsurance programmes. Although the group has

not disclosed its exposure to the Christchurch earthquake, it general only does so where losses are material.” The group has announced, though, that it holds specific high-level catastrophe covers for both Australia and New Zealand.In related news, the Bloomberg news agency has reported that the earthquake could lead to higher prices for reinsurance in the Asia-Pacific region. In a note to clients, Credit Suisse said that rates could climb as companies such as Munich Re and Swiss Re count the cost of the ’quake, along with the price to be paid for the floods in Queensland earlier in the year. “Losses are building in the reinsurance industry in the first quarter,” said Credit Suisse. “With continued high levels of excess capital in the global reinsurance industry, the losses suffered to date are unlikely to be sufficient to cause a turn in global pricing, although we would expect pricing in the Asia Pacific region to increase.” Munich Re, Swiss Re and Hannover Re, the world’s largest reinsurance companies, have all said that it is still too early to give accurate representations of their exposure in Christchurch, especially as they will need to assess which buildings were damaged first by the earthquake of September last year, and which were affected by the more recent earthquake.

NEWSWIREThe Indian Premier League cricket tournament has attracted heavier insurance than for the World Cup, according to the Times of India. The Board of Control for Cricket in India bought cancellation cover worth nearly Rs7.4 billion (US$163.8 million) for the tournament.

Tokio Marine Holdings has posted an increase in net profit for the April-December period in 2010, while two of its largest rivals reported a year-on-year decline in consolidated net profit for the first nine months of the current 2010-11 fiscal year.

A confidential government briefing prepared for lawmakers has revealed the extent, or lack of, reinsurance arrangements in states and territories, according to the Sydney Morning Herald. The document shows varying levels of insurance across Australia, including cover taken up by local and council governments.

Insurers in the Philippines have asked the government to allow civil servants to pay their life insurance premiums through monthly salary deductions, rather than a one-off payment, in order to make insurance payments less burdensome for policyholders.

Zurich Financial Services has underlined the importance of the fast-emerging Latin American market with the purchase of a majority stake in Santander’s insurance operations in five of the region’s key countries – Brazil, Mexico, Chile, Argentina and Uruguay.

The RSA Group has reported its full-year results for 2010, which show a strong top line and robust underwriting performance.

Premium growth in the Chinese life insurance market in January was lower than in the same month in 2010, with the overall pace of increase estimated to be slower by at least 20 per cent, as a result of the tightening of bancassurance rules last November.

The South Korean and Japanese trade insurance agencies have agreed to work together to help their respective businesses participate in joint projects in overseas markets.

Aon Benfield has released a report into the Chilean earthquake, a year after the event, which considers the science behind the quake, the effect on the reinsurance market, lessons learned and the future for catastrophe models in Chile.

Zurich Financial Services has reduced its 20-per-cent stake in New China Life Insurance Co. to 15 per cent. The five per cent has been sold to undisclosed buyers.

Billionaire investor Warren Buffet’s investment firm Berkshire Hathaway has said that it plans to enter the Indian non-life insurance sector as a corporate agent of Bajaj Allianz General. As part of its plans, Berkshire India will sell and distribute general insurance products in the country with an initial focus on car insurance.

Hardy Underwriting Bermuda Ltd has announced its 2010 full year results, which show gross written premiums of £279.4 million; profit before tax of £10 million; and a combined ratio of 94.7 per cent.

American International Group has raised US$6.3 billion through the sale of shares in its US rival Metlife in a move that will help the troubled insurer to accelerate its repayment to the US government. The sale puts an end to AIG’s unusual position as a major shareholder in one of its competitors.

Disaster insurance spotlight in Australia

Spanish industry consolidatesTogether, the economic crisis and European Union policy seem finally be starting to bring about what decades of talk have failed to encourage in Spain – a concentration of the country’s insurance sector. David Ing ponders this further

While analysts have agreed for years that there are too many companies in the market, the fact that these companies have remained solvent over-rode

that argument, according to financial analysts. Only now – with the rapid restructuring of savings banks in the wake of the property price crash, the high-street banks shedding their insurance interests, and the demands for greater professionalism and size expected from the European Union directive Solvency II – is the picture starting to change. There are still around 300 companies selling insurance policies in Spain, yet the top 30 account for 80 per cent of the market, and the first 100 account for 94 per cent, according to a recent report in the financial daily Cinco Dias. It is this ‘enormous atomisation’, with many small companies unable to find the

money to pay the quotas needed to join the sector’s association UNESPA, that helps explain why the idea of concentration is ‘once again gaining strength’, said the paper.But that is not the only challenge facing the insurance sector in Spain. The arrival of foreign competitors, growing differences in policy prices, and worries about the future of the social security system are all affecting the market. “The logical thing would be that there were no more than 100 firms to have a powerful and ordered industry,” commented one analyst. Analysts agree that while some smaller companies could continue to operate on a local basis, the main boost to the concentration process is likely to result from the sector’s close relationship with the current government-promoted policy of savings banks merging to stay afloat and the Basel III proposals for separating the interests of bankers and insurers. Recent accords like the one between the La Caixa savings bank and insurer Mutua Madrileña, and Grupo Santander’s decision to sell 51 per cent of its Latin American insurance business to Zurich, are expected to be the spearhead of what is yet to come.

Christchurch ’quake impact limited

The Australian Government has launched a major review into the level of disaster insurance carried by different states, in order to study a number of issues, such as whether the government should subsidise such insurance premiums for people in high-risk areas, the ability of private insurers to offer cover that is both adequate and affordable, and to assess the need for a national disaster fund.When he was announcing the launch of the review, assistant treasurer Bill Shorten said: “This review provides an opportunity for an independent review of issues relating to insurance in light of the recent disasters, in the context of the long-term funding of disaster relief. [I hope] the review will provide

answers about how individuals and communities affected by the floods and other natural disasters are able to recover and rebuild as quickly as possible.” As part of its remit, the review will investigate the levels of non-insurance and under-insurance for flood damage, and examine the reasons why there is such a problem in Australia. In addition, the reviewers will look into whether or not insurance companies are providing people with enough information about the risk of disasters, and the limitations of their insurance policies. The review, led by a three-man panel appointed by the government, is expected to deliver its findings by the end of the year.

www.itij.co.uk

INSURANCEMATTERS 11

The China Insurance Regulatory Commission (CIRC) has reported that four major disasters – both natural and manmade – in different parts of the country last year resulted in compensation claims of 55.2 million yuan (US$8.4 million). The four incidents were the 6.9-magntitude earthquake in Yushu, a landslide in Zhouqu, an aircraft crash in Yichun and a fire in a high-rise residential block in Shanghai.The Yushu earthquake, which occurred in April, killed around 2,700 people and injured over 12,000; until March 2011, 148 claims were paid, totalling 3.89 million yuan. In Zhouqu, deforestation and extensive damning projects caused a serious landslide that killed more than 1,400 people; so far, 289 claims have been received with payouts reaching 17.7 million yuan. The most expensive disaster, though, in terms of insurance, was the crash of a Henan Airlines passenger plane in August, after which 21 insurers paid out claims of 24.6 million yuan. In the accident, 42 people were killed and a further 54 injured. In the Shanghai fire, a 28-storey building was destroyed, killing 58 people and injuring more than 70 others. Total insurance claims paid out for the disaster have reached nine million yuan.Although the total insurance payouts may seem low

compared to the scale of the disasters, CIRC also said that the insurance industry as a whole raised donations to the sum of 74.8 million yuan for victims in Yushu and Zhouqu. The next job lying ahead of the regulator, though, is to carry out an assessment of the work done by insurers with respect to the disasters, and tap into the networks and resources of the companies in order to increase disaster prevention and mitigation capabilities, disaster assistance systems and risk management abilities amongst the public.

International consulting firm Oliver Wyman has released its latest report, Charting a New Course – The Future of Life Insurance in India, which shows that the current state of flux in the Indian life industry offers an opportunity for existing players to reassess their strategy and realign their business to take advantage of industry changes. The situation also offers new entry opportunities for next-generation business models for either domestic or international players, claims the report. Changes already made in India include a minimum lock-in period of five years for insurance products, as well as a cap on surrender charges. Upcoming changes include agent productivity rules and restrictions on outsourcing levels, all of which will inevitably cause disruption in the development of the life insurance industry, according to Oliver Wyman. Says the report: “In our view, the changes reflect the regulator’s determination to correct existing structural gaps in the industry caused by the poor market positioning of core insurance offerings, resulting in a skewed product mix, low productivity of sales channels and cost inefficiencies.”The report also highlights key trends that the company believes will dominate the industry’s evolution, which include clear management actions to review the mix of products on offer, a renewed focus on customers, and a reinvention of distribution channels. It predicts that management teams will be required to review their product mix, to drive innovation in product design, and capture new opportunities, particularly niche segments that have the potential to become big business propositions. Oliver Wyman’s report concludes: “In spite of the current phase of uncertainty, we are bullish about the long-term prospects

of the industry when taking into consideration the underlying demographic and macro-economic drivers. We expect the industry’s growth to be fuelled by a demand for both protection and investment products, given the country’s savings-orientated culture, the overall growth outlook and the distribution reach for insurance.”

NEWSWIREThe Indian Premier League cricket tournament has attracted heavier insurance than for the World Cup, according to the Times of India. The Board of Control for Cricket in India bought cancellation cover worth nearly Rs7.4 billion (US$163.8 million) for the tournament.

Tokio Marine Holdings has posted an increase in net profit for the April-December period in 2010, while two of its largest rivals reported a year-on-year decline in consolidated net profit for the first nine months of the current 2010-11 fiscal year.

A confidential government briefing prepared for lawmakers has revealed the extent, or lack of, reinsurance arrangements in states and territories, according to the Sydney Morning Herald. The document shows varying levels of insurance across Australia, including cover taken up by local and council governments.

Insurers in the Philippines have asked the government to allow civil servants to pay their life insurance premiums through monthly salary deductions, rather than a one-off payment, in order to make insurance payments less burdensome for policyholders.

Zurich Financial Services has underlined the importance of the fast-emerging Latin American market with the purchase of a majority stake in Santander’s insurance operations in five of the region’s key countries – Brazil, Mexico, Chile, Argentina and Uruguay.

The RSA Group has reported its full-year results for 2010, which show a strong top line and robust underwriting performance.

Premium growth in the Chinese life insurance market in January was lower than in the same month in 2010, with the overall pace of increase estimated to be slower by at least 20 per cent, as a result of the tightening of bancassurance rules last November.

The South Korean and Japanese trade insurance agencies have agreed to work together to help their respective businesses participate in joint projects in overseas markets.

Aon Benfield has released a report into the Chilean earthquake, a year after the event, which considers the science behind the quake, the effect on the reinsurance market, lessons learned and the future for catastrophe models in Chile.

Zurich Financial Services has reduced its 20-per-cent stake in New China Life Insurance Co. to 15 per cent. The five per cent has been sold to undisclosed buyers.

Billionaire investor Warren Buffet’s investment firm Berkshire Hathaway has said that it plans to enter the Indian non-life insurance sector as a corporate agent of Bajaj Allianz General. As part of its plans, Berkshire India will sell and distribute general insurance products in the country with an initial focus on car insurance.

Hardy Underwriting Bermuda Ltd has announced its 2010 full year results, which show gross written premiums of £279.4 million; profit before tax of £10 million; and a combined ratio of 94.7 per cent.

American International Group has raised US$6.3 billion through the sale of shares in its US rival Metlife in a move that will help the troubled insurer to accelerate its repayment to the US government. The sale puts an end to AIG’s unusual position as a major shareholder in one of its competitors.

2010 catastrophe costs shown

Change brings opportunity in India

Rules differ for life and non-life insurersAhead of its annual budget, the Indian government has released its 2010-11 Economic Survey, which proposes different sets of disclosure requirements for life and non-life insurance companies in their initial public offerings (IPO), due to the distinct nature of the two businesses. The report says: “While laying down the stipulations on disclosure requirements, the Insurance Regulatory and Development Authority (IRDA) has drawn on

international best practices. It is proposed that the disclosure requirements for life and non-life companies be separately mandated given the nature of their respective businesses.” The Economic Survey highlights the fact that several major insurers in the country will soon be reaching 10 years of operation, after which they are allowed to make an IPO, with the permission of the authorities. The report states: “It is essential that the investors be made fully aware of the financial performance, company profile, financial position, risk exposure, elements of corporate governance in place, and the

management of such insurance companies.”The IPO rules, though, have yet to be finalised by IRDA and the Securities and Exchange Board of India. SB Mathur, secretary general of the Life Insurance Council, a trade body that represents life insurers in India, explained the differences between the two natures of business: “While life insurance is a long-term contract, non-life or general insurance policies are usually one-year contracts. In respect of life insurance companies, the assumption of current and future business forms the basis of profitabality, hence factors such as the persistency ratio are very critical.”

NEWSWIRETokio Marine Holdings has obtained approval from authorities in Malaysia to sell all of its shares of Hong Leong Tokio Marine Takaful to the Hong Leon Group, its joint venture partner.

The vice governor of the Saudi Arabian Monetary Authority has said that demand for insurance in the country is growing, with premium income rising 12 per cent year-on-year to US$4.4 billion in 2010.

The South Korean life insurance industry is expecting to see sustained improvement in its financial performance in 2011, on the back of the solid recovery of the South Korean economy, improvements in the financial markets, increasing risk awareness and the need for traditional insurance protection, according to a recent report from Fitch Ratings.

The Indian government has said it is willing to move forward on a series of laws that would increase the amount of foreign direct investment in the insurance, pension and banking sectors.

UKI Investigations, the investigations and insurance fraud company, is now using web-based software from ediTRACK that allows its clients, often solicitors, to manage their cases and track the progress of each of their investigations.

Zurich Financial Services has announced that it has closed the sale to Unnim of its 50-per-cent stakes in the life and general insurance bancassurance companies CaixaSabadel Vida de Seguros y Reaseguros and CaixaSabadel Companyia d’Assegurances Generals in Spain.

The Syrian insurance market grew by 31.5 per cent from 2009 to 2010 to reach US$404 million in premium income, according to the Syrian Insurance Supervisory Commission.

Global ratings agency Standard & Poors has affirmed its long-term counterparty credit and insurer financial strength ratings on Hannover ReTakaful, Trust International Insurance & Reinsurance Co., and Saudi National Insurance Co. The outlooks are stable.

Abu Dhabi National Insurance Co. has achieved its premium growth target of 14.1 per cent, reaching AED1.77 billion ($481.9 million) in gross written premiums in 2010 by expanding its consumer product suite and distribution network, specifically targeting the broker channel.

Royal Shield Ltd, a reinsurance broking firm, has received a licence from the Dubai Financial Services Authority to operate in the Dubai Financial Centre.

The London-based Joint War Committee, which represents the interests of companies writing war risks in the London market, has added Libya to the list of areas it considers high risk for merchant vessels and prone to war, strike, terrorism and other related perils.

Gross insurance premiums in Jordan increased by 17.4 per cent year-on-year to $68.2 million by the end of January, compared to $58.1 million recorded in the same period in 2010, according to the Insurance Commission in the country.

The Lebanese insurance sector reported a 13-per-cent growth in total premiums to $1.16 billion in 2010, surpassing the six-per-cent increase in 2009.


12 HEALTHMATTERS

Last month, health authorities in Bali reported over 100 deaths caused by rabies since December 2008, with both human and animal rabies cases confirmed near popular tourist areas on the southern tip of the island. The US Centers for Disease Control and Prevention has therefore advised travellers to the entire island of Bali to take precautions against the disease. It then highlighted certain activities that could put travellers to the island at higher risk of contracting the disease, which include working closely with animals of unknown rabies exposure or vaccination history, and spending a lot of time in rural areas or participating in

outdoor activities such as bicycling, camping or hiking.Travellers were also urged to consider obtaining a rabies vaccine, which is a three-shot series that should be started at least 28 days before travel. However, if bitten even after receiving a pre-exposure vaccine, travellers were told to seek immediate medical treatment.

Bolivia declares health emergencyAlthough dengue fever is common in Latin America, the Bolivian Ministry of Health has declared a state of emergency due to a large increase in the number of people suffering from the mosquito-borne disease. The state of emergency is expected to remain in place until at least the end of March.All departments in the country have seen effects of the rise in cases of dengue, but the Department of Beni has seen the most significant rise. The Ministry of Health has said that there were 1,486 cases within the country between October 2010 and January 2011, of which large numbers were registered in Beni. So far, the Ministry has reported 285 confirmed cases in the same time period, and six deaths in 2011, but unconfirmed reporting in local newspapers in January suggested that the real figures could be higher.Elsewhere, the Ministry of Health reported that there were 994 confirmed cases of yellow fever in 2010, prompting the requirement that all foreigners entering areas that have been designated as ‘high risk’ for yellow fever need a valid certificate to show they have been immunised against the disease. High-risk areas include all the regions of Santa Cruz, Pando and Beni, as well as large swathes of Cochabamba, Tarija and La Paz. When outbreaks of yellow fever occur, the Bolivian government sets up vaccination points at police checkpoints, and at each of these, travellers may be vaccinated if they do not hold the necessary certificate.In addition, there is a high incidence of malaria in the lowland tropical areas of Beni and Pando, and the area known as Chaco in the south of the country. At the end of last year, the Ministry of Health reported an increase of 25 per cent in the number of cases of malaria across the country.

Flu breakthroughA team of scientists at Oxford University in the UK has successfully tested a universal flu vaccine that could be effective against all known strains of the illness. The treatment uses a new technique that was tested for the first time on humans infected with flu, targeting a different part of the virus itself, so that the vaccine does not need expensive reformulation each year to match the present most virulent strain. The universal vaccine targets proteins inside the flu virus that are common across all strains of flu, instead of the proteins that sit on the external coat of the virus, which are liable to mutate, therefore making individual vaccines less effective. If it were to be used worldwide, the new vaccine could contribute to the prevention of pandemics such as swine flu. Said Adrian Hill, director of Oxford’s Jenner Institute and part of the research team: “The problem with flu is that you’ve got lots of different strains and they keep changing. Occasionally, one comes out of wildfowl or pigs and we’re not immune to it. We need new vaccines and we can’t make them fast enough.” Dr Sarah Gilbert, who led the team, added: “If we were using the same vaccine year in, year out, it would be more like vaccinating against other diseases like tetanus. It would become a routine vaccination that would be manufactured and used all the time at a steady level. We wouldn’t have these sudden demands or shortages – all that would stop.”

Keeping seniors safeThe US Centers for Disease Control and Prevention (CDC) has issued some simple travel advice to senior citizens, saying that with a little planning and some caution, seniors can safely visit almost any destination. The advice to travellers is that they should see a doctor for a pre-travel visit, ideally four to six weeks before they plan to travel, although even a last-minute visit is better than no visit at all. Travellers are urged to inform their doctor about any illnesses they may have and medicines they are taking, since this would influence medical advice and decisions. In addition to providing vaccines, medicine and advice for keeping healthy, a doctor could also conduct a physical examination to assess a senior’s fitness to travel. The CDC said: “Seniors should consider their physical limitations when planning a trip. Seniors with heart disease, for example, might choose an itinerary that does not involve strenuous activities. Seniors may also have a hard time recovering from jet lag and motion sickness, so they should take these factors into account when planning a trip.” The CDC added that before they travel, seniors should have information about their destination that could affect their health, such as the altitude and climate of a destination. They should also be aware of whether the place is prone to natural disasters, such as earthquakes or hurricanes, as seniors could have more problems evacuating in such extreme situations.Regarding vaccinations, the CDC said that before they travel, seniors should ensure they are up-to-date with routine injections such as measles, mumps and rubella as well as seasonal flu. “Some of these may be considered ‘childhood’ vaccines,” continues the advice, “but their protective effect decreases over time, and the diseases they protect against are often more

common in other countries than in the US. More than half of tetanus cases are in people over 65, so seniors should consider getting a tetanus booster before they travel.” A warning about the nature of some vaccines was then given, as the use of some vaccines could be restricted on the basis of age or chronic illness. The vaccine against yellow fever, for example, should be given judiciously to people over the age of 60, and it should not be given at all to people with certain immune-suppressing diseases.

Rabies in BaliTuberculosis hope in pipelineDrugmaker AstraZeneca has joined a consortium – which includes French firm Sanofi-Aventis and the University of Cambridge – whose mission it is to fight the growing problem of tuberculosis around the world. The consortium, named the More Medicines for Tuberculosis (MM4TB), is funded by a n16-million grant from the European Union, and is led by TB expert Professor Stewart Cole, from the Ecole Polytechnique Federale de Lausanne in France. Cole said of the ambitious venture: “This is one of the strongest consortiums ever put together. It is led by

academia but with the drug discovery know-how of big pharma and biotechs.”Tuberculosis takes the lives of 1.8 million people globally each year, and while there are existing drugs to

treat the disease, they are nearly 50 years old, and should be taken for between six and nine months, which can prove too much for many patients, leading to erratic treatment, which in turn can prompt drug-resistant variants of the disease to emerge. Cole said that the new drugs being developed by the consortium would reduce the length of treatment needed to just a few months.


IPMI NEWS14

Aviva’s passport to healthIn a bid to help people remember to take important health information with them when they move abroad, Aviva UK Health has developed My Health Passport, which captures the most important medical details that expats may need. Available in both a short downloadable format – which includes basic information such as personal details, blood group, illnesses, and GP and insurance provider contact details – and a printed booklet – which includes additional information on areas such as screenings, operations, vaccinations and wellness checks – the Health Passports are aimed at providing those who chose to live or work abroad with a record of their previous health status. A study carried out by Aviva revealed that 69 per cent of people don’t know their blood pressure, 63 per cent don’t know their blood group, and over a third have struggled to remember details of their medical history when they’ve changed GP as a result of a house move. Teresa Rogers, business lead for international private medical insurance for the provider, said: “Unfortunately, medical records are not easily accessible, particularly as they aren’t automatically transferred by your GP. Easy access to personal health information can be vital, particularly in a medical emergency situation or when visiting a GP or pharmacist abroad.”

CIGNA in military moveIn a move that will see the end to many of its clients’ employees and contractors having to seek medical care in surrounding countries, CIGNA now provides access to healthcare for workers on a number of military bases in Afghanistan. Agreements with TMH Medical Services and Onsite OHS have established onsite healthcare clinics on the Kandahar and Bagram air bases.“CIGNA is responding to our clients’ concerns and has already taken important first steps to make primary medical care more accessible for those assigned to work in Afghanistan,” said Timothy Blevins, chief network officer for CIGNA International Expatriate Benefits. He went on to state that the company recognised that medical care for clients’ staff on military bases in the country was limited to conditions that were life-threatening or disabling, leaving them with virtually no options for routine healthcare services on base. The alternative – seeking care abroad – was costly and disruptive to their assignments, he said.The new clinics will allow workers to take advantage of primary healthcare, urgent care and routine physicals, as well as basic laboratory, radiology, pharmacy, and dental services. The care is provided by physicians’ assistants and registered nurses – all of whom are trained in western medicine and speak English – under the direction of physicians. The clinics will bill CIGNA directly for services provided to customers, who simply need to present their CIGNA customer ID card in order to access care.

ECJ ruling effect on PMI

Health cover nowA new international

private medical insurance provider launched earlier this year is entering the market with a service promise that should make for speedy customer service. Now Health International is living up to its name by providing customers with six promises when buying, claiming, editing or renewing a policy – including a promise to respond to all enquiries within one working day, to provide a guarantee of payment for medical providers within two working days, and a guarantee to respond to underwriting referred business within two working days.Martin Garcia, the company’s CEO, said: “We call ourselves Now Health and we mean to provide immediate access wherever it’s possible.” Policies are available directly and via intermediaries, and are underwritten by AXA.

Humana JV offers incentivesHumana Inc., the US healthcare group, is to partner with Discovery Holdings Ltd, Africa’s largest medical insurance administrator, to offer clients of the US company wellness and loyalty programmes. The programmes, designed by Johannesburg-based Discovery, include discounted gym memberships, hotel rooms and electronic goods, as well as subsidies towards the cost of fruit and vegetables for those members who attend health education courses and work out regularly. As part of the deal, Humana, based in Louisville, Kentucky, will set up a new entity in the US to which it will pledge up to $50 million and in which Discovery will have a 25-per-cent stake. Humana will also buy 25 per cent of The Vitality Group, Discovery’s US subsidiary, for around $15 million.The action reflects the rising use of such incentives to motivate people towards healthier lifestyles, at a time of growing concern amongst employers about rising medical costs – poor diets and a lack of exercise have fuelled an epidemic of chronic diseases, triggering worker absenteeism and doctor consultations. It also marks an effort to respond to the fresh pressures on insurers to reduce claims and improve their competitive position.

Smylie new recruitInternational health insurance organisation Expacare has appointed Gary Smylie as head of sales and marketing. With vast experience in the PMI industry, Gary has spent a significant amount of time as an intermediary so is well placed to understand the needs of both brokers and their clients. He is keen to meet and build long-term relationships with new and existing intermediaries. With their new recruit onboard, Expacare aims to introduce a consultancy approach to its products, allowing the company to meet all of its clients’ requirements.

The UK’s Association of Medical Insurance Intermediaries (AMII) has said that the effect of the recent European Court of Justice (ECJ) ruling on the private medical insurance sector will be ‘negligible’. The ECJ ruled at the beginning of March that gender-based pricing in the insurance market

is discriminatory; but Lindsey Joseph, executive committee member of the AMII, said: “The vast majority

of PMI providers do not have premiums for gender and for those that do, the difference in premium is not particularly significant.” For those few insurers with older policies on their books, some adjustments will need to be made, said Joseph, but she sees a way forward in more sophisticated underwriting. This, says the AMII, paves the way for a rise in more medically based underwriting within the protection sector: “It might be that insurers need to look at a far more sophisticated model that does not highlight gender but looks at biological differences.”

Gary Smylie

www.itij.co.uk

15IPMI NEWS

Aetna enhances IPMI suite

Dedication reaps awardDoug Polifron, director of international insurance brokerage the New York International Group, has accepted International Medical Group’s (IMG) 2010 Producer of the Year award. Polifron was chosen out of thousands of other IMG producers to be the bearer of this year’s coveted title. Accepting the award, he said: “I don’t take anything for granted, but I think this honour shows that 17 years of loyal and dedicated service to my clients has been well worth the effort.” In 2011, Polifron says he intends to continue placing his main focus on customer service: “Without customers you have no business … not only can my clients rely on me to find them the insurance policy they need, but they can also depend on me to understand what those needs might be and how to best meet them.” His company specialises in providing international health and travel insurance plans to expatriates, US and non-US citizens, corporations and individual travellers.

Doctor knows bestBest Doctors, the international company that provides members with access to medical information and practitioners via its database of 50,000 medical specialists, has launched a new online service that allows wider access to its services. The web portal Ask Best Doctors allows members to use all the core company services as well as consult with doctors online and access an extensive medical video library, which includes over 270 video clips that are designed to help members understand a range of medical ailments and the corresponding available treatment. Dominic Howard, director of Europe for Best Doctors, said: “Insurers, employers and affinity groups already offering our expert medical opinion service are now eligible for this online service … [which] responds to the growing number of people interested in searching for specific health information on the Internet.”

Bupa shows 2010 resultsInternational healthcare group Bupa has announced its results for the year ended 31 December 2010, which show that revenue grew by nine by cent year-on-year to £7.58 billion. Underlying surplus before taxation was also up by nine per cent compared to 2009, which the company says was driven by strong performances in Australia and Asia, and an advance in profits in Bupa Health and Wellbeing UK. Bupa’s integration of Australian firm MBF has now been completed ahead of expectations, which has also served to boost profits. There has also been a return to customer growth in Bupa International in the second half of the year, with the expatriate market lifted by improving economic conditions.Commenting on the results, Ray King, Bupa’s chief executive, said: “Bupa delivered a good trading performance in 2010, despite mixed conditions in some of our markets. Underlying surplus increased by nine per cent, up for the third successive year since the start of the global recession, and leverage reduced by 23 per cent.”

Global diversified healthcare benefits company Aetna has revamped its International Healthcare Plans (IHP). The new suite of four basic plans for employers with globally mobile employees includes the company’s industry-leading health risk assessment free of charge as part of its package of wellness tools and resources to encourage employees to adopt healthy behaviours. Employers can select one of the four basic plans before choosing from a menu of up to 49 additional benefits and limits, allowing them to add cover tailored to their employees’ needs – so, for example, for employees in China traditional Chinese medicine can be included; or for employees who travel more frequently, extended evacuation assistance can be included.

“We recognise that employers need a comprehensive level of core health benefits and flexibility in plan design in order to meet the needs of their varied employee populations,” said Donna Otten, head of Aetna Global Benefits. “We have redesigned our health plans to provide a richer level of base benefits to work with different budgets.” The IHP Essential, Plus and Elite plans include new benefits of hospice care, vaccinations, compassionate emergency travel to allow expatriates to return home should a close family member be taken seriously ill, and prosthesis coverage, depending on the plan chosen. The plans are available now in Europe, the Middle East and Hong Kong, and will be rolled out over the coming months in China, Jakarta and Singapore.


CROSS BORDER CARE16

Indian hospital open to NigeriansLapses in the Nigerian healthcare system are paving the way for foreign companies to take advantage of the increasing number of wealthy Nigerians who want high-class medical treatment. One such company that has already entered into the marketplace is Indian firm Primus International, which has opened a super speciality hospital in Karu, a suburb of the Federal Capital Territory of Abuja. Achia Deman, chairperson of the hospital network, has hopes that the hospital is the start of a trend, saying that the company’s objective is to establish a network of world-class health centres, providing state-of-the-art facilities and ethical and compassionate patient care. The new super speciality hospital offers some of the latest medical treatments available, including neuroscience, kidney transplants, bariatric surgery and preventive health treatments.

Post-operative concerns raisedMedical tourists from the US, under increasing pressure from healthcare bills in a difficult economy, are reportedly considering undergoing more complex operations abroad. Although many Americans opting for medical care overseas went for dentistry, cosmetic surgery and other procedures typically not covered by their insurers, with the looming spectre of healthcare reform, more

individuals are considering travelling for medically necessary surgery, such as hip or knee replacements or reconstruction, or heart operations.However, according to Dr Nicholas Abidi of the Santa Cruz Orthopaedic Institute, patients who are considering such options for their surgery need education that goes beyond how much money they could save. He said that certain hospitals and surgery centres overseas market their facilities as top-flight and promote the expertise of their clinical staff, many of whom have been educated in the US. Abidi, though, is concerned that such marketing can obscure the reality of conditions and risks associated with overseas surgery options: “If they encounter unexpected findings during the surgery or post-op problems like blood clots, can the physician and

the facility respond in a timely fashion that is up to US standards? There is also always the chance of infections post-surgery, and many doctors here are reluctant to take on such patients for the long-haul.”Abidi is also concerned about the level of expertise that is so often championed by hospitals overseas trying to attract lucrative foreign patients, saying that American total joint replacement centres are trying to get each total joint implanted to millimetres of perfection, while most centres overseas are just trying to get through the operation. He added: “Many don’t have access to the type of equipment that we use to monitor patients during surgery or install the implants. Artificial joints can also fail or be recalled, which will quickly eat up cost savings patients realise from opting for surgery abroad.”

Ambitious Mauritius

NZ promotedMedtral, a company set up with the aim of promoting New Zealand as a destination for medical tourists, has set up an office in California, US, and begun a marketing campaign targeting Americans who are in search of cheaper elective surgery at the Auckland-based Ascot Hospitals and Clinics. Medtral’s California unit, Ascot Hospitals International, offers American businesses a free review of their elective health benefits packages in a bid to show them the choices on offer.Medtral chief executive Edward Watson said that although the company had struggled to gain interest from US patients since it opened operations there before the global financial crisis, the situation has been made even murkier as a result of the healthcare reforms proposed by President Obama. He added: “The environment has been extremely difficult – people are switched off and more worried about keeping their own job.” However, with an outpost now open in California, Watson said he was making a new push to attract hundreds of patients to New Zealand, rather than the current numbers, which he termed ‘a handful’. The most it could cater for, though, would be around 5,000 patients a year. He added that with the healthcare reforms likely to push up health insurance premiums even further in the US, Medtral is seeking to make sales to self-insured businesses, which will take much of the strain under the proposed reforms.Private hospitals in New Zealand are able to maintain a competitive environment in terms of the cost of operations, even though they might not be as low as nearby Asian medical tourism destinations; but with a public healthcare system that covers most medical procedures, the private sector can specialise in medical tourism without needing to offer services such as emergency care. The hospitals are also aided by the existence of the Accident Compensation Corporation, which covers malpractice and medical accidents, putting paid to a culture of litigation. Medtral’s strength, said Watson, was not necessarily in competing in terms of cost with Asian destinations, but instead offering American patients a similar cultural experience to their home country.A Deloitte report commissioned by the New Zealand Trade and Enterprise organisation in 2010 found that the wider economy could see significant gains from an increase in the number of foreign patients treated. Said Watson: “For every dollar that is spent in medical tourism, there’s a $3-return to the broader economy. [We] haven’t seen any other industry with that return to NZ Inc.”

South Korea aims highHopes that South Korea could turn medical tourism into one of its most lucrative industries are high, with several initiatives underway that could see the number of people travelling to receive medical care continue to rise. One such project is being led by the local government of Gangnam, a district of Seoul, which is aiming to become a hub for healthcare tourists. A government employee, Shin Yeon-hee,

has been tasked with the job of making the region more internationally friendly. She said: “Unlike other spontaneously developed cities, Gangnam is a planned area. As Korea becomes globalised, Gangnam is also growing into a truly international district, aiming to attract at least 30,000 medical tourists by 2012. Medical tourism also benefits hotels, transportation and restaurant businesses, creating more economic effects than just sightseers. There are many hospitals and clinics in Gangnam, renowned for cosmetic surgery and dermatology.”Elsewhere, the Yonsei Severance Hospital in Shinchon, northern Seoul, is also making strides to ensure foreign patients feel comfortable in their surroundings. To that end, its international healthcare centre has employed Russian, Chinese and English-speaking staff, in total adding 13 bilingual personnel to help manage the increasing flow of foreign patients. Another international hospital that is under construction in Incheon has already planned for foreign medical tourists, through adding special beds for taller patients.

The Board of Investment for Mauritius has said that the island expects the number of foreign patients seeking medical care in the island’s hospitals to increase by 36 per cent this year, compared to 2010. The Port Louis-based board said that following a survey of healthcare providers, it expects to see around 15,000 medical tourists visit Mauritius in 2011, adding: “Mauritius has set itself a target of attracting 100,000 foreign patients by 2020,” who would contribute around US$1 billion

annually to the economy. The foreigners already heading to the country for medical care come from all over the world – 28 per cent of patients treated last year were from Madagascar, which was the biggest contributor to medical tourism, followed by patients from the Seychelles, Reunion island, France and South Africa. For more information about healthcare facilities in Mauritius, please see ITIJ’s World Markets feature on p38.

www.itij.co.uk

17CROSS BORDER CARE

Taiwan promotes services

Medical tourism strains systemsThe growth of the medical tourism industry in Asia has been well documented, with much emphasis placed on the benefits brought to the countries selling such services, but little has been reported about the negative effects medical tourism can bring. The World Health Organization (WHO), though, has reported that medical tourism is leading to some highly skilled local specialists, as well as other trained medical staff, leaving public health services for private organisations. The WHO has found that this trend has resulted in unemployed or untrained staff filling posts due to chronic staff shortages in some remote areas.Churnrurtai Kanchanachitra, a professor at Thailand’s Mahidol University and author of a recent paper that examined the effects of health tourism, warned: “There are five countries in southeast Asia facing a shortage of health professionals, mostly in rural areas. This will only become a more pressing issue with the continued growth in trade in health services.” The WHO’s research supported Kanchanachitra’s findings, showing that Indonesia, Vietnam, Laos, Cambodia and Burma are together short of nearly 250,000 health professionals if they are to meet WHO minimum standards of care.Nigel Crisp, a UK politician and doctor who has worked around the issues of global health partnerships and the training of medical professionals, concluded: “The trend is towards an increase in health worker migration, and the chance is weak that poor countries can benefit.” He added that although the knowledge gained by working overseas, strengthened accreditation and remittances help individuals, they could still leave poor countries worse off due to migration. Crisp said: “Migration is an issue, but it is not the biggest issue. In Africa, some 135,000 health workers have emigrated [in recent decades] and there is a shortage of some 1.5 million health professionals. The biggest issue, though, is how to improve training to fill that gap.” In order to try and resolve the problem, Crisp is calling on developed countries to form agreements with the countries from which they accept health worker migrants that would invest in the exporting countries’ health systems and training, instead of setting up alternative training facilities that could compete with and wipe out local ones. The first step towards such practices was taken in May last year, when United Nations member states adopted an international code of practice to promote the ethical recruitment of health personnel, protect the rights of migrating workers and minimise the negative effects of such migration.

Saudi Arabian scope expandsThe market for both inbound and outbound medical tourism is growing in Saudi Arabia, with its popularity increasing in certain countries more than others, but particularly in Germany. According to Lutz Vogt, head of sales for medical travel for national airline Lufthansa, Saudi Arabia is ‘an important source market for medical travel

to Germany’. He continued: “And with the Kingdom heavily investing in home-grown healthcare services and infrastructure, as evidenced by plans to develop medical cities in Jeddah, there is a growing demand for inbound travel too. This augurs well for the industry, and more health-related travel to and from Saudi Arabia is to be expected.”In an interview with Arab News, Vogt added that the airline has witnessed a ‘substantial increase’ in medical travel, largely motivated by globalisation and the rise of new centres where the medical services on offer are of high quality.Germany treated 68,000 medical tourists in 2008, mainly heralding from countries in Arabia and Russia.

The Taiwan External Trade Development Council (TAITRA) has said that the country intends to continue its promotion of medical tourism to Chinese visitors to build on the currently developing trend. So far in 2011, 13 groups of Chinese tourists have booked medical tours to Taiwan, and according to Tsai Hsiu-Chen, section chief at TAITRA’s Service Industry Promotion Centre, the trend is predicted to continue with an average of five such groups visiting the nation each month this year.While accompanying a group of 32 Chinese officials from Mongolia who were having health checks performed at a hospital in south Taiwan, Tsai said that the main services medical tourists were interested in were health checks and medical cosmetology. Chung Chin-Yuan, head of an association that promotes medical tourism in Taiwan, said that there is a great potential market in Taiwan for cosmetology tours that involve non-invasive procedures, especially those with little to no risk of medical malpractice lawsuits.


18 AIRAMBULANCENEWS

The devil is in the documentThere is an old saying in healthcare: ‘If it’s done it’s documented; if it’s not documented it’s not done’. As such, each assistance company has a set of documentation for its repatriations that allow its clinicians to record and document the care, decisions or interventions they have taken, or not, and why. Gerry Bolger examines the nature of clinical documentation as it relates to in-flight medical care

The power of paperMuch of the necessary clinical documentation happens before the patient leaves the hospital or clinic – including the many permissions and clearances. One such key clearance is medical clearance, which for commercial airline carriage is obtained through a MEDIF form – set by the International Air Transport Association (IATA) – with the standardised required information for commercial airlines to make a risk assessment on suitability and preparation for carriage. While there are FREMAC forms – available from most airlines for frequent travellers requiring assistance for transportation – the need for a MEDIF is based on a sudden or recent illness. The assistance company’s medical team informs the airline – usually by fax – and then a clearance decision is made. The second ‘clearance’, as such, is required by airlines in some countries that need an assurance of a ‘fitness to fly’ certificate. This is issued by the local treating medical staff, sometimes already in a pre-formatted form, as in Spain, and presented at check-in. There are some issues with this; firstly that the responsibility of the treating physician at the hospital finishes at the time of discharge, and secondly, not all staff are sufficiently skilled to make a decision on fitness to fly in an aircraft, despite the fact that the airline has already pre-cleared the patient. Thirdly, the aeromedical crew transporting the patient can override any local decision and declare someone unfit to fly, so what is the point in all this bureaucracy? However, we do need to realise that we live in a changing world, and while many of the systems, forms and procedures for transporting patients are relatively new – most developed in the last 30 years – the industry continues to use systems and processes developed for and designed in the 1970s and 80s to manage medical clearance. Why can’t medical clearance be done as a routine online procedure and then linked to the reservation of the passenger being flown back? Some would argue that without a fax (as currently), medical clearance wasn’t confirmed or in place. We allow visas to be approved electronically, linked to a unique identifier (the passport number); the patient being flown back already has a unique identifier (their reservation number) and medical clearance could be linked to this. With the emergence of tablet computers, one could rightly ask why we don’t have more

standardised information for repatriations? Having electronic aeromedical repatriation records would be both beneficial for processing and transmitting key logistical and clinical information, support cost control and could be aligned to the three key elements of quality:Safety – was the repatriation completed with minimal risk?;Effectiveness – were the right decisions made around equipment and prescribing of medicines and devices used?; and finally The experience – was the repatriation for the patient and their family as they expected?Such integrated solutions mean having as close to real-time information as possible, which would then be sent electronically back to base (encrypted of course) to allow for analysis and completion of case management. So why isn’t this happening? Is it because of a lack of a critical mass or is it the lack of standardisation?

Is standardisation of key clinical datasets for aeromedical crews the next element in releasing information flows to the 21st century? Airlines are able to run statistics on the number of passengers, those needing assistance, those carried as medical cases and so on, and IATA has set the standardised data elements required for clearance and incidence on aircraft, so why don’t we have a standardised clinical record form that can be used universally? It would reduce costs for assistance companies, as they currently design their own versions. By having an electronic repatriation data form, assistance companies and their underwriters could have more information on what happened, when and where, and it provides useful intelligence for forecasting claim trends, and likely profiling of passengers’ needs. It also allows assistance companies to audit their staff on what they are doing, when they are doing it and how often; it then allows them to tailor training programmes and ensures clinical governance with clinical audits supporting

the clinical practice and decisions. Financial governance and clinical governance in aeromedical transportation are intrinsically linked. As healthcare becomes more regulated and transparent (as, for example, in the UK), such ways of working support the evidence for future regulation for licensing of digital medical forms. Being able to show that there are processes in place for the registration of staff, their training, evidence of outcome and evidence of impact on quality care, are all key future registration models. While some may see this as going too far, in fact it supports assistance companies having evidence on why key skills, key decisions and key equipment and their costs are necessary for underwriters. So let’s have the discussion and the agreement on what data is needed and what information should be shared based on effective governance by embracing the modern way of using systems.

Is standardisation of key clinical datasets for

aeromedical crews the next element

in releasing information flows

to the 21st century?

Medevac Phenom 300 ordered for BrazilEmbraer has signed a contract for the sale of one Phenom 300 jet to Amil Assistencia Medica, one of the largest healthcare companies in Brazil, covering more than 3,600 hospitals. The contract is significant as it is the first medical evacuation version of the executive jet, which entered into service in May last year. Delivery of the medevac-configured plane is expected for the fourth quarter of 2011, after supplementary type certification and the installation of the special medical rescue package.Luis Carlos Affonso, executive vice president of executive jets for Embraer, said: “The sale of this Phenom 300 configured for medical evacuation to Amil, which is a national benchmark healthcare organisation in this area, shows our firm commitment to meeting the needs of customers with distinctively different products.”The aircraft will be operated by Aeromil, a company created in 1993 to manage Amil Regate Saude, which is an air and land rescue organisation dedicated to handling complex emergency situations. The new version of the Phenom 300 will be equipped with the traditional Patient Loading Utility System, manufactured by LifePort. The jet, overall, will be an aerial semi-intensive care unit for patients, with a 10-hour oxygen provision, 1,000 watts for vital equipment, a compressed air system, space for a ventilator, medical injection pump, defibrillator, IV poles and a neonatal incubator. The new cabin configuration will have space for a horizontal stretcher and four seats for medical personnel or companions of the patient. The jet has the lowest cabin pressurisation in the light jet category, which is an important parameter for patients who must be kept at sea-level atmospheric conditions. The access door of the plane is also the largest in its class, facilitating the entrance and exit of patients.Dr Jorge Ferreira da Rocha, president of Amil Assistencia Medica, said of the new aircraft: “The Phenom 300 will complement our medical evacuation transport fleet, ensuring our main objective when creating Amil Resgate Saude: to offer our clients state-of-the-art technology on behalf of their health. We are [especially] proud because this unit is an Embraer jet, produced in Brazil.” President of Aeromil Dr Henrique Grossi added: “Our capacity for service will be facilitated by the Phenom 300, while offering more modern equipment that is fully customised for rescues and inter-hospital shuttles.”

Nobel peace prize nomination for Wings of HopeChesterfield, Virginia-based Wings of Hope has been nominated for the 2011 Nobel Peace Prize. Founded in 1962, the organisation provides aeromedical transportation to people in need across the world, operating from 155 bases around the globe. Douglas Clements, president of the not-for-profit organisation, said the domestic and international programmes assist over one million people every year. He said of the Nobel Peace Prize nomination: “We knew about six months ago we were being evaluated by an approved nominator by the Nobel Committee. We were very humbled and honoured to be recognised. Wings is a great organisation and our volunteers are all deserving of being nominated.”A short Peace Prize nominee list will be compiled by the end of March, with the Nobel laureate selected by the autumn. Wings vice president Michele Rutledge is confident the organisation is deserving of the award: “Doctors Without Borders, which won a past Nobel Prize, uses our aircraft to deliver their services. We do the work the awards committee looks for, of promoting peace by helping people achieve self sufficiency.”

Children’s Air Ambulance changes information

Phenom 300 jet Embraer

The UK’s Charity Commission has concluded that The Children’s Air Ambulance (TCAA) organisation misled potential donors by implying in its literature that it already ran a helicopter air ambulance service, when in fact it was raising money to set one up. The Commission investigated the charity after receiving what it said was ‘a significant number of complaints over a number of months from members of the public’. The subsequent investigative report from the Charity Commission says that TCAA’s literature suggested to potential donors that its helicopter was already in operation and donations were needed to continue flying, which was not the case. “The trustees accept that this claim was misleading as they did not own, lease or operate an air ambulance,”

says the report. “The investigation advised the trustees to amend their literature and the charity did this immediately.”Nicola Howkins, chief executive of the charity, said: “Some of the literature may have been a little misleading and some people read into it incorrectly. We have changed it now.” She was unable to comment on the fact that in the charity’s first year of operation, ending August 2006, nearly all of its £46,865 income was paid to its founder, as she only started working for the charity in April last year. She added: “When I joined the charity, we had a big shake-up. All but one of the trustees have stood down and have been replaced by new people. We are making a fresh start.”

Nicola Howkins

www.itij.co.uk

AIRAMBULANCENEWS 19

The Royal Flying Doctor Service (RFDS) of Australia has launched a new aeromedical service for the people of Victoria. The first flight of the RFDS non-emergency patient transfer service took off on 24 Feburary, transporting a 16-year-old patient from his home in Shepparton to the Royal Children’s Hospital in Melbourne to access vital orthopaedic treatment that was not locally available.Scott Chapman, chief executive of the RFDS in Victoria, said that the service was developed after a survey of country and metropolitan hospitals in Victoria found that a large number of patients are transported by road due to the unavailability of preferred air travel: “Air Ambulance Victoria does a great job of transporting patients who require emergency medical assistance, but their priority is understandably on those emergency cases. This can leave non-emergency patients with no option but to wait or to travel by road. In launching this new service, our aim is to alleviate the pressure on hospitals by providing an efficient, safe and timely alternative for patients requiring non-emergency hospital transfers.”Operating as a joint partnership between two RFDS sections – RFDS Victoria and RFDS South Eastern – the service offers two King Air B200 aircraft and is staffed by RFDS flight nurses, pilots and engineers.Meanwhile, the RFDS has announced the appointment of Greg Rochford as its new national chief executive officer (CEO). Major General Michael Jeffery, the national chairman of the organisation, said: “We are very pleased to have such a proven

performer in Greg joining our team to help deliver the Commonwealth Government’s national healthcare policies.” Rochford brings more than 31 years of experience in the public health system, including a wide range of clinical and managerial roles, to his new position

at RFDS. Having led the state agency responsible for the co-ordination of aeromedical retrieval services, Rochford is already well versed in RFDS operations. He said of his new role: “I am pleased to be appointed as the new national chief executive officer of the RFDS. It is an exciting time to be involved in leading the delivery of regional and remote health services across Australia. It will complement the commitment I had to

patient care during my time with the New South Wales Ambulance Service.”New South Wales (NSW) Department of Health Director General Debora Picone said: “Greg has enjoyed a long and distinguished career with the NSW Health System. A feature of his leadership at the Ambulance Service has been an ongoing commitment to increasing the number of highly trained paramedics across NSW. His advocacy led to the provision of 800 new paramedics and patient transport officers, with a renewed focus on education and training that increased the professionalism of the service.” She added: “Greg has always placed the highest priority on developing the quality and safety of clinical care to patients and providing support for ambulance staff. The Ambulance Service, under his stewardship, has played an integral role in supporting NSW Health to deliver high-quality clinical care to patients.”

NEWSWIRENewly established firm Aeromedevac Ireland has celebrated the successful completion of its first intensive care repatriation. The company used its refurbished Cessna Citation to transport a level three patient from the Canary Islands to Cork in the Republic of Ireland.

UK-based Wings Medical Group has taken delivery of its latest state-of-the-art ground ambulance, which was custom-built at a cost of £80,000. The ambulance is equipped with special features for long-distance transports, including a DVD player and refreshment facilities.

Air Ambulance Worldwide’s affiliate Air GATO has been granted a license to operate flights between Cuba and the US, after receiving authorisation from the US Treasury Department.

US-based Pilots for Patients, an organisation that provides free flights to patients needing diagnosis and treatment not available to them locally, flew its 800th mission recently. It flew Brittany Henagon and her ill one-year-old daughter Evangeline to Meridian, Mississippi.

AirMed adds jet in HawaiiAirMed International has announced the arrival of a Learjet 36R/X at its Honolulu, Hawaii base. The long-range jet will be used for urgent transports to the US mainland, serving the transport needs of Hawaiian hospitals as well as the US Department of Defense. The Learjet is permanently configured with state-of-the-art medical equipment, including an ECG monitor with a hands-free pacer defibrillator, while a mobile extra corporeal membrane oxygenation (ECMO) machine can be added to transport critically ill ECMO patients.Sandra Apter, programme director of AirMed’s Pacific operations, said: “We are pleased to add the capability of long-range transports from Honolulu. The Lear will also allow for more efficiency in turnaround times for the emergency medical teams that accompany patients in-flight.”

FAI bases jet in West Africa

Magpas teams with CareflightUK-based emergency medical charity Magpas has agreed an historic partnership with Careflight – an air ambulance and international retrieval charity based in New South Wales, Australia. In operation for 25 years, Careflight is a $50-million-a-year service that operates three helicopters, four fixed-wing turboprop aircraft and four medical jets from eight bases across Australia. Speaking on behalf of Careflight, medical director Dr Alan Garner said: “When we visited Magpas last year and witnessed one of their residential training events for doctors and paramedics, we realised that we had at last found a UK partner that shared our high ethical standards and commitment to medical excellence. We look forward to exchanging information and personnel over the coming years so that both charities can continue to build up their knowledge and experience base for the benefit of patients.”Chief operating officer of Magpas Daryl Brown said of the partnership: “This is very good news indeed. It marks the next phase in Magpas’ remarkable 40-year history. This partnership will bring great benefits to both organisations, linking two world-class life-saving services.”

RFDS begins Victorian service

Wing-to-wing agreement reachedEuropean Air Ambulance (EAA) and Skyservice Air Ambulance (Skyservice AA) have announced a co-operation agreement that will see them providing the wing-to-wing transfer of patients on both sides of the Atlantic. During the International Travel Insurance Conference in Miami, held in February, representatives from both companies organised a reception to officially announce their collaboration and formally launched the partnership.As per the agreement, EAA and Skyservice AA will perform critical patient transfers in secure environments at the relevant service’s home airfields – in Canada at the Skyservice bases in Montreal or Toronto, and in Europe at EAA bases in Luxembourg or Baden/Karlsruhe Airport; all four facilities have medical equipment available. According to the companies involved, the new service helps to accelerate the repatriation of patients, as no time will be lost on obligatory crew rest, since the wing-to-wing transfer would take place at the end of duty time and include the handover of the patient to a fresh crew from the partner organisation. Over the past few months, crews from both services have undertaken air ambulance flights with wing-to-wing transfers, allowing both sides to gain experience on how best to perform the joint missions.

German firm FAI rent-a-jet has announced that it is to base a Learjet 55 with two Lifeport stretchers

onboard in Dakar, Senegal, offering a dedicated air ambulance jet service. The company set up flight operations and maintenance facilities in Dakar in 2006 in connection with an NGO contract, which will continue to operate beside the newly established air ambulance operations.Volker Lemke, sales

director for FAI, said: “The strong demand coming from FAI’s clients within the insurance and assistance

industries for an aircraft based in West Africa, mainly in order to reduce the response time in high-acuity cases, has led to this decision. The aircraft will be staffed with a heavy pilot crew, allowing round trips of up to 18 hours of duty time.” He added: “It makes no sense to base an ambulance jet somewhere in Africa without having established the appropriate maintenance facilities there before. In addition, FAI will be supported by a West African representative to facilitate arrangements like ground transports in the region or medical assessments in French. The medical team comprises a local ICU doctor trained by the FAI medical director and an FAI flight nurse or paramedic.” Lemke went on to say that once the company has a better understanding of client demands in the region, it may consider moving the aircraft to a different location, such as Abidjan in the Ivory Coast, especially once the present political turmoil has ended.

Greg Rochford RFDS

Conference Schedule 2011Featuring ITIC International, ITIC Domestic, ITIC Asia Pacific and Waypoint AirMed & Rescue events


22 NEWSANALYSIS

Gender realignmentYou can hardly fail to have noticed all of the headlines over the last few weeks concerning the Euro-judges banning cheap insurance premiums for women and the diffi cult consequences for pensions and other forms of insurance. But what has actually happened and how will it affect the cost of travelling? Simon Sheaf and Nigel Cooke explain

www.itij.co.uk

NEWSANALYSIS 23

Gender realignmentAt the start of March, the European Court of Justice (ECJ) issued a judgement preventing European insurers from continuing to charge different premium rates based on an applicant’s gender. The ban takes effect from 21 December 2012. Many types of personal insurances will be affected by the judgement because gender is currently a key element of their rate structures. Insurers would argue (with much justification) that this is because the risks are very different for men and women. Among the biggest statistical differences are in motor insurance for young drivers, life expectancy (used for term insurance and annuities) and in some forms of health insurance. While the influence is weaker in other types of insurance, there will still be some impact and, as a result, changes could occur in such products as travel insurance and car hire insurance in order to deal with the ruling.

Why did it happen?The principle of the equality of individuals is enshrined in European law. Race, gender, disabilities and age are four areas where that principle demands that positive action is taken by all EU states to remove discriminatory behaviour. As you might expect, therefore, it is illegal to charge someone more or less for a product or service simply because of their race or their gender, and explicit European Union (EU) Directives have been issued over the years to stamp this out. Each State then has to adopt the Directives into their own laws.Because of the statistical evidence showing that some claims rates differ so much between men and women, insurance has had an exemption option since the Gender Directive came out in 2007. Any EU State that chose to make use of this exemption was given a period of five years in which to evidence that using gender as a rating factor was fair. Insurers who failed to demonstrate this would have to relinquish the exemption on 21 December 2012. In 2009, a Belgian consumer group, together with two individuals, challenged the exemption and this challenge made its way to the ECJ last September. This action was not challenging the statistics on claims; it was challenging the principle – because, in effect, they felt that equality of price should mean exactly that. On that basis, the ECJ found that it really had no option but to uphold the challenge under the principles of Article Six of the Treaty on European Union. However, it is also a principle of the Union that changes of any law should not be so quick as to

risk damage to any stable markets and so the ability to differentiate insurance prices based on gender remains legal until 21 December 2012, five years

after the original Directive. Ironically, because of this last point, the Belgian challenge failed as it related to prices charged before 2009!

What will happen to premiums now?Nothing for now. Insurers need to consider what they do and they have more options available to

Events like this

represent an

opportunity to

innovate and find

a new way to be

competitive


24 NEWSANALYSIS

them than just charging an average price. In fact, they cannot easily jump the gun because if, for example, an insurer started charging an average premium rate to young drivers next month it would get all of the young male drivers and none of the young female drivers (who would stay with the insurers charging them a lower rate). This would leave them with a much riskier book of business than their competitors and one for which the premium they received would be inadequate.In fact, if you see offers promoting a unisex rate you should be suspicious. Either gender difference was never significant or the rate or cover is not likely to be that good.However, in the run up to December 2012, UK insurers will have to change their pricing processes to ignore gender. Insurers who are charging differential premiums based on gender will have a major exercise to undertake that will take time to get right.

What will happen later? Insurers will have three choices:- They can change their premium rates. Put simply, this will mean rises for one gender and falls for the other. The problem is that if only the premiums change, insurers will have to be conservative and assume that they get more of the high-risk applicants than low-risk applicants. In reality, that will mean that any price improvements for one gender will be less than the price rises for the other.- They can use new rating factors or increase the impact of existing ones. For example, in motor insurance (including the insurance sold when a car is hired) the type of car you are driving may now have a bigger impact on your premium than it did before. One can imagine that the colour and trims on your car may also start to play a bigger role. In life insurance, there may be fewer ‘standard rate’ policyholders, things like your weight and your occupation may then start to produce a wider range of premiums. The challenge for insurers will be to

find any underlying risk identifiers that sit behind the gender differences and to move towards using these as rating factors by December 2012.- They can change the policy benefits. This may result in products focused on female health risks, for example, which men will not want to buy and vice versa. Equally, greater use may be made of exemptions from cover where the insurer believes that such risks are heavily affected by the policyholder’s gender, which it cannot now price for.It is likely that insurers will do all of these to some degree or another. The exact mix will depend on which types of insurance an insurer writes, how it sells the cover and what everyone else is doing. For some types of insurance, such as life insurance and motor insurance, the size of the market and

extent of competition means that it is unlikely that substantial price increases will occur when there are other options available to the insurers, even if they are not perfect. However, this is going to be a period of change and insurers will need to carefully consider the most appropriate balance between increasing premiums and reducing the level of cover. Events like this represent an opportunity to innovate and find a new way to be competitive and the reality is that any insurer who simply puts their rates up towards that of the most expensive gender is going to find that they rapidly lose their customers to the new options being put into the market.A further concern for insurers is that the timing of this could not be worse. The end of 2012 already sees big changes both to capital rules due to the EU’s Solvency II initiative and to the taxation of insurance that will change pricing anyway. What else could happen?There are two additional areas where there is likely to be further debate, if not legal challenge. Firstly, there is a risk that as a consequence of the judgement, differential pricing that has occurred since the Treaty was implemented in 2004 may still be challenged as a fundamental infringement of the rights enshrined in the European Union Treaty, despite the fact that the Directive permitted the differential and still permits it. Logically, this would not appear to be a big risk given the ECJ comments and the fact that such a challenge would have major repercussions beyond insurance regulations.Of potentially greater concern for insurance pricing, however, is that the principles of equality in European law extend well beyond gender. The UK’s Equality Act (2010) is derived from the EU Directives and it prohibits discrimination against anyone with a ‘protected characteristic’. There are nine protected characteristics, which are: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, gender and sexual orientation. Were these all to follow the same path as gender, the impact would be dramatic. The most worrying item on the list is age, which at present has a very similar exemption to that which will be lost to gender pricing from the end of 2012. While the arguments are compelling for the use of age as a rating factor in certain insurance products (most notably, the same ones as affected by gender) and the wording used for its exemption is slightly stronger than it was for gender, we are still expecting a heightened debate on this following this ECJ ruling. Were the exemption for rating on age also to be lost, this would have a substantially more dramatic impact on pricing for the affected products than the removal of the exemption for gender. The thought of pricing for a life insurance product, for example, without allowing for age, seems to defy logic.

What is the likely impact on travel insurance? Returning to what is definitely happening rather than what might happen, many of the traditional benefits in a travel insurance policy have never been affected by gender, but ancillary insurances of the person (such as death and healthcare) are. As these will be a small part of the premium and not a key driver of the decision to purchase the cover, the chances are that the rates will equalise somewhere around the middle. Certainly, premiums for policies covering two adults of different genders are unlikely to change at all.However, insurers may impose greater restrictions on holiday pastimes, or charge more explicit additional premiums to back that cover. There will probably also be a change to car hire insurance offers. At present, many deals will not hire to drivers under the age of 23 anyway and it may be that other exclusions will appear in order to keep insurance costs reasonable.Once these changes take effect, it will be even more essential than usual for insurers to be vigilant since periods during which the market goes through a significant change are always riskier and more difficult for insurers to navigate their way through. As ever, the best defence is to be on your guard. n

Simon Sheaf leads Grant Thornton’s provision of actuarial services to the general insurance industry. He has worked in or consulted to the sector for more than 20 years.

His areas of expertise include pricing of insurance products, claims reserving, Solvency II, capital modelling and the provision of strategic advice to senior management.

Nigel Cooke is a senior life actuary with over thirty years of experience in the life and health insurance market. He has been working

at board level since the 1980s, including time as the CEO of a fast-growing life and health insurer. He moved into a consultancy role nearly ten years ago, joining Grant Thornton in 2010.

this is going to be a

period of change and

insurers will need to

carefully consider the

most appropriate

balance between

increasing premiums

and reducing the level

of cover


26 FEATURE

In more mature health insurance systems, such as the US, billions of dollars are lost to fraud and abuse each year. Currently, there is no reliable

data on the extent of the problem in the Gulf region; however, some estimate fraud and abuse to be about 10 per cent of medical claims, while others estimate it as high as 30 per cent. With health insurance laws still in their infancy in the region and paper submission of claims still the norm, the problem might have devastating effects if no action is taken.

Definitions in contextWhat is the meaning of fraud and abuse in this context? What are the current and projected impacts? Who are the usual culprits? What can be done to thwart fraud and abuse at this stage and in the future? Is there hope for the UAE to apply prior knowledge to address the problem and enact laws that would help insurance companies prosecute the perpetrators? And finally, how can actuaries help in identifying fraud and abuse?First, it is helpful to define the terms ‘fraud’ and ‘abuse’ in the context of health insurance. Fraud is an intentional deception that results in injury to another person; the key word here is ‘intentional’, meaning that the person committing fraud has full knowledge that they are committing fraud and that they intend to cause harm or injury to others. In this case, the injury is mostly monetary, although physical injury could also happen in some cases. Abuse, on the other hand, is the overuse or misuse of services and healthcare resources.When a provider bills an insurance company for services that he or she did not perform, this is fraud. When a broker advises his client not to report that he has asthma, this is fraud. When an employer lists his cousin as an employee in order to include her in the group policy that he is buying, knowing that she is critically ill, he is committing fraud. When a physician runs more tests than are needed because even though she suspects what the problem is, she wants to protect herself from lawsuits, then she is committing abuse. In this case, she actually performed the services and billed for them, but they were unnecessary tests and still increased the cost of healthcare without benefiting the patient. Private health insurance is new to the region and is still limited, for the most part, to high earners in most of the GCC countries. Only the Kingdom of Saudi Arabia and the Emirate of Abu Dhabi have introduced mandatory private health insurance. Other countries in the region, including the Emirate of Dubai, are on the cusp of introducing some model of mandatory health insurance. As it becomes widespread and includes people who are not accustomed to health insurance, the potential for fraud multiplies. Examining fraud and abuse in a developed private insurance market such as the United States may allow us to estimate future fraud and abuse in the UAE health insurance market and develop measures to tackle them.

Regional disparitiesAccording to the National Health Care Anti-Fraud Association in 2008, of the more than $2 trillion that

the US spends on healthcare annually, at least three per cent of that spending – or $68 billion – is lost to fraud each year. Other estimates by government and law enforcement agencies in the US place the figure as high as 10 per cent of the nation’s annual healthcare expenditure – or a staggering $226 billion – each year. Medicare and Medicaid made an estimated $23.7 billion in improper payments in 2007 (split almost evenly between Medicare with $10.8 billion and Medicaid with $12.9 billion). Medicare’s fee-for-service reduced its error rate from 4.4 per cent to 3.9 per cent. With the staggering amount at stake in the US health and insurance systems, considerable time and effort have been devoted to analysing the behaviour of fraud and abuse perpetrators. Fraud and abuse can be attributed to one of five major categories of perpetrators: 1. Providers and medical professionals, 2. Hospitals and facilities, 3. Consumers and the public,4. Insurance companies and third party

administrators (TPAs),5. Brokers, agents and employees.

In the US, providers and medical professionals account for the majority of fraud, or 72 per cent, while hospitals and facilities account for over eight per cent of all suspected fraud cases, according to an America’s Health Insurance Plans (AHIP) survey. Consumers account for 10 per cent, and the final 10 per cent comes from all other sources, including brokers and agents, laboratories, pharmacies, and employees (fig. 1).Some people would find it hard to believe that

Fraud in the UAE:a Western perspective

With health insurance laws still in their infancy in the region and paper submission of claims still the norm, the problem might have devastating effects if no action is taken

Fraud and abuse in health insurance may become a very costly problem to the United Arab Emirates (UAE) and Gulf Co-operation Council (GCC) in the near future. Nabila Taha details the different types of health insurance fraud international insurers should be wary of

www.itij.co.uk

FEATURE 27

medical professionals would commit fraud to this extent; however, you have to consider that some physicians believe that they are in fact helping the patient, who is their main concern, by billing for services that are covered by insurance instead of the ones they are actually performing, or by billing for services that have a higher cost (up-coding) in order to waive the cost sharing for the patient. Whether the physician benefits personally is not the key issue in defining fraud, because the fact remains that he intended to defraud the insurance company, or the Federal government (in the case of Medicare and Medicaid). Thus, billing for services not rendered constitutes the highest single category of suspected fraud by providers, at 34 per cent, followed by up-coding at 22 per cent, fraudulent diagnosis or dates at 18 per cent, and pharmacy provider fraud at 10 per cent (fig. 2).

When medical professionals are suspected of fraud, physicians are the most suspected at 59 per cent, with dentists and chiropractors each at four per cent

(fig. 3).On the other hand, of the total suspected fraud cases perpetrated by facilities, acute care hospitals account for the highest percentage at 59 per cent, while outpatient ambulatory care clinics account for nine per cent, and psychiatric hospitals for three per cent (fig. 4).Of all suspected fraud and abuse by consumers, enrollees constitute the vast majority with 97 per cent. It is incredible that some cases of fraud and abuse are overlooked. Medicare paid dead physicians 478,500 claims totaling up to $92 million from

2000 to 2007. These claims included between 16,548 and 18,240 deceased physicians. Nearly one in three claims (29 per cent) Medicare paid for durable medical equipment was erroneous in fiscal year 2006. Medicare and private health insurers pay up to $16 billion a year for needless imaging tests ordered by doctors. There are a multitude of laws in the United States that target fraud. Most states have codified or are in the process of codifying laws that pertain to fraud, with some specific to ‘insurance fraud’. On the Federal level, Congress, through the Health Insurance Portability and Accountability Act of 1996 (HIPAA), established that healthcare fraud is a federal criminal offence. If a person is proven guilty of health insurance fraud, they could face up to 10 years in prison, as well as major financial penalties. In addition, both Medicare and Medicaid have laws and programmes that target health insurance fraud and abuse.

Looking EastWhile there are no official figures on the scale of fraud and abuse in the UAE and GCC, there is little doubt that it exists, and it will grow unfettered unless laws are developed to limit it and systems to detect it. Abu Dhabi implemented electronic claims submission about two years ago, which should have improved service, but according to most research on

0

10

20

30

40

50

60

70

8080%

10% 10%

MedicalProfessionalsand Hospitals

Consumers All others

(�g. 1)

Examining fraud and abuse in a

developed private insurance market

such as the United States may allow

us to estimate future fraud and

abuse in the UAE health insurance

market and develop measures

to tackle them

(fig. 2)

Billing for services not given

Upcoding

Fraudulent diagnosis or dates

Pharmacy claims

Waiving of cost sharing

Fee splitting

All other


28 FEATURE

the subject, it has actually exacerbated the problem. Fraud is easier to detect by vigilant claims examiners who see claims that look suspicious, than by systems of ‘pay first and investigate later’ that are used in order to meet stringent deadlines of quick payment. If you add to that the fact that in the United States, the most vulnerable people to fraud and abuse are the old, the poor, and the uneducated, and that at least 65 per cent of the residents in the UAE, for

example, are poor laborers from third-world countries, it becomes very clear that extrapolating these factors to the region would have a devastating effect on the economy and the cost of health insurance. Additionally, some people in the region who are not accustomed to health insurance would think that they are performing a good deed by lending their health insurance card to their

0

10

20

30

40

50

60

4%

59%

33%

4%

Physicians Dentists Chiropractors All others

(�g. 3)

“Over the 15 years I have been involved in the administration of medical claims in Dubai, I have noticed huge improvements in the management of medical insurance policies. As the medical profession has come to accept the necessity of healthcare insurance, they have accepted that they have to work with the insurance community and increasingly view us as their partners. The largest area of fraud, or maybe the easiest to detect, are those by providers and professionals, whether it be hospitals issuing duplicate claims over a period of time, clinics and pharmacies acting in collusion with each other or just over-utilisation of scanners, in the end the systems and checks employed by the insurance community tend to catch them out.With the arrival of compulsory insurance and the strengthening of the regulatory environment, things should be improving, but a new threat is arriving in terms of the electronic delivery of claims.”

Peter Hogg, CEO, Asian Healthcare Holdings

some physicians believe that they

are in fact helping the patient, who

is their main concern, by billing for services that are covered by

insurance instead of the ones they are actually performing

0

10

20

30

40

50

60

Acute carehospital

Otherfacility

Otherhospitals

Psychiatrichospitals

Outpatientambulatory

care

4% 3%

59%

25%

9%

(�g. 4)

www.itij.co.uk

FEATURE 29

neighbour or their relative who are not insurance holders. Likewise, physicians would think that they are helping their patients by performing a service that is not covered and bill the insurance company for one that is covered. This happened to one of our employees while I was managing the health insurance programme for the employees of the Government of Dubai. The patient went for an eye exam for glasses. The doctor who examined him recommended Lasik surgery, which is not covered, and submitted the claim for a disease of the eye that is covered. Lucky for us, the patient is a physician and knows that this is fraud. He reported the culprit to us before the scheduled surgery. Awareness of the propensity for fraud and abuse in this area and experience abroad are necessities for insurance companies, reinsurers and governments. Laws that target fraud in health insurance need to go hand-in-hand with laws that make health

insurance compulsory.Health insurance companies, however, do not need to wait for laws to be enacted in order to tackle the problem and reduce the cost of health insurance. They have resources through data mining, claim examination, provider profiling (seeing the red flags) and pattern algorithms. Actuaries can help to comb through data and identify patterns that signal the possibility of fraud or abuse. As the patterns of fraud change with time and as the perpetrators change their approach with time, it becomes more important that analyses must be vigilant. In cases where companies or governments have established robust programmes of identifying and targeting fraud and abuse, the rewards were significant compared to the cost. By most accounts, return on investment (ROI) in fraud and abuse detection and investigation ranges from 1:1.5 to 1:7 which means that for every single dirham or dollar spent on fighting fraud, up to seven dirhams or dollars could be saved. n

Nabila Taha, ASA, MAAA

Nabila Taha is the managing director and chief actuary for Taha - Actuaries & Consultants. She has extensive experience in consulting for insurance companies and governments, assessing profitability, pricing, underwriting, product development and provider contracting. Ms. Taha served as the director of actuarial analysis at the Dubai Health Authority where she led Enaya, the Dubai government employee health insurance programme with approximately 90,000 members and was able to save more than AED 80 million for the Dubai Government.

Abu Dhabi implemented

electronic claims submission about

two years ago, which should have improved service, but according to most research on

the subject, it has actually exacerbated

the problem

Sources:National Healthcare & Fraud Association website.U.S. Office of Management and Budget, 2007.AHIP, Healthcare Fraud: An Introduction to Detections, Investigation, and Prevention; Page 288,289, 291.US Senate Permanent Committee on Investigations, 2008.Inspector General, Department of Health and Human Services, August 2008.American College of Radiology, 2004.

“What is peculiar about medical insurance fraud in the region is that those who engage in it seem not to consider it to be wrong or inappropriate – and, least of all, as criminal. When, for instance, medical providers collude with insured patients – the type of fraud that safeguards such as personalised membership cards can do little to prevent – they do so for their own benefit, but also as some form of modern-day Robin Hood act. They help ‘rob’ the ‘rich’ insurers and give the ‘poor’ insured members their ‘rightful’ due. The fact that each medical insurance policy is an agreement between the two parties with clearly defined terms and conditions is neither acknowledged nor respected. Alongside efforts to put up barriers to thwart fraud, a concerted attempt needs to be made to raise awareness and to change this mindset – and the misplaced sense of moral righteousness with which these acts, minor and major, are perpetrated.”

Pradeep Dharmapalan, chief executive, BDAE Expat Consultancy JLT

2011

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Griselle Chernys, CEO, Payerfusion Corporation

On 23 March 2010 President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law – a very necessary step, according to Griselle, who noted she participated in the administration’s planning for healthcare reform. Her message was clear: The US needs this law, which is an effort to make healthcare accessible and affordable to as many as 40 million uninsured people. Currently, healthcare spending is about 16.2 per cent of the US gross national product (GNP) and surpassed $2.57 trillion in 2009. But Griselle added that PPACA focuses more on providing insurance than on limiting costs. From 2010 through to 2016, it calls for everyone in the US to be insured either individually, with employer plans or through government-sponsored insurance exchanges. There are fi nes to individuals and employers who do not comply. However, the fi nes are minimal for individuals, but higher for employers, who may decide not to offer insurance and have their workers join one of the exchanges. “Critics of the plan feel the administration made the penalties low to end up with a public national health insurance plan,” she said. But regardless of the vehicle, by 2014 all US residents must have essential coverage, including preventive and wellness services. The PPACA includes a programme for chronic disease management and provides for coverage of dependent adult children under the age of 26. The

focus, Griselle added, is on primary care in order to guide the patient and keep overall costs down.Currently, there is litigation challenging the PPACA. Meanwhile, the exchanges are not yet ready. In addition, waivers in four states will allow insurers to offer less generous health benefi ts. “The landscape is changing all the time,” Griselle said, “so you have to pay attention and see what happens next.”As for the global travel insurance industry, Griselle said that travel policies are considered short-term policies and are not addressed by the PPACA. Also, the PPACA pertains only to US nationals, including outbound expats who are covered by their employers. It does not pertain to foreign lives. “For most people in the travel insurance industry, it will be business as usual,” she concluded. “But everyone in the international arena needs to understand that the system will be changing over the next few years.”

Ralph Lawson, CFO, Baptist Health International Centre of Miami

Ralph explained that Baptist Health is a large system with six hospitals in Miami-Dade, Broward and Monroe Counties. Currently, about 56 per cent of non-elderly patients have insurance coverage, while older patients are covered by Medicare. From a provider’s perspective, US healthcare reform poses a tremendous risk, because it may affect insurance premiums and hospital revenues. “It would be dangerous for employers to stop providing health insurance and have employees get coverage from the public exchanges,” he said. “That’s because Medicare pays much less than

commercial carriers.” He added that Medicare and Medicaid paid about 64 per cent of the hospital’s costs per patient in 2005, but that fi gure fell to 48 per cent in 2010. Ralph said that Baptist would operate at a loss unless someone paid more than its costs. That means the insured patients must make up for the shortfalls incurred in caring for Medicare, Medicaid and uninsured patients. While everyone thinks it’s good to have more Americans covered by insurance, as a society the US needs to fi nd better ways to reduce healthcare costs. One of the best ways to do so is to focus on quality, according to Ralph. For instance, Baptist invested $8 million in a 24/7 remote monitoring system for all its ICU beds. After implementation, mortality rates fell by 30 per cent and ICU length of stay dropped by 29 per cent. But, Ralph said, “We have yet to be able to bill anyone a single penny more for this technology.”In fact, Ralph added, more than 30 per cent of healthcare spending is administrative in nature. While this might seem like a great place to cut waste, the PPACA created more than 150 new federal agencies and imposed new reporting requirements. “If people are hoping this law will reduce costs, it won’t happen.”

Alex Sanchez, vice president, American Association of Medical Audit Specialists

Alex focused his comments on how healthcare reform will affect the travel insurance industry. Noting that the law does not directly affect international patients or travellers, he said the US

government continues to tell providers how much it will pay for Medicare and Medicaid patients. Therefore, providers will be looking at increasing their revenue stream from other sources. “Some are going after the international market by offering elective and cosmetic procedures,” he said. “On the other side, providers are being more aggressive in using collection agencies and limiting access to US networks for international patients.”What can a travel insurance agency do to reduce costs? Alex suggested using a service that can steer an international patient through the US system when non-emergency care is needed. In some cases, a doctor could issue a prescription over the phone or come to the patient. He noted that many European travellers were stuck in the US without medication for a week or longer due to the 2010 volcanic ash crisis. Having a system in place to fi ll those prescriptions reduces the risk of having to provide emergency care.Another way to cut costs is to carefully manage the patient’s case while in the hospital. “Everything needs to be authorised,” Alex said, “and there should be no surprises with the patient and provider.” Since a bed in an ICU can cost thousands of dollars a day more than a regular room, the travel insurance company needs to monitor the intensity of care. Discharge planning should also be done at the earliest possible stage, ideally before admission, to anticipate any ongoing medical needs. Alex suggested looking for providers who will give 30 to 40 per cent of contracted rates for upfront payments or trying to negotiate a package payment for all provider services. He also emphasised the importance of reviewing the patient’s bill carefully: Were there duplicate services or extra charges? “An auditor needs to be sure the statement is clean before paying,” he said.

The inaugural ITIC Americas conference was held in February in Miami, and attracted hundreds of delegates from all over the continent, representing all the diverse aspects of the international travel insurance industry. This ITIC review includes synopses of all the speaker and panel sessions that took place at the Lowes Hotel, Miami Beach, along with photos of the sponsored events

US healthcare reform – how it will change the industry

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ITIC REVIEW 31

Lisa Beichl, president and CEO, Transparent Borders LLC

Looking at the US medical tourism market, Lisa said the fi rst inbound wave of international patients was focused on centres of excellence like the Mayo Clinic. “Typically, these centres have a high level of technology and clinical expertise, and the patient is paying for quality,” she said. Now, the market is moving into general medical tourism, looking for affordable, quality-focused accessible medical treatment. Therefore, the travel insurance industry needs to be able to understand the individual’s preferences, and conduct environmental and medical risk assessments of various providers in order to match the patient with the best venue. For instance, some patients may want an aggressive approach to their healthcare, while others do not. “As the marketplace evolves with social media, the idea of preference becomes more relevant,” Lisa added. “We also need to recognise that those individual preferences may change over time.”One of the most positive factors for looking at the US as an inbound medical tourism market is that the nation’s hospitals welcome self-insured patients. Telemedicine is another supportive trend, because it can provide a bridge to medical tourism, she said. A board-certifi ed physician can develop a relationship with an international patient prior to travel. Because US healthcare costs are generally higher than other countries, many US and non-US patients

are looking at other medical travel destinations in the Americas. However, insurers must carefully assess the different levels of risk in cross-border medical care, Lisa said. Risks to the patient include quality of care and long-term outcomes, as well as transition risks – how long the patient will need to stay on site and what kind of care will be needed after returning

home. Insurers also need to get as much information as possible about the provider – not always easy in less-transparent markets – including sources for medical devices like heart stents. Summing up her presentation, Lisa said, “The sustainability of the cross-border market is questionable at this time. If consumers are not convinced medical tourism is a viable option, then it’s not. They have to be the ones who make the decision to move forward.”

Jim Krampen, co-founder, principal and executive offi cer, Seven Corners

Jim began his presentation by asking the question: Is the outbound US medical tourism market fact or fi ction? Based on his 20-plus years of experience, Jim says the statistics vary widely and may often be overstated. He defi ned a US medical tourist as someone who travels out of the US for elective treatments, such as cosmetic surgery, dental work or bariatric care, as well as major medical procedures. US expats overseas and US tourists who have an emergency when abroad do not count as medical tourists, according to Jim. Nor do recent US immigrants who return to their home countries for medical care. On the other hand, there are millions of US residents who take spa holidays that may have a slight medical component or who drive across the border to Mexico for dental work. “When you look at true medical tourism, though, the numbers get smaller,” he said. Jim cited a 2008 Deloitte report that claimed 750,000 US citizens went abroad for medical care in 2007 and projected that number would rise to six million in 2010. A year later, that projection was scaled back to 878,000 for 2010. In contrast, a 2008 McKinsey report said only 60,000 to 85,000 US citizens travelled abroad for medical care in 2007, not counting cosmetic and dental procedures. Finally, a 2010 report from the

University of Iowa based on data collected from 45 medical tourism facilitators found that 13,500 US residents travelled abroad for treatment in 2008. Jim said his fi rm surveys more than 200 medical tourism facilitators in the US, with the largest claiming to have 1,000 outbound patients in a year. After the recession, he estimates there are now about 100 US-based organisations facilitating some type of treatment for US citizens aboard. About 70 per cent of them were startups after 2009. In conclusion, he said: “We estimate there were 25,000 US medical tourists in 2010, not counting spa, dental or cosmetic treatments. Since medical tourism does not work for insured US citizens or US employer groups, we will see very little growth in this market until individuals’ out-of-pocket costs increase signifi cantly.”

Mike Torino, vice president, business development, Costa Rica MD

Costa Rica MD is a medical tourism company that facilitates arrangements for patients from the US and Canada who come to Costa Rica for medical, dental and cosmetic treatments. “We are looking for people who need care, but can’t afford it in the US,” said Mike. “Someone who can’t cover the bill for a US procedure may be interested in coming to Costa Rica.” Currently, much of the demand is for dental care, because most US residents don’t have dental insurance and have to pay out of pocket for treatments. Mike said one patient paid $5,000 for dental work that would have cost $16,000 in the US. Other patients seek cosmetic surgery, or elective surgeries like hip replacements, knee replacements, laser eye surgery and cataract removal. Those medical procedures are also less costly: $25,000 in Costa Rica for heart bypass surgery, compared with $144,000 in the US. “These savings will drive this industry, which is now in its infancy,” Mike said. When considering medical travel, one of the important things for patients to consider is the experience and credentials of the provider. Mike said there are 371 hospitals in the world that are accredited by the Joint Commission International, including 33 in the Caribbean and three in Costa Rica. “This accreditation provides the patient and the insurer with a degree of comfort knowing the facility has been inspected by an international agency,” he said. Other factors that will drive medical tourism include the posting of more online information about international providers and the development of new insurance products to cover medical travel. “Improved quality of care in other countries will also be an important factor,” he concluded.

Q. Do malpractice lawsuits increase US healthcare costs?Ralph Lawson: Yes. We have a culture where we sue somebody if anything goes bad. The malpractice losses in the UK, France and Germany are much lower. What we need are better tort laws that compensate victims in a reasonable way.

Q. Are international insurers paying for the US healthcare system?Ralph Lawson: I think there’s some truth to that. International insurers are paying for the shortfalls just as US insurers do.

Q. If you could change one thing about the US system, what would it be?Alex Sanchez: Have a system with costs and payments based on the patient’s diagnosis, not insurance coverage. Ralph Lawson: I would like to see a clear vision for our system, something like making the US the healthiest society in the world in 10 years.Griselle Chernys: Better consumer and patient education. People don’t take care of themselves. They don’t realise that today’s claims will be tomorrow’s premiums.

Medical tourism – crossing borders into South America and the Caribbean


32 ITIC REVIEW

International Services

The ITIC Miami 2011 Welcome Function sponsored byBaptist Health South Florida

www.itij.co.uk

ITIC REVIEW 33

Ignacio Márquez, international operations director, Assist-Card International

Ignacio opened his talk by presenting an overview of Latin America as a tourist destination. From Mexico to the Tierra del Fuego, Latin America attracts nearly 50 million visitors a year, compared with 92 million for North America and 460 million for Europe. Latin American tourism has been growing in recent years, he added. There was a three-per-cent drop in 2009 and a two-per-cent rise in 2010, with projections for a two-per-cent increase in 2011 and four-per-cent rise in 2012. From the opposite travel perspective, Latin America generated 41 million departures: 47 per cent within the region, 24 per cent to North America and 22 per cent to Europe. Next, Ignacio explained the differences between travel assistance, which protects the individual, acts in the present and is focused on well-being, and insurance, which protects people’s assets, acts after the event and pays claims. Assist-Card, which is not licensed or regulated as an

insurance company, provides assistance to travellers. About 34 per cent of its business comes from Latin America, nine per cent from the Caribbean, 24 per cent from the US and 29 per cent from Europe. Most medical problems handled by the company involve a household doctor or urgent care services, with about 13 per cent involving emergency care. About five per cent of cases involve transfer and repatriation.“Our clients in Latin America are most concerned about medical issues, while trip cancellation insurance

is the most important service for US travellers,” he said. In Latin America, the company’s valued features include speaking the same language, providing a cashless service, and offering legal assistance and luggage tracking as part of its concierge services. “We expect to see continuing growth in Latin America’s assistance market,” Ignacio said. “It will become more competitive as new players come in, and the products will become more specialised.”

Eugenio Chinchilla, managing partner, Redbridge Group

From a market perspective, Latin America has 600 million people and almost seven per cent of the world’s gross domestic product, Eugenio said. That places the region ahead of Eastern Europe, Africa and the Middle East on a population basis. In terms of insurance, Latin America produces about $100 billion in premiums, about 2.5 per cent of the world market. In turn, that $100 billion is divided into 40 per cent life and 60 per cent non-life policies. “We have a good vantage point for the region with new products and distribution channels,” said Eugenio, noting that Redbridge provides underwriting, risk management and consulting services to insurers, as well as developing specialty risk products for insurance companies. Within Latin America, Brazil, Mexico, Argentina, Venezuela and Colombia account for around 90 per cent of premiums. “Motor insurance is a great way to distribute travel products,” he added. “While Brazil has been difficult to penetrate, it has recently opened up and is now attracting attention.”Insurance generally has a low penetration rate in the region. For instance, dollar per capita spending on health insurance is just $176, compared to $618 for the rest of the world. In northern Europe and the US, the average expenditure is $4,000 and more. “The bottom line is that insurance is growing faster in Latin America than in other parts of the world,” he said. The key drivers include economic prosperity, a favourable regulatory environment and the development of new products. Banks, retail stores and affinity groups are increasingly being used as alternative distribution channels in the region. “It’s a big opportunity for companies with risk capacity,” he concluded.

Jose Luis Vargas, vice president of mass marketing division, Pan American Life Insurance

Jose provided background information on Pan American Life, which offers an international major medical package for wealthy individuals and families in Latin America and the US Hispanic market, as well as benefits solutions for US and European multinationals in the region. Founded in 1911, Pan American’s portfolio includes life, medical, accident and affinity products. “Business-related travel insurance is a major opportunity,” Jose said. “It’s an attractive niche market that is not well explored in Latin America, and there are opportunities for pre-packaged programmes. This is a receptive audience for insurance and assistance products.”Jose said that travel agencies play a key role in the distribution of retail travel insurance products, accounting for 70 to 80 per cent of the market. Other channels include websites, airline reservation systems, booths in Latin American airports and wholesale private label programmes. While Internet distribution is picking up, Latin Americans still like the personal touch of a live travel agent or a representative at an airport booth. “Unlike Europe’s automated systems, in Latin America you need to go out and engage travellers,” he said. Looking to the future, Jose predicted that the region’s insurance market would steadily mature in the next decade. He added, “From a global perspective, this is a clear growth opportunity.”

Jack L. Zemp, CPCU, deputy general counsel USA, Mondial Assistance

John Fielding, Of Counsel, Steptoe and Johnson LLP (pictured right)

Jack and John focused their presentation on how they have been working with the National Association of Insurance Commissioners (NAIC) to change the rules on how states regulate the sale of travel insurance. Their goal has been to develop a model law that would then be enacted by each state, providing greater consistency of regulation throughout the US. “We want to help the NAIC develop a simpler, better process that reduces the licensing burden, creates a uniform system and protects the consumer,” Jack said.Travel insurance in the US is driven mostly by trip cancellation and interruption coverage, as well as loss of baggage, according to Jack, which is different from other parts of the world, where accidents and health are the most important features. In the US, travel insurance is a discretionary, short-term buy; annual policies are rare in this market.In the US, there are approximately 30 licensed travel

insurance providers, who distribute products through local retailers like travel agencies, online agencies like Orbitz and through the airline reservation systems. Cruise lines and tour operators also sell travel insurance, which is included in memberships of the American Automobile Association (AAA). Jack noted that the profile of the travel agent is changing – rather than serving a local clientele, they often focus on certain types of trips, such as African safaris or Caribbean cruises. Most of the 9,500 US travel agencies are small – five employees or less – and travel insurance is about two per cent of their total revenue. Currently, a licence is required to sell travel insurance. However, there are 19 different types of licences in the US, and seven states require two separate licences. The rules are inconsistent and regulators interpret them differently, Jack said. It can take six months to get licensed in all 50 states, which poses a problem for high-turnover call centres. “Travel agents are presenting the material for the client to review, just like a sales person at Best Buy sells service contracts to customers,” Jack said. “A provider like Mondial is considered the responsible party.”John said he and Jack have been working with NAIC

since 2008. In essence, their approach would be to shift the regulatory burden from the agent to the provider, who would be responsible for training and registration. “These standards are not law yet, but the NAIC has given its blessing to this approach,” John said. “Once the states adopt this model, travel agents will be able to offer travel policies without

being licensed, as long as consumer protection requirements have been met.”While most states can implement this process without changing their laws, legislative action will be needed in others, including Florida, California and Texas, John said. “We will try to convince those states to adopt this new approach.”

Q. Do you have to adjust your travel insurance policies by country in Latin America or do you take a uniform approach?Ignacio Márquez: We roll out new products simultaneously irrespective of market.

Q.How do your policies handle pre-existing conditions? Ignacio Márquez: We try to give the client the benefit of the doubt, but we do have to deny claims related to a chronic condition or if the problem was present or emerging before the trip.

Growth of the Latin American market, in and outbound travellers

Insurance sales and distribution


34 ITIC REVIEW

Tom Hudson, senior vice president and general counsel, Medex (pictured below)

Donald Grauel, principal, L.E. Goldsborough & Son, Inc. (pictured right)

To kick off the joint discussion of liability issues, Tom presented the fictitious case of a US tourist taking a guided tour of a historic site in Istanbul. She falls, injuring her hip, and is taken to a local hospital. The examining doctor tells her she needs hip replacement surgery. At that point, the assistance company is informed of the case, and has to decide whether the surgery should be done in Istanbul or if she needs to be evacuated. After consulting with the insurance company, the local surgeon is given the go-ahead for the surgery. Eight days later, the traveller is ready to be transported home by the assistance company on a commercial airliner with a medical escort. But en route to the airport, her limousine is struck by another vehicle and the tourist injures her hand. A decision is made to fly her home anyway. While in flight, the woman’s hip becomes dislocated, and she requires further surgery after arriving back in the US. As Tom said, “This case raises a host of liability issues. For instance, is anyone at fault? Does she have a cause of action against anyone? And who is responsible for the damages?”

Certainly, the chain of potential liability would include the travel agent who sold her the policy and provided the tour guide, the surgeon, the hospital, the assistance company, the limousine driver and company, the medical escort and the commercial airline. “Should any of these parties have done something differently?” Tom asked. “That’s a key question in determining how this case might be resolved.”At that point, Donald entered the conversation, emphasising a key point regarding indemnification: “If

your insurance policy does not protect you from a particular incident, you’re out of luck. The days of the company saying ‘you’ve been a good agent and we’ll take care of you’ are over.”That means all parties involved in travel insurance need to understand their policies, particularly commercial general liability and E&O (errors and omissions) professional liability. But Donald said that travel agents typically buy a policy by price, rather than reading the coverage provisions. “Do your policies cover bodily injury caused by the wrongful acts of third-party providers?” he said. “That’s a good starting point.”Tom said that there are often a series of contracts that come into play when a travel-related mishap occurs. In the Istanbul case, for instance, there are contracts involving the traveller, travel agency, assistance company, insurance company, limousine company, medical assistance company, medical escort company and commercial airline. “Those contracts define the rights, duties and obligations of the parties, and likely contain indemnification provisions,” he said. “Be careful you don’t take on a contractual liability for which you do not have insurance coverage.” That’s because one of the questions that arises in liability cases is the matter of control. Does the assistance company, for instance, have control over a hospital staff or surgeon? Probably not, said Tom. But the assistance company might have a responsibility to properly vet and credential those providers. Another issue, Donald said, is whether the policy also covers legal defence, an important financial issue in the event of a complex and costly lawsuit. Summing things up, Don said, “There are many moving parts in insurance policies, and some of the variables come into play when a claim is made. Remember, there’s a correlation between how closely a policy is read by the insurer and the size of the claim.”

Dick Atkins, legal counsel, International Recoveries

Dick began his talk by recounting one of the stranger cases in his long career. Back in the 1980s, a tourist who was injured after being thrown from a camel in Egypt was offered an unusual form of compensation: two camels to take back to the US. Since then, the development of releases, liability waivers and indemnification forms have helped to formalise the travel industry, but every case is still unique, he said.For assistance companies, Dick emphasised the importance of due diligence in selecting a subcontractor. “If you pick a hospital or air ambulance firm using objective criteria, you’ll likely be safe if something bad happens,” he said. He recommended using an accredited transport company, making a site visit, checking the aircraft and personnel, and reviewing the provider’s reputation. Overall, Dick said, there are very few lawsuits filed against fixed-wing air ambulance companies. “Over the length of the flight, there is a bond of care and concern with the medical team,” he said. “These patients and their families do not want to sue their guardian angel. However, there are many lawsuits involving rotary aircraft, as these flights are short and family members have not had time to bond with the crew.”Dick’s next point was that travel companies should use forms that allow for responsible consent. If travellers must sign a ‘contract of adhesion’, the courts will likely rule that the release was invalid. He cited the case of a charity worker in Kazakhstan who needed emergency evacuation to a hospital in St. Petersburg. “I told the family to sign a release of indemnity because that clause could not be enforced,” he said. “The girl’s life was saved and that was the end of the case.”Dick said there should be a subrogation clause in any travel insurance contract that authorises the company to recover the money it has paid out in the event of an injury or accident to the traveller.

Finally, Dick said the companies should retain high-quality legal help in drafting their contracts and forms. But even more important is the need to respond quickly and personally to crisis situations. “Assistance is meant to be humanitarian, helping people get out of terrible situations,” he said. “In general, the assistance companies do a wonderful job in achieving that goal.”

Q. What advice do you have to avoid litigation?Tom Hudson: It’s important to have a good relationship with your insurance broker or agent who can help you analyse risk. Analyse your risk, insure properly and read those insurance contracts.Don Grauel: Make your broker earn the commission and explain your policies, especially E&O coverage.Dick Atkins: It’s important to have quality legal help with experience in the industry to be sure release forms, consent forms and indemnification forms are up to date for each jurisdiction. Having the subrogation clauses worded the right way can save you substantial dollars.

Q. How should an assistance company handle the case of a person in China with a ruptured appendix in terms of credentialing the hospital and surgeon?Tom Hudson: In general, you evaluate the member’s condition and make a decision. You might need to go ahead with the local surgery but get the member to higher-level care as soon as possible.

Mistakes, mishaps and consequences: Indemnification

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ITIC REVIEW 35

Aron Gampel, vice president and deputy chief economist, Scotiabank

Aron began his talk by emphasising that the global economy is recovering from recession; stock markets are rising, long-term interest rates are declining, and the emerging markets are the new locomotives of growth. For example, Brazil, Russia, India and China (the BRIC countries) are the largest car markets in the world, with plenty of room for further growth. In the Americas, Canada is benefitting from worldwide demand for forest products, grains, oil, uranium, metals and gold. “The global economy runs on trade,” Aron said, “and we are seeing more evidence that trade flows are improving,” he said. However, there are still plenty of risks in the world, Aron added. In the US, the ‘housing virus’ is still constraining consumer spending and economic growth. High levels of debt in the US, UK and other European countries will also slow global markets. “Global financial

imbalances will add to market volatility,” he said. “The US dollar is on shaky ground and inflation risks are rising,

as food and energy costs are being pushed up.” While ‘ultralow’ interest rates have helped revive economies in the developed world, credit demands are rising in the public and private sectors. As a result, Aron expects rates to rise about one per cent in the next 12 months.Aron said the travel business is very tied to the global economy, which is projected to grow about 4.5 per cent annually in 2011-12. While Americans are travelling less, more tourists

are attracted to China, Brazil and Russia, bypassing traditional visitor destinations in the developed world.

“From a travel standpoint, the emerging markets have the highest potential for growth,” he concluded. “They will be driving tourism inflows and outflows for the foreseeable future.”

Milan Korcok, North American correspondent, ITIJ

Reflecting on his long service as a travel insurance ombudsman, Milan said it is essential for physicians to disclose medical information to their patients prior to travelling. “Sometimes a doctor doesn’t want to worry a patient needlessly,” he said, “but a lack of disclosure can be catastrophic for the patient who depends on travel insurance.” Milan cited the example of a 76-year-old Canadian snowbird who complained of wheezing and dizziness, but saw a cardiologist two years ago for a slow heart rate and a slight arterial blockage. Her doctor wanted her to enjoy her annual trip to Florida and told her to see him when she returned. While in Florida, she ended up in the hospital and was diagnosed as needing a pacemaker. The assistance company wanted to wait until she stabilised and then take her home to Canada. But the US cardiologist decided she needed the

pacemaker first. The result was a $50,000 hospital bill that the insurer declined to pay. “When the woman filled out her medical application she was asked in last 12 months have you been seen or treated for coronary or vascular conditions,” Milan said. “Her doctor told her everything was normal and cleared her for travel, but the insurer said she didn’t disclose her heart problem. How could she disclose what the physician didn’t tell her? This is the kind of case that calls for an ombudsman.”Milan pointed to another cost-related issue. If the US cardiologist had realised his role, the medical arsenal might not have been mobilised so quickly. Many doctors look to resolve the problem immediately, but in this case stabilisation was really the right answer. “Sometimes, it’s a matter of professional education,

making sure the physician understands what travel insurance is designed to do.”

Dr Jose Quesada, director of finance and operations, UHealth International

Jose said that many travellers in the Caribbean and Latin America seek emergency treatment at Miami’s major healthcare facilities. Each year, the University of Miami Miller School of Medicine/Jackson Memorial Hospital handles about 600 to 700 medical evacuation cases from the region. To see whether or not the medical school’s physicians understood travel insurance, Jose interviewed the medical director of an insurance company and a provider. They told him that the meaning of pre-existing conditions was not clear, and ‘fit-to-fly’ criteria were not discussed during medical training. “As a result, there can be conflicts between the referring

physician and the air ambulance doctor,” he said. Jose added that US healthcare tends to be more aggressive due to liability issues. A person in Latin America with a heart problem might be treated with drugs, while a stent might be implanted in the US. Of course, the costs of care also vary widely across countries, pointing to the importance of teamwork between the provider and the insurer at a case management level.That’s particularly important during air ambulance transfers to avoid a gap in communications. Jose said the referring physician relinquishes responsibilities after the air ambulance team accepts a transfer. “In many cases, there is no discussion between the referring doctor and the patient’s primary physician back home,” he said.In summary, Jose emphasised the need to address certain issues before, during and after an emergency: communication among the different care teams, patient stabilisation versus treatment, documentation for

travel, and delivery of reports for follow-up care. “Co-ordination of care is vital for this type of patient,” he said.

Sandro Bacchelli, MD, International Patient Care, La Clinique Soleil, Hollywood Medical Clinic

Sandro explained that he is board-certified in family medicine and has been involved with travel insurance for 20 years, handling 2,000 to 3,000 of these cases. Patients who seek treatment in a foreign country often have a number of fears about the process. They also want VIP treatment, to receive immediate care and have some sort of personal relationship with the US physician. “Understanding the patient psychology is extremely important in these cases,” he added. “You want to be sure to ease the patient’s fears and treat the problem appropriately.”Communication among all parties is the key to satisfying the patient, the physician and the insurer, Sandro added. “In family medicine, that’s always the key. You can agree upon what’s expected in the case and provide high-quality care in the least costly manner. After all, the insurance company wants a satisfied member who will recommend the company and buy a policy next year.”Sandro also warned that because the profit margins are so high with travelling patients, insurers need to examine the bills with a critical eye. There might be extra workups, unnecessary prophylactic care, double charges and other misstatements. “Perhaps the travel insurance industry could create a coalition that demands changes in the reimbursement structure,” he concluded. “That’s needed to make a difference.”

Q. How can travel insurance companies educate physicians?Milan Korcok: One suggestion is to develop short educational programmes such as 30-minute talks. That’s one of the roles the industry can play in the future.

Q. Are international patients treated differently from other cases?Jose Quesada: The standard of care is the same. We look at case management as a way for the payer and provider to work together to deliver the care that will result in the best outcome for the patient.

Q. How can you prevent a patient from getting more care than would be absolutely necessary?Jose Quesada: You have to work with hospitals and physicians to be sure they understand this is a travel insurance case and the goal is to stabilise the patient.

Q. How will global market uncertainties affect travel and health insurance?Aron Gampel: Many people are thinking more about insurance, and this sector will continue to grow. There should be a couple of reasonably good years ahead.

Travelling through the global economy

Hospital cost containment: Do doctors really understand travel insurance?


36 ITIC REVIEW

Jacob Bercovici, general manager, Aero Jet International

Jacob discussed the challenges faced by an air ambulance company like Aero Jet, which is based in Fort Lauderdale, US, and San Juan, Puerto Rico, and

handles about 750 missions a year. First on the list are the medical issues, such as obtaining an accurate report. “We are told that the patient is stable and ready to be transported,” he said. “When we arrive, we find the patient needs special equipment, a sea-level cabin and a full medical team. That has a huge impact on our operations.”Next comes the issue of obtaining patient information. Jacob said most Caribbean countries use the Advance Passenger Information System (APIS) to identify arriving and departing passengers. However, Cuba and the US have their own systems. Finally, there are the operational challenges. That can include obtaining any required landing or overflight permits. “When we get a call, we have to check the airport to see if it will be open when we arrive, if there are any restrictions on landing and any weather conditions in the area,” Jacob said. Medical transport flights are also affected by the number of stops required before reaching the final destination, as the US Federal Aviation Administration (FAA) sets a limit of 10 hours of flight time and 14 hours of duty time in a day. Also, an aircraft flying at low altitudes because of the patient’s medical condition may need an extra stop for fuel. “A lot of people think that you make a phone call and that’s it,” he concluded. “There are a lot of things that

go on behind the scene that affect medical transports.”

Anne Rodenburg, international relations manager, USMX for Airlink Air

Ambulance

In her talk, Anne emphasised the cultural differences of doing business in Latin America. Her company specialises in repatriating patients to the US and Canada and operates six aircraft. “When you are dealing with visitors beyond national borders, you have to take culture into account, because that affects the medical transport process,” she said.While every Latin American country is different, there

are some common cultural aspects, she said. One example is perceptions of time. In the air ambulance industry, time is a critical factor in emergency

operations. The medical team expects to pick up the patient at 3 p.m. However, Latin Americans have a looser sense of time, Anne said. They live more in the present and worry less about the future – one reason they may be less likely to buy insurance than other cultures, she said. For an air ambulance team en route to a pickup, that means calling ahead to see if the ground ambulance has left the hospital, and being sure the fuel truck is at the airport ready to service the aircraft. Unlike Europe, where rules tend to govern business dealings, Latin Americans are more concerned about relationships, and personal ties play an important role. “If you are a friend of the airport commandante, he might come down at night and open it up for you,” Anne said. Latin Americans also tend to laugh and joke more than Europeans, and they display their emotions more openly, Anne said. They also enjoy social conversations before coming to the point. “My point is that cultural differences are often overlooked,” she said. “But I believe in the saying, ‘When in Rome, do as the Romans do.’”

Alejandro Sanchis, business development director, HAA/AXA Assistance

Alejandro first discussed how AXA selects air ambulance providers and the company’s expectations for their services. When a medical evacuation is needed, AXA taps the expertise of its regional staff to help identify the closest, most appropriate facility for treatment. From there, arrangements can be made to stabilise the traveller and take them back home. “Our responsibility starts at the location of the first episode and ends at the patient’s home country,” he said.Once the AXA team understands the patient’s medical situation, they can determine if a commercial stretcher or commercial medical escort is appropriate, or if a dedicated plane or helicopter is necessary. About 80 per cent of transports are commercial medical escorts. AXA also works directly with commercial airlines to arrange the proper medical team, equipment and supplies for a patient, who can travel in a separate area with family members.

When an emergency occurs, air ambulance decisions are made based on location and availability of the aircraft, medical equipment and cost, in that order, Alejandro said. AXA expects a bed-to-bed service

and does not intervene in the middle of a transport. The company stays in continual touch and sends updates every two hours to the team staffing the case as well as the family. “Ultimately, everyone wants to go home,” Alejandro said. “We work through all the bumps on the road until that can be accomplished.”

Q. As an air ambulance company, what is your biggest challenge?Anne Rodenburg: The aviation, medical and cultural challenges.Jacob Bercovici: Keeping up with changing country and airport regulations – and keeping the customer happy.Alejandro Sanchis: Resolving critical situations in an area without modern medical facilities for a customer with low coverage benefits.

Repatriation: Unique challenges in the Caribbean, Mexico and Latin America

www.itij.co.uk

ITIC REVIEW 37


38 ASSISTANCE&HEALTHCAREWORLDMARKETS

Mark Twain once famously wrote: “Mauritius came first, and then came heaven.” As a role model for emergent multi-cultural

societies rapidly elevating themselves from Third World status, the idyllic Indian Ocean Island of Mauritius has been extremely resilient, with highly religious Christians, Muslims, Hindus, Buddhists and Jews not only managing to co-exist successfully, but also interweaving their indivudual cultures.There was civil strife for independence back in 1968 and again, less seriously, a few years back. But those sad events are now seen as hiccups – albeit large ones – on the otherwise smooth road to status as one of the African region’s most integrated, stable, democratic and prosperous nations.

Growth centreIn the four decades since

the end of British rule, Mauritius

has seen

average annual growth figures of between five and six per cent – transforming itself from a poor, essentially single-crop, agricultural economy into a diversified middle-income economy with growing textile manufacturing, fish and seafood processing and financial sectors and a thriving tourism industry. Sugarcane fields can still be found across the island – accounting for a whopping 90 per cent of all

agricultural land – but they now compete for space with new-build luxury hotel properties.Pharmaceuticals are another fast-growing sector of the economy. Such products as gelatine capsules, bulk drugs, medicaments, disposable syringes, perfusers and diffusers are now being produced on the island for the export market – especially within the COMESA (Common Market for Eastern and

Southern Africa) region.Per capita gross domestic product, measured at purchasing power parity, stands at US$12,356 – the region’s sixth highest, behind the Seychelles, Equatorial Guinea, Gabon, Libya and Botswana. Mauritius is one of only three African countries to achieve a high UN Human Development Index rating.

Increased life expectancy – currently standing at 75 – lowered infant mortality rates, and a vastly enhanced infrastructure have been among the many benefits of sustained growth. Mauritius is currently ranked at 65 out of the 177 nations listed in the Human Development Index and at 63 in the gender-related Development Index. Population of the island currently stands at 1.23 million.

The government’s ongoing development strategy centres on foreign investment. Mauritius has attracted more than 9,000 offshore business entities over the past decade, with many targeting commerce with South Africa and India and a growing number in the medical sector. Inward business investment has reached more than US$1 billion.To attract tourists and stimulate the economy, Mauritius is aiming to achieve duty-free status within the next five years. Already, tax has been reduced or eliminated altogether on more than 1,850 products, including food, clothing and audio-video and photo equipment, while corporation tax has been lowered to 15 per cent to encourage non-resident companies to trade or invest through a permanent establishment on the island or otherwise.Underpinning the new society are comprehensive state-provided education and healthcare systems, the latter coping well with not only the locals but the needs of the hordes of visiting tourists.

Health mattersHealthcare in Mauritius is viewed as a human rights issue. As a consequence, public healthcare services are free and fully tax funded. Current annual public

TO ATTRACT TOURISTS AND STIMULATE THE

ECONOMY, MAURITIUS IS AIMING TO ACHIEVE

DUTY-FREE STATUS WITHIN THE NEXT FIVE YEARS

A burgeoning tourism sector is driving the Indian Ocean nation’s growth – and medical tourism is on the way, discovers Roger St Pierre

Mauritius: dream island

www.itij.co.uk

ASSISTANCE&HEALTHCAREWORLDMARKETS 39

A MAJOR WEAKNESS OF THE MAURITIAN

HEALTH SYSTEM LIES IN ITS PRIMARY CARE

PROVISION, GENERALLY THE FIRST POINT

OF PATIENT ENTRY INTO THE SYSTEM

Mauritius: dream island



health spending is running at some US$222 per capita, accounting for 9.8 per cent of total central government expenditure. However, in a World Health Organization (WHO) compiled report on the overall efficiency of health service provision, Mauritius ranked just 84th of the 191 countries rated – behind some countries with a per capita GDP of less than half its own.In the recent book ‘The Idea of Justice’, Amartya Sen voices the opinion: “Individuals sometimes do not realise how bad their health systems are. Someone raised in a community with many prevalent diseases and poor facilities may be inclined to view symptoms as being normal when they are actually clinically preventable.” A major weakness of the Mauritian health system lies in its primary care provision,

generally the first point of patient entry into the system. Most GPs, outside the hospitals, are in private practice with a vested interest in seeing that their patients, who are generally poorly informed, stay within the private system. All GPs working outside the hospitals are in private practice and charge for their services.Serious steps are now being taken to develop participatory approaches to health service planning and delivery. There has been recent heavy government investment in new technology, such as telemedicine. The long-term aim is to both decentralise and modernise the healthcare system.Over recent decades, there has been an epidemiological transition as the main causes of morbidity and mortality have shifted from infections

to chronic and degenerative diseases. Comments Dr Romesh Munbodt, the WHO Liaison Officer for Mauritius: “Though malaria has been eliminated, Mauritius is prone to outbreaks of viral fever. Traveller’s diarrhoea is the most common disease and vaccination is required for yellow fever, rubella, cholera, rabies, hepatitis A, measles, polio and mumps. Non-communicable diseases now represent 74 per cent of the total burden of disease in men and 76 per cent in women.”Improved water quality has been a major health issue. The EC has been a key player in assisting the Mauritian government to implement a modern wastewater treatment infrastructure, which has dramatically improved the situation. The public health system is open to all citizens

PRIVATE AIR AMBULANCE SERVICES BASED ON REUNION

ISLAND AND IN EAST AND SOUTH AFRICA PROVIDE

EMERGENCY EVACUATION FROM THE ISLAND

www.itij.co.uk

ASSISTANCE&HEALTHCAREWORLDMARKETS 41

and funded entirely from the government’s tax revenues, with no compulsory health insurance scheme being in operation at present. The country has no reciprocal healthcare agreements with other nations. However, when a patient – be they a local or a foreigner with a work permit or resident permit – enters a government health facility, all services are provided completely free of charge. This inclusive free healthcare approach runs from doctor consultation and initial treatment through to the most complex operations and includes the cost of medications, though the range offered by hospital dispensaries is sometimes limited and can include low-quality imported medications from India. A nominal charge, though, may be made for visitors on a tourist visa.

Emergency careTrauma centres are to be found in the big regional public hospitals in Candos, in the capital city of Port Louis and in the north. Free ground ambulance coverage is provided island-wide by the state health service run by SAMU (Service Aide Medicale Urgence) but that organisation’s air ambulance service is overdue for improvement. A private ground ambulance service is operated by MediCare, while private air ambulance services based on Reunion Island and in East and South Africa provide emergency evacuation from the island. Mauritius has a well-established EMS system, with a single 999 ambulance dispatch system covering the whole island.The oldest but – thanks to a recent 275-million

Mauritius Rupees (£5.9-million) investment – also the most modern private health clinic on Mauritius is the Fortis Clinique Darné, in Floréal. It was established in 1953 by Dr François Darné, with a handful of beds and just one operating theatre. The brand new, much-expanded clinic now offers 110 operational inpatient beds, with installed capacity for up to 120 beds and a wide range of general and specialised services. The five-storey building has been carefully configured to provide for an efficient flow of patients between departments.Other prominent private clinics include Clinique du Bon Pasteur, in Rose Hill, and City Clinic, in Port Louis, while the islands’ principal public hospitals are Queen Elizabeth Hospital on Rodrigues Island (Mauritius is a Commonwealth member state); Flacq Hospital, in Flacq; Dr AG Jeetoo Hospital, in Port Louis; and Jawaharkal Nehru Hospital, also in Port Louis.The public primary care service currently has a network of two mediclinics, 23 area health centres and 103 community health centres. Fully 100 per cent of the population enjoys a first point of contact with the health service within just three miles of their homes.Secondary level healthcare is provided by two district hospitals and five regional hospitals, which provide primary inpatient and outpatient services, including A&E, general medicine, general and specialised surgery, gynaecology and obstetrics, orthopaedics, traumatology, paediatrics



and intensive care, as well as supervising the emergency services and satellite area health centres and community health centres. The tertiary level is the highest referral level, comprising four specialised hospitals with a 980-bed capacity. A 53-bed cardiac centre offers specialised services in cardiac surgery, invasive cardiology and neurosurgery.Outside the state system, private healthcare has

evolved in two forms – fee-paying private medical and dental care practices and 13 clinics that provide private beds and facilities for consultation, examination and diagnostic procedures, mainly in the spheres of radiology and clinical pathology.The public/private healthcare debate is ongoing and things are heating up with the arrival of Indian group Apollo, which has just opened its first hospital in

Mauritius in a joint venture with a politically influential local group. To quote a recent Expatblog posting: “A local friend recently had to undergo surgery and consulted with a private clinic, quickly concluded that he could not afford it, and thus turned to a public hospital. Much to his surprise the surgeon in the public hospital was the very same surgeon that also worked in the private clinic!” The blogger added: “Now, I’m aware that it’s not all about the surgeon/doctor but also about equipment, expertise, consultation, language, patient care and the general management of the hospital etc but I still keep asking myself: are we paying through the roof for medical insurance that we don’t actually need?”Founded in 1991 in partnership with International SOS Assistance of Geneva, Medic Assistance International became wholly owned and independent three years later. Today it has five full-time employees and a part-time staff of 12 and is the only locally based medical assistance company. It operates across the Indian Ocean, covering cases in the Seychelles and Madagascar, as well as Mauritius, using US, UK and European Union (EU)-trained doctors.Chief executive officer and medical director Dr Siddick Maudarbocus trained in Dublin then worked as an emergency physician for a US oil drilling company in West and Central Africa before settling in Mauritius and working closely with the local tourism industry, delivering healthcare to visitors through a network of well-trained doctors and specialists. Over the past decade, the company has developed close

working relationships with such major international assistance groups as MAPFRE (Spain), Mercury (Germany), Touring Club (Belgium), First Assist and Worldwide Assist (UK), MRI and International SOS Assistance (South Africa), AEA and SOS Assistance (Singapore) and World Care (Australia). Services provided by the company include air ambulance evacuation, medically supervised repatriation, legal, compliance and regional regulation advice and consultation and cost containment services.Dr Maudarbocus sees quality control as the biggest challenge facing the public health sector: “Graduates working in the system have qualified all over the world – they have trained in the UK, the EU, North Africa, Russia, the Ukraine, India, Pakistan and, most recently, at the Chinese universities – and sometimes quality of care varies more than one would wish. In our dealings with the medical profession and with overseas insurance and assistance companies, there are sometimes communication problems, despite our being a multi-lingual organisation.” He went on to say: “I have seen many poorly worded medical reports and we consequently get many requests from our overseas’ partners for more detailed and updated medical reports. [Conversely], we are often kept waiting overly long for guarantee of payment letters from partner assistance companies. This is most often due to long delays in getting GPs to present their medical history reports. In some cases, such as acute gastroenteritis, such reports are not even relevant, yet we still suffer these delays.”Medic Assistance claims a solid advantage in having a multilingual workforce. The company’s doctors have been trained in many countries so that, for example, a French tourist can be placed in the care of a Parisian-trained local doctor while a Russian visitor can have access to a Mauritian doctor who speaks fluent Russian and qualified in Russia.Cost containment of medical expenses, though, has become a major issue for international travel insurers. Given the island’s isolation, overseas insurance and assistance companies find it hard to assess local hospital pricing structures efficiently and many bills are hyper-inflated. Comments DR Fontana, of Italian-based ACI Global: “We have frequently dealt with two repatriation cases from Mauritius and in one of them found the hospital charges to be what was felt were excessively high.”Observes Dr Maudarbocus: “We are regularly being asked to renegotiate clinic bills and have now appointed specialist full-time staff to deal with such matters. “Mauritius has aims to develop itself as a medical tourism destination, but cost containment will be a critical factor in winning such business.” n

THE PUBLIC/PRIVATE

HEALTHCARE DEBATE IS

ONGOING AND THINGS

ARE HEATING UP WITH

THE ARRIVAL OF INDIAN

GROUP APOLLO

CATEGORY KEY CLAIMS MANAGEMENT INSURERSAIR AMBULANCE CLAIMS SUBROGATION MEDICAL ESCORT ON COMM. AIRLINEAIR AMBULANCE INTERIOR COMMERCIAL REPAT SPECIALISTS MEDICAL PROVIDERAIRCRAFT PERFORMANCE SOLUTIONS CRITICAL CARE PATIENT TRANSPORT MEDICAL SCREENINGASSISTANCE COMPANIES FUNERAL DIRECTORS RE-INSURANCECATASTROPHIC CLAIMS SPECIALIST HEALTHCARE CLINICS TRAVEL AGENTSCOST CONTAINMENT HOSPITALS WEB & DESIGN SERVICES


44 SERVICEDIRECTORY To have your company listed in the Service Directory email: [email protected]

AMREF Flying Doctor ServiceDr Bettina Vadera – Medical Director

Wilson Airport, LangataRoad, PO Box 18617, Nairobi, KENYA

tel: fax:

+254 20 6000 090+254 20 344 170

email: website:

[email protected] www.amref.org

Netcare 911 InternationalJacques Pienaar – Fixed Wing Operations Manager

Riverview Park, Janadel Avenue, Midrand, SOUTH AFRICA

tel: fax:

+27 10 209 8392+27 10 209 8405

email: website:

[email protected]

West African Rescue AssociationFlorian Zagel – Managing Director

Klotey Cresent 6, North Labone, Accra, GHANA

24hr tel: tel:

+233 243 666 111+233 302 781 258

email: website:

[email protected]

AeroMed Asia Inc.Cindy Wong / Lorraine Paul – International Account Management

SINGAPORE BANGKOK THAILAND

tel: fax:

+603 7965 3883+603 7629 8810

email: website:

[email protected]

AirMed International LLCJeffrey T Tolbert – PresidentAirport World Trade Center, 1 Sky Plaza Road, Hong Kong International Airport, HONG KONG

tel: fax:

+852 3756 3680+852 3756 3681

email: website:

[email protected]

CareFlight Group Medical and Tasking Centre

PO Box 5078, Robina Town Centre, Queensland, 4230, AUSTRALIA

24hr tel: fax:

+61 7 5553 5955+61 7 5553 5914

email: website:

[email protected]

CareFlight InternationalPaul Smith – National Manager

Westmead Hospital Campus, PO Box 159, Westmead, NSW 2145, AUSTRALIA

tel: fax:

(+61) 2 9893 7683+61 2 9689 2744

email: website:

[email protected]

Flying Doctors AsiaPrithpal Singh – CEO , Director313 Old Bird Cage Walk, #01-15/02-16, Seletar Airport, SINGAPORE24hr tel:

fax: +65 9297 7757+65 6483 5407

email: website:

[email protected] www.flyingdoctorsasia.com

Hope Medflight Asia Pte LtdDr Charles Johnson – Medical Director

2 Loyang Lane 03-01, Singapore 508913, SINGAPORE

24hr tel: fax:

+65 6100 1911+65 6400 5254

email: website:

[email protected]

Medic’Air International 每递安国际Dr Huaqun Gao – Medical Director

885 Renmin Road, Huaihai China Building, Room 808, 200010 Shanghai, CHINA

tel: fax:

+86 2163 558289+86 2163 558285

email: website:

[email protected]

ADAC-Ambulance ServiceRobert Glueck – Marketing & Sales Director

Am Westpark 8, 81373 Munich, GERMANY

tel: 24h Alarm:

+49 89 76 76 52 85+49 89 76 76 50 05

email: website:

[email protected]/ambulance

Air Medical LtdGlenn Salt – Flight Operations Manager

Oxford Airport, Kidlington, Oxfordshire OX5 1QX, UK

tel: tel:

+44 1865 842 887+44 1865 370 642

email: website:

[email protected]

Augsburg Air AmbulanceRoland Schoberth – Director

Roseggerstr 17, D-86368, Gersthofen, GERMANY

tel: tel:

+49 821 299 1020+49 821 299 2030

email: website:

[email protected]

Capital Air CharterLisa Humphries – Sales Director

Exeter International Airport, EX5 2BD, UK

tel: fax:

+44 845 055 2828+44 1392 350 039

email: website:

[email protected]

European Air AmbulancePatrick Schomaker – Director Sales & Marketing

175A, rue de Cessange, L-1321, LUXEMBOURG

24hr tel: fax:

+49 711 7007 7007+49 711 7007 7009

email: website:

[email protected]

FAI – rent-a-jet AGVolker Lemke – Director Sales & Marketing

Flughafenstrasse 100, D-90268 Nuremberg, GERMANY

tel: fax:

+49 911 36009 31+49 911 36009 59

email: website:

[email protected]

German Red Cross Air Ambulance ServiceAndreas Speich – Managing Director

Aufm Hennekamp 71, 40225 Düsseldorf, GERMANY

tel: fax:

+49 228 2300 23+49 228 2300 27

email: website:

[email protected]

Greek Flying DoctorsDimitris Kanellis – Manager

3 Doukisis Plakentias Str, 152 34 Halandri, Athens, GREECE

tel: fax:

+30 210 674 0600+30 210 674 0634

email: website:

[email protected]

IAS MedicalGeorge Ditchburn – Operations Manager

145-157 St John Street, London, EC1V 4PY, UK

tel: fax:

+44 870 042 1465+44 870 042 1480

email: website:

[email protected]

IFRADr Christian Steindl – Director

Bahnhofplatz 13/5, POB 160, 3500 Krems, AUSTRIA

tel: fax:

+43 2732 825 610+43 2732 851 01

email: website:

[email protected]

Jet Executive International CharterIrena Dimitrijevic – Marketing & SalesMündelheimer Weg 50, D-40472, Düsseldorf, GERMANY“Homebase FRA & MUC”

tel: fax:

+49 211 602 7775+49 211 602 77766

email: website:

[email protected]

Mayoral Executive JetJuan Carlos García Caparrós – Commercial Director

Dominguez Toledo S.A., 118 La Orotava, Malaga 29006, SPAIN

tel: fax:

+34 952 048 609+34 924 048 612

email: website:

[email protected]

Medic’Air InternationalDr Herve Raffin – General Manager

35 rue Jules Ferry, 93170 Bagnolet, Paris, FRANCE

tel: fax:

+33 141 72 1414+33 148 57 1010

email: website:

[email protected]

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45SERVICEDIRECTORYcall +44 (0) 117 925 5151 To make an alteration to a listing email: [email protected]

AIMSBernadette Breton – Managing Director

Private Bag X5, Benmore Gardens 2010, Johannesburg, SOUTH AFRICA

tel: fax:

+00 27 11 783 0135+00 27 11 783 2950

email: website:

[email protected]


Wilson Airport, Langata Road, PO Box 18617, Nairobi, KENYA

tel: fax:

+254 20 6000 090+254 20 344 170

email: website:

[email protected]

Interhealth TechnologiesKevin Thomas – Director - International

P O Box 3058, Bedfordview 2008, SOUTH AFRICA

tel: fax:

+27 11 622 8010+27 11 622 8264

email: website:

[email protected]

Medical Services Organisation (MSO)Vernon Pillay – Operations Director - International Division

PO Box 1578, Gallo Manor, 2052, SOUTH AFRICA

tel: fax:

+27 (0)11 259 5403+27 (0)11 259 5001

24hr email: website:

[email protected]

Netcare 911 InternationalLouis Mabele – International Assistance Operations Manager

Riverview Park, Janadel Avenue, Midrand, SOUTH AFRICA

tel: fax:

+27 (0)10 209 8387+27 (0)10 209 8405


[email protected]

West African Rescue AssociationFlorian Zagel – Managing Director

Klotey Cresent 6, North Labone, Accra, GHANA

tel: fax:

+233 244 312 496/7+233 21 781 259

email: website:

[email protected]

On Call InternationalMichael J. Kelly – President & CEO

One Delaware Drive, Salem, NH 03079, USA

tel: fax:

+ 888 289 0567+1 603 328 1770

email: website:

[email protected]

SelectCare WorldwideMagdi Riad – President

#1201, 438 University Avenue, Toronto M5G 2K8, CANADA

tel: toll free:

+1 416 340 7265+1 866 261 6718

email: website:

[email protected]

World Travel ProtectionDavid McLean – Vice President, Sales & Marketing

400 University Avenue, 15th Floor, Toronto, ON, M5G 1S7, CANADA

tel: fax:

+1 416 205 4646+1 416 205 4676

email: website:

[email protected]

To have your company listed in our service directory

contact the sales department now:

[email protected] or telephone: +44 (0)117 922 66 00

Assistance OnlineBertrand Guichoux – CEO

Zendai Cube Edifice 6/F, 58, Changliu Road, Pudong, 200135 Shanghai, CHINA

tel: fax:

+86 21 6104 9500+86 21 6104 9484

email: website:

bertrand-guichoux@assistance-online.com.cnwww.assistanceonline-china.com

DynamiqJanine Benson – Director of Emergency Assistance

Level 5/33 York St, Sydney 2000, NSW, AUSTRALIA

tel: fax:

+61 (0) 2 9978 6600+61 (0) 2 9888 3609

email: website:

[email protected]/assist

North Flying a/sJesper Kragelund – Sales Manager

North Flying Terminal, Aalborg Airport, DK-9400, Nørresundby, DENMARK

tel: fax:

+45 9632 2900+45 9632 2909

email: website:

[email protected]

Redstar AviationMustafa Atac – CEO

Sabiha Gokcen International Airport, J Blok Kurtkoy, 34912 Istanbul, TURKEY

tel: fax:

+90 216 588 0216+90 216 588 0225

email: website:

[email protected]

Swiss Air Ambulance / RegaPeter Meierhans – Director of Sales

PO Box 1414, Zurich Airport, CH-8058, SWITZERLAND

tel: fax:

+41 333 333 333+41 44 654 3590

email: website:

[email protected]

Tyrol Air AmbulanceJakob Ringler – Managing Director

PO Box 81, A-6026, Innsbruck Airport, AUSTRIA

tel: fax:

+43 512 224 220+43 512 288 888

email: website:

[email protected]

Aero Jet InternationalStuart Hayman – President

4631 NW 31st Avenue, #220 Ft Lauderdale, FL 33309, USA

tel: fax:

+1 954 730 9300+1 954 485 6564

email: website:

[email protected]

Air Ambulance Professionals, Inc.Brian L. Weisz – PresidentFt. Lauderdale Executive Airport, 1535 South Perimeter Rd, Hangar 36B Ft. Lauderdale, Florida 33309, USA

tel: fax:

+1 954 491 0555+1 954 491 6114

email: website:

[email protected]

Air Ambulance SpecialistsTom Cox – Director of Business Development

345 Inverness Drive South, Suite A110, Englewood, Colorado, 80112, USA

tel: fax:

+1 720 875 9182+1 720 875 9183

email: website:

[email protected]

AirMed International LLCJeffrey T Tolbert – President

1000 Urban Center Drive, Suite 470, Birmingham, AL 35242, USA

tel: fax:

+1 205 443 4840+1 205 443 4841

email: website:

[email protected]

Global Jetcare, Inc.Bart Gray – President

16479 Runway Drive, Brooksville, FL 34604, USA

tel: fax:

+1 352 799 7771+1 352 799 7776

email: website:

[email protected]

JET ICUMike Honeycutt – President

2561 Rescue Way, Brooksville, FL 34604, USA

tel: fax:

+1 352 796 2540+1 352 796 2549

email: website:

[email protected]

LIFESUPPORT Patient TransportGraham Williamson – CEO

#9-1009 Allsbrook Road, Parksville, British Columbia, V9P 2A9, CANADA

tel: fax:

+1 250 947 9641+1 877 288 2908

email: website:

graham.williamson@LifeSupportTransport.comwww.LifeSupportTransport.com

Skyservice Air AmbulanceDavid Ewing – VP International Business DevelopmentMontreal/PE Trudeau Int Airport, 9785 Avenue Ryan, Montreal (Quebec), H9P 1A2, CANADA

tel: fax:

+1 514 497 7000+1 514 636 0096

email: website:

[email protected]/airambulance

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First AssistanceMary-Jo McDonald – General Manager

PO Box 17-310, Greenlane, Auckland, NEW ZEALAND

tel: fax:

+64 9 356 1650+64 9 525 1278

email: website:

[email protected]

Global Assistance & HealthcareMario Babin – Chief Executive OfficerCilandak Commercial Estate - # 111 GC, Jl. Raya Cilandak KKO, Jakarta 12560, INDONESIA

tel: fax:

+62 21 299 78 999+62 21 299 78 9555/66

email: website:

[email protected]

ADAC-Ambulance ServiceRobert Glueck – Marketing & Sales Director

Am Westpark 8, 81373 Munich, GERMANY

tel: 24h Alarm:

+49 89 76 76 52 85+49 89 76 76 50 05

email: website:


Altas AssistanceArvydas Bebravicius – Managing Director

Lentvario Str. 7, Lt-02300 Vilnius, LITHUANIA

tel: fax:

+370 5 264 4020+370 5 264 4021

email: website:

[email protected]

AP CompaniesNatalya Butakova – Business Development Manager

17 Varshavskoye Shosse, Moscow 117105, RUSSIA

tel: fax:

+7 495 989 1120+7 495 989 1130

email: website:

[email protected]

ARC Europe SAHans Biekmann – Network Director

Avenue des Olympiades 2, 1140 Brussels, BELGIUM

tel: fax:

+32 2 706 6660+32 2 706 6601

email: website:

[email protected]

CNASCarole Luisy – Managing Director

80 rue des alliés, 38100, Grenoble, FRANCE

tel: fax:

+33 438 49 83 49+33 438 49 83 40

email: website:

[email protected]

DRK AssistanceAndreas Speich – Managing Director

Aufm Hennekamp 71, 40225 Düsseldorf, GERMANY

tel: fax:

+49 211 2711 2020+49 211 3018 0527

email: website:

[email protected]

Global Assistance a.s.Petr Bold – General Manager

Dopraváku 749/3,184 00 Prague 8, CZECH REPUBLIC

tel: fax:

+420 266 799 770+420 266 799 797

email: website:

[email protected]

Global Voyager Assistance - RussiaCostas Danilenko – CEO

PO Box II, 125124 Moscow, RUSSIA

tel: fax:

+7 495 775 0999+7 495 775 0998

email: website:

[email protected]

Global Voyager Assistance - Black SeaOlga Turubarova – General Manager

77-79 Nezhinskaya Str., 65023, Odessa, UKRAINE

tel: fax:

+38 048 7373 441+38 048 7373 442

email: website:

[email protected]

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tel: fax:

+30 210 674 0600+30 210 674 0634

email: website:

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Marm AssistanceJill Atac – CEO


tel: fax:

+90 216 588 0588+90 216 588 0602

email: website:

[email protected]

med con team GmbHMichael Weinlich – Managing Director

Gerhard-Kindler-Str.6, 72770 Reutlingen, GERMANY

tel: fax:

+49 7121 433 660+49 7121 433 619

email: website:

[email protected]

ONE AssistLinda Norman – Group Client Relationship ManagerC/Cardenal Rossell No.1, Esc. A 2˚. Desp 8-9, Palma de Mallorca 07007, Baleares, SPAIN

tel: 24 tel:

+44 (0) 1992 708 700+44 (0) 1992 405 718

email: website:

[email protected]

Save Assistance FranceFranck Molinier – Director of Business Development

19 rue de Provence, 78310 Maurepas, FRANCE

tel: 24 tel:

+33 13062 6752+33 13062 1122

email: website:

[email protected]

SavitarLydia Semchenkova – Business Development Manager

25/1, 7th Floor, Trubnaya Str., Moscow, 127051, RUSSIA

tel: fax:

+7 495 987 1775+7 495 987 1776

email: website:

[email protected]

SOS InternationalHelle Drager Sandahl – Communications & Marketing Manager

Nitivej 6, DK-2000 Frederiksberg, Copenhagen, DENMARK

tel: fax:

+45 7010 5055+45 7010 5056

email: website:

[email protected]

TBS Team 24 d.o.oEdvard Hojnik – General Manger

CROATIA, SLOVENIA, SERBIA, MNE, BH, KOS, MAC

tel: fax:

+386 2616 5819 +386 2618 5800

email: website:

[email protected]. tbs-team24.com

CONNEX Assistance Middle East Lara Helmi – International Network Director

Office 703, Block B, Belrasheed Towers, Qusais, Dubai, UAE

tel: fax:

+97 14 257 82 84+97 14 257 82 85

email: website:

[email protected]

IES Medical Eitan Kariv – CEO

2 Yagea Kapaim Street, Tel Aviv, ISRAEL

tel: fax:

+972 3 639 9990+972 3 687 2950

email: website:

[email protected]

Dr Colin Plotkin & Sons Consulting INC.Dr Colin Plotkin – Managing Director

27-3088 Francis Road, Richmond, British Columbia V7C 5V9, CANADA

tel: fax:

+1 604 241 9677+1 604 241 0733

email: website:

[email protected]




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UnitedHealth InternationalPhilip Brun – Vice President of Sales & Service

3100 SW 145 Avenue, Miramar, FL 33027, USA

tel: fax:

+1 954 378 0694+1 954 378 0771

email: website:

[email protected]

Global Assistance & HealthcareMario Babin – Chief Executive OfficerCilandak Commercial Estate - # 111 GC, Jl. Raya Cilandak KKO, Jakarta 12560, INDONESIA

tel: fax:

+62 21 299 78 999+62 21 299 78 9555/66

email: website:

[email protected]

Global Excel ManagementMichael Drew – Vice President of Sales73 Queen St, Sherbrooke, QC J1M 0C9, CANADA17548 Deer Isle Circle, Winter Gdn, FL 34787, USA

tel: fax:

+1 866 566 1130+1 819 566 8335

email: website:

[email protected]



tel: fax:

+27 11 622 8010+27 11 622 8264

email: website:

[email protected]

ONE ClaimsLinda Norman – Group Client Relationship Manager1-4 Limes Court, Conduit Lane, Hoddesdon, Hertfordshire EN11 8EP, UK

tel: 24 tel:

+44 (0) 1992 708 700+44 (0) 1992 405 718

email: website:

[email protected]



tel: toll free:

+1 416 340 7265+1 866 261 6718

email: website:

[email protected]

Star HealthcareGigi Galen – President

850 7th Avenue, Suite 803, New York, 10019, USA

tel: fax:

+ 1 212 581 8228+ 1 212 581 8272

email: website:

[email protected]

LIFESUPPORT Patient TransportGraham Williamson – CEO

#9-1009 Allsbrook Road, Parksville, British Columbia, V9P 2A9, CANADA

tel: fax:

+1 250 947 9641 +1 877 288 2908

email: website:

graham.williamson@LifeSupportTransport.comwww.LifeSupportTransport.com

Voyageur Aeromedical TravelMarc Lucas – General Manager

Voyageur Buildings, 43 Colston Street, Bristol BS1 5AX, UK

tel: fax:

+44 (0)117 927 3554+44 (0)117 925 5940

email: website:

[email protected]

ADACChristoph Ullrich – Director of Purchase / International Network

Am West Park 8, 81373 Munich, GERMANY

tel: 24hr Alm:

+49 89 7676 2912+49 89 7676 5005

email: website:


Lufthansa Medical ServicesDoris Ehring – Manager Sales & MarketingLufthansa German Airlines, Lufthansa Base, FRA SX/M, D-60546, Frankfurt/Main, GERMANY

tel: fax:

+49 (0)69690-20904+49 (0)69690-58147

email: website:

[email protected]

Albin Repatriation LtdEmerson De Luca – General Manager

83 Westbourne Grove, Bayswater, London W2 4UL, UK

tel: fax:

+44 20 7313 6920+44 20 7313 6999

email: website:

[email protected]

AIMSBernadette Breton – Managing Director

Private Bag X5, Benmore Gardens, 2010 Johannesburg, SOUTH AFRICA

tel: fax:

+00 27 11 783 0135+00 27 11 783 2950

email: website:

[email protected]



tel: fax:

+27 11 622 8010+27 11 622 8264

email: website:

[email protected]

Medical Services Organisation (MSO)Vernon Pillay – Operations Director - International Division

PO Box 1578, Gallo Manor, 2052, SOUTH AFRICA

tel: fax:

+27 (0)11 259 5403+27 (0)11 259 5001


[email protected]

ChargeCare InternationalChristiane Burniston – Managing Director

Monument Business Park, 1D Park Offices, Warpsgrove Lane, Chalgrove, Oxford, UK

tel: fax:

+44 1865 400 007+44 845 003 9923

email: website:

admin@chargecareinternational.co.ukwww.chargecareinternational.co.uk

Marm AssistanceJill Atac – CEO


tel: fax:

+90 216 588 0588+90 216 588 0602

email: website:

[email protected]

Medical Claims International SpainFatima Guillen Grande – Managing Director

C/Ciudad de Aguilas No.2, Local 2A, Madrid 28030, SPAIN

tel: fax:

00 34 913 016 14500 34 913 016 160

email: website:

[email protected]

Global Excel ManagementMichael Drew – Vice-President Sales73 Queen St, Sherbrooke, QC J1M 0C9, CANADA17548 Deer Isle Circle, Winter Gdn, FL 34787 USA

tel: fax:

+1 866 566 1130+1 819 566 8335

email: website:

[email protected]

Global Medical ManagementRaija Itzchaki – COO

1300 Concord Terrace, Suite 300, Sunrise, Florida 33323, USA

tel: fax:

+1 954 370 6404+1 954 370 8613

email: website:

[email protected]

Olympus Managed HealthcareSteven Jacobson – CEO

777 Brickell Avenue, Suite PH70, Miami, Florida 33131, USA

tel: fax:

+1 305 530 8600+1 305 530 0766

email: website:

[email protected]

OneWorld AssistTaka Katsube – Director Assistance & Cost Managment

10th Floor, 6081 No.3 Road, Richmond, BC V6Y 2B2, CANADA

tel: fax:

+1 604 303 2113+1 604 276 4593

email: website:

[email protected]



tel: toll free:

+1 416 340 7265+1 866 261 6718

email: website:

[email protected]

Star HealthcareGigi Galen – President

850 7th Avenue, Suite 803, New York, 10019, USA

tel: fax:

+ 1 212 581 8228+ 1 212 581 8272

email: website:

[email protected]

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CareFlight Group Medical and Tasking Centre

PO Box 5078, Robina Town Centre, Queensland, 4230, AUSTRALIA

24hr tel: fax:

+61 7 5553 5955+61 7 5553 5914

email: website:

[email protected]

CareFlight InternationalSue Robshaw – Co-ordinatorWestmead Hospital Campus, PO Box 159, Westmead, NSW 2145, AUSTRALIA

tel: fax:

+61 1300 655 855+61 2 9689 2744

email: website:

[email protected]

Medic’Air International 每递安国际Dr Huaqun Gao – Medical Director

885 Renmin Road, Huaihai China Building, Room 808, 200010 Shanghai, CHINA

tel: fax:

+86 2163 558289+86 2163 558285

email: website:

[email protected]

AMREF Flying DoctorsDr Bettina Vadera – Medical Director


tel: fax:

+254 20 6000 090+254 20 344 170

email: website:

[email protected]



tel: fax:

+30 210 674 0600+30 210 674 0634

email: website:

[email protected]

Redstar AviationMustafa Atac – CEO


tel: fax:

+90 216 588 0216+90 216 588 0225

email: website:

[email protected]


Voyageur Buildings, 43 Colston Street, 43 Colston Street, Bristol BS1 5AX, UK

tel: fax:

+44 (0)117 927 3554+44 (0)117 925 5940

email: website:

[email protected]



tel: fax:

+254 20 6000 090+254 20 344 170

email: website:

[email protected]

StandbyMDAlex Sánchez – Managing Director

777 Brickell Avenue, Suite 1370, Miami, Florida 33131, USA

tel: fax:

+1 305 459 4882+1 305 421 5575

email: website:

[email protected]



tel: fax:

+44 (0)117 927 3554+44 (0)117 925 5940

email: website:

[email protected]




V Creative DesignSteve Annette – New Media Director


tel: fax:

+44 (0)117 929 4636+44 (0)117 925 2040

email: website:

[email protected]

Funeral Home AURIGA Ltd.Helen Pradova – Chief of International Department

B. Nmcové Street 1052/1, 412 01 Litomerice, CZECH REPUBLIC

tel: fax:

+420 724 257 899+420 416 735 800

email: website:

[email protected]

Funeralcare InternationalLouisa Killen – Repatriation Specialist

Murray House, 50 Whitta Road, Manor Park, London, Essex E12 5DA, UK

tel: fax:

+44 20 8788 5303+44 20 8788 2525

email: website:

funeralcare.international@letsco-operate.comwww.co-operativefuneralcare.co.uk

John Allison Monkhouse Co., Ltd (Thailand)Apple Kaewprasert – General ManagerPresident Park View Tower, 99/243 (30B) Pine Tower, Sukhumvit soi 24, Klongton Klongtoey, Bangkok, THAILAND

tel: fax:

+66 2382 5345-7+66 81 584 5942

email: website:

[email protected]

Lutece InternationalZouhaier Hertelli – Repatriation Specialist

56 rue Olivier de Serres, 75015 Paris, FRANCE

tel: fax:

+33 1 56 08 00 23+33 1 56 08 00 43

email: website:

[email protected]

Mortuary Brussels Airport | Worldwide Funeral Repatriations part of DELA

Greta Plas – Repatriations Manager

Ringlaan 49, 1930 Zaventem, BELGIUM

tel: fax:

+32 2 720 80 00+32 2 720 88 22

email: website:

[email protected]

Rowland Brothers InternationalMelanie Walkling – Partner

299-305 Whitehorse Road, West Croydon, Surrey CR0 2HR, UK

tel: fax:

+44 20 8684 2324+44 20 8684 8000

email: website:

info@rowlandbrothersinternational.co.ukwww.rowlandbrothersinternational.co.uk

ServilusaVanda Castro – Manager International DepartmentAgencias Funerarias SA, International Dept. Rua do Entreposto Industrial, 8-2 Esq, 2610-135 Amadora, PORTUGAL

tel: fax:

+35 121 470 6300+35 121 470 6499

email: website:

[email protected]

USP Hospitales S.LFrancisco Rico – International Relations Manager

C/Miguel Angel, 23 3˚, 28010 Madrid, SPAIN

tel: fax:

+ 34 951 91 30 30+ 34 951 91 30 40

email: website:

[email protected]

Baptist Health South Florida International ServicesYohandra Fuentes – Assist V-P/Int. Insurance Dev. & Revenue Mangement

8940 North Kendall Drive, Suite 601-E, Miami, Fl 33176, USA

tel: fax:

+1 786 596 2373+1 786 596 5979

email: website:

[email protected]/international

Integrated Healthcare ServicesBrenda Escobar - International Program Coordinator

450 E. Las Olas Blvd., Ft. Lauderdale, FL 33301, USA

tel: tel:

+ 1 305 222 6750+ 1 305 222 6751

email: website:

[email protected]

Jackson Memorial Hospital InternationalLuis Felipe Arango – Vice President of International BusinessJackson Medical Towers, East Tower, Suite 829,1500 NW 12th Avenue, Miami, FL 33136 - 9998, USA24hr tel:

tel: + 1 305 355 1212+ 1 305 355 5544

email: website:

[email protected]

University of Miami Health SystemJose Quesada M.D., M.B.A. – Director Finance & Operations

1099 N.W. 14th Street, Miami, Florida 33136, USA

tel: fax:

+1 305 243 9100+1 305 243 9101

email: website:

[email protected]

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50 REGULARS

Dear Editor,

In an otherwise interesting article on the standards of aeromedical training in the UK – ‘Setting the standard’, ITIJ 119, December 2010 – the author clearly outlines the statutory requirements for ‘initial training to practice for qualification’, including NMC registration. He then discusses that in-flight nurses ‘recommend’ a minimum of three years’ experience in an acute setting before commencing a recognised course ‘that adequately trains one to practice as an in-flight nurse’. In this setting, one assumes that the author is referring to the Royal College of Nursing (RCN) recommendations, and it should be pointed out that, however well meaning these recommendations are, they are neither statutory, nor widely followed in the UK.More worrying, the author goes on to state that there are two ‘recognised’ courses for nurses which give ‘initial training to practice’. He then goes on to describe the RCN In-Flight Nurses Course, which the author must know full well has been inactive for several years and was finally closed in early 2010. Training enquiries to the RCN and South Bank University (where the course was run) have been referred to the CCAT Aeromedical Training organisation since 2008 and nurses have successfully been training alongside doctors and paramedics in what has been a

multidisciplinary course since the inception of CCAT in 1996. In fact, one third of the delegates of the first ever CCAT course were nurses, and this proportion has risen to over 50 per cent in recent years.Beyond this foundation level course, CCAT goes on to offer a wide selection of specialist and advanced training options (both in the UK and in other centres around the world) for those wishing to specialise in such areas as medical assistance, dedicated air ambulance transportation, commercial airline repatriation or HEMS. The suite of courses also includes study days for ILS (immediate life support) in the flight environment, aeromedical CRM and annual refresher updates for flight nurses (since the RCN has cancelled its own study days in the past two years). All the CCAT courses and study days are acceptable for Continuing Professional Development accreditation and are well recognised internationally.The author rightly mentions the Royal Air Force training for flight nurses but, by its very nature, this course is not an option for civilian nurses. On the other hand, he gives not a single mention of CCAT despite 15 years of delivering high standards of professional training, including, latterly, much on behalf of the RCN itself. This omission harms the opportunities for civilian nurses who are looking for education in the industry yet who might not be aware that CCAT has been successfully involved in accredited

international flight nurse education since 1996. The author writes ‘it is the nurse who must satisfy the regulator and their representative in supporting any claim that they demonstrate the adequate skills and competencies to practice’ [sic], and yet I am sure he is aware that there are a large number of nurses in the UK aeromedical industry who have had no training at all, or who have not received training updates for many years. So who must they satisfy, and how? In addition to designing and delivering aeromedical training, I have been involved in the set-up of seven air ambulance organisations around the world. Part of that process is to ensure that the right people with the right background are given the right training for the right job. Currently, the onus for establishing and maintaining educational standards for all those employed in aeromedical transport and retrieval lies, ultimately, with the employers and, by default, those subject to respondeat superior, i.e. those who take ultimate responsibility for the actions of their employees and subcontractors. This group will include the insurers and other financers who ultimately fund aeromedical services.

Terry MartinConsultant in Anaesthesia and Intensive Care MedicineDirector, CCAT Aeromedical Training

Letter to the Editor

Locked upYou know the drill – ‘ladies and gentlemen, please fasten your seat belt, ensure your seat is in the upright position and that all toddlers are placed in the overhead lockers’. That was the slightly unusual procedure adopted by a flight attendant onboard a Virgin Blue plane recently as 17-month-old Riley Williamson travelled with his parents from Fiji to Sydney, Australia. According to reports, the flight attendant picked Riley up without warning, stowed him in an overhead locker and closed the hatch.Mother Natalie Williamson took a dim view of the prank, to say the least, telling Australian newspaper The Sunday Herald Sun: “I stood up and there were people laughing and then I said ‘Get my son out of there now’. I was devastated. Absolutely devastated.”Although the Australian airline has admitted that Riley was placed in the locker, it claimed the flight attendant was joining in with a game of peek-a-boo he was playing with his father. However, Virgin Blue did take the incident seriously enough to fire the flight attendant – or worse, depending how you interpret the airline’s words: “We conducted a thorough investigation of the incident and the staff member involved was subsequently terminated.”Underlining the seriousness of the situation, his mother revealed that since being locked in the compartment in the pitch dark, Riley has seen a number of specialists for treatment for anxiety and withdrawal. So – if you found the start of this story amusing … err… shame on you. In an attempt to make amends, Virgin Blue refunded the cost of the flight and offered to provide three free flights. Unsurprisingly, the Williamsons have declined.

Wise wordsLooking through famous quotes recently, we thought we’d share some of our favourite travel-themed pearls of wisdom. From US journalist Dave Barry: “Another well-known

Paris landmark is the Arc de Triomphe, a moving monument to the many brave men and women who have died trying to visit it, which we do not recommend because it’s located in the middle of La Place de la Traffic coming from All Directions at 114 miles per hour.” Meanwhile, fellow US writer Charles Kuralt once said: “Thanks to the interstate highway system, it is now possible to travel from coast to coast without seeing anything.” Susan Heller adds: “When preparing to travel, lay out all your clothes and all your money. Then take half the clothes and twice the money.”

Crazy claimsInsurance claims can sometimes lead to a belief in extra terrestrial intelligence, given that some policyholders seem to be living on a different planet. Take the claimant who petitioned Direct Line for a pay out to cover the loss of a guitar – made from a pumpkin. Or, also on a food-based theme, the couple that returned from Mauritius to find a pair of precious mementos missing in the form of two absent coconuts. Considering the £50 excess on the policy versus the £0.50 cost of replacing each coconut, the claim was turned down. Also rejected due to a £50 excess was the traveller whose possessions were stolen whilst on holiday. Asking for a complete inventory of the contents of the lost bag, the insurer was dutifully informed it was one newspaper, one bottle of water and one packet of mints. Hot on the heels of that claim (prepare to groan) was the case of a woman trying to get served at the aptly named Fire Bar in Greece. Despite the fact that her fellow drinkers ran out of the bar when a loud buzzer started to sound, she still couldn’t get a drink and waited for service. When the area became engulfed in flames and smoke, it dawned on the woman that the buzzer sounded a lot like a fire alarm, and she escaped with third degree burns. Her understanding insurer covered £300 in medical expenses. Flaming Sambuca anyone?

Ambulance getaway for plane thiefA man recently stole almost €172,000 on a flight from the French island of Guadeloupe to the Franco-Dutch island of St Martin in the Caribbean. The money was taken from a bundle of €1.2 million, which was being carried on the Air Antilles flight for the Brink’s Security Company. Pretending to be ill, the man spent most of the 40-minute flight in the lavatory, during which time

he successfully removed several wall panels to gain access to the hold in the rear of the ATR-42 plane, say police. Shortly before landing, the unnamed man asked a stewardess for an ambulance to meet him on the tarmac. When the ambulance arrived, the man said he suddenly felt better and walked out of the airport without having to go through normal security checks. Police have been unable to trace him.

Flight crew funniesHere are some of our favourite recent quotes reportedly heard from flight crews. A flight attendant’s comment on a less than perfect landing: “We ask you to please remain seated as Captain Kangaroo bounces us to the terminal.” Another flight attendant after a particularly bumpy flight: “Ladies and Gentlemen, welcome to Amarillo. Please remain in your seats with your seatbelts fastened while the captain taxis what’s left of our airplane to the gate!” On near arrival at the terminal, this gem was announced: “As you exit the plane, please make sure you gather all your belongings. Anything left behind will be distributed evenly among the flight attendants. Please do not leave children or spouses.” And, finally, truer words were never spoken: “As we prepare for take-off, please make sure your tray tables and seat backs are fully upright in their most uncomfortable position.”

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The Arc de Triomphe in Paris NeilWhelan

www.itij.co.uk

51ONTHEMOVE

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In a move to drive greater product and service innovation to support its broker partners, Groupama Insurances has boosted the expertise within its customer proposition team under the leadership of Lynn Harris, head of customer proposition. Joy Boden has joined the team as customer proposition manager from the role of commercial schemes underwriter at Groupama, while Linsey Scott joined from Bollington, where she looked after motor trade risks. Hew new role is customer proposition associate.

Ms Harris said: “Our team now not only benefits from Joy’s broad market knowledge but also has the benefit of useful insights from Linsey’s broking background. This will be invaluable as we look for opportunities to deliver real innovation to our broker partners and as we work on a number of key projects this year.”Ms Boden and Ms Harris join Liz Kuhler and Kerry Farrell to make up the customer proposition team.

Ageas adds to broker teamAgeas Insurance Limited has appointed three new broker account executives to cover different regions in the UK, in an effort to support the company’s strategy to grow its commercial business and reflect the value it places on building relations with brokers. The first new employee is Jonnie Armstrong, who was previously a regional sales executive for LV=. He brings with him over 20 years of experience in the insurance industry, including roles at Zurich and NIG (RBS). Secondly, Gavin Peacock has joined the team from the UK General Insurance Group, where he was a schemes business development manager. Peacock has 31 years of experience working in the insurance sector, having worked for Towergate and Eagle Star/Zurich. Finally, Jason Jackson has joined the firm from Westinsure Group Ltd, where as operations manager he was responsible for looking after 180 brokers and a number of insurer relationships across the UK.

The UK’s CEGA Air Ambulance has strengthened its management team with the appointment of a new general manager, Dr Juliane Kause. Dr Kause, who has worked with the company since 1997, brings significant medical expertise to the management team, enhanced by her ongoing roles as a consultant in critical care and acute medicine for the National Health Service, and as CEGA’s chief flight doctor.Speaking about her new role, Dr

Kause said: “I look forward to leading CEGA’s highly skilled critical care team in implementing a service that gives every patient top-quality, uninterrupted care. My focus is now on expanding the business, both in general terms and with the continued development of specific areas such as the provision of extracorporeal membrane oxygenation and high-frequency oscillation ventilation.” Euro-Center

promotionsTwo promotions have been made at cost containment company Euro-Center recently, with Ronald Groenendijk being promoted to general manager of Euro-Center USA. Having worked in the travel and assistance business for almost 20 years, Groenendijk has worked around the world. Before he came to the US, he was an assistance co-ordinator and operations supervisor at SOS International in Amsterdam, but since 2001 he has been the claims manager for the US arm of Euro-Center.Elsewhere, Lisa Resling Halpern has been named as global commercial director of Euro-Center Holding A/S. Ms Halpern has over a decade of direct cost containment and expatriate planning, and extensive knowledge of the American healthcare system.

Groupama boosts proposition team

On Call expands medical teamUS-based assistance firm On Call International has hired Patrick Lanzetta, MD, Reed Brozen MD, and Richard Linsky MD to join its in-house medical director Dr Robert Wheeler. As part of the company’s global response centre, the medical team is responsible for the continual monitoring of travellers around the world seeking medical attention. Wheeler and his expanded team of physicians will manage more than 7,000 medical cases this year, ensuring that On Call members receive appropriate medical care.President and chief executive of On Call International Mike Kelly said: “We are honoured to have such accomplished professionals as Dr Lanzetta, Dr Brozen and Dr Linsky join our current medical team. Each brings his unique talents to the team and will continue to improve our global physician and hospital networks to provide more immediate referrals for doctors and hospitals than many of our counterparts.” Dr Lanzetta is certified in emergency medicine and established RESCUE, a joint committee of local police, fire and EMS leadership in Rochester, New Hampshire, and developed the Rochester Paramedic Service. Dr Brozen served in the emergency department as the medical director of air transport for the Dartmouth-Hitchcock Advanced Response Team, and sits on multiple committees including the AirMed 2011 AMPA PreConference in Brighton, UK. Prior to joining On Call International, Dr Linsky was the medical director of Rescue Nurse International in Texas, having trained in tactical emergency medicine.

Brit terrorism underwriter chosen Brit Insurance has announced the expansion of its war and terrorism team with the appointment of Charles Barrett as a terrorism underwriter. Barrett’s appointment is effective immediately, and he is responsible for underwriting a diverse range of political violence and aviation war-related risks to support the company’s war and terrorism portfolio. Barrett joins Brit from Willis, where he was vice president for its North American practice,

responsible for leading the London-based team specialising in terrorism placements for North American-domiciled clients.Matthew Wilson, chief executive of Brit Insurance’s global markets division, said: “Charles’ specialist knowledge of the global war and terrorism market will complement and broaden our existing underwriting capabilities in this important area of our global markets portfolio. His experience of developing products will also be of real value to our team.”

CEGA appoints general manager

Dr Juliane Kause CEGA Air Ambulance

Ronald Groenendijk

Lisa Resling Halpern

Jonnie Armstrong

Clockwise from top-left:- Linsey Scott, Lynn Harris, Liz Kuhler, Joy Boden and Kerry Farrell

ObituaryMario DiLuzio died on 16 March at the age of 79 in Tustin, California. Mario was a retired executive of The Travelers Insurance Company and was one of the first travel insurance visionaries that changed the world of travel insurance. Under his leadership, The Travelers grew to be one of the recognised premier travel insurance providers to the US travel industry. He became one of the most highly visible and supportive figures in the industry, always active at industry functions. He is preceded in death by his wife, Adelina, of 55 years who passed away five days earlier. Mario is survived by his son, Michael, and his daughters Marianne and Jeanmarie, four grandsons and a great granddaughter, Aurora Rancourt.

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