Medical expenses and repatriation

What we look at

• When policyholders are asked to make contact before incurring medical expenses

  Most travel insurance policies state that the policyholder must make contact with the insurer before they incur medical expenses.

  We don’t think a customer’s claim should automatically fail just because they didn’t contact you first. We’d look at:

  • what the customer’s reasons were for not contacting you
  • whether the medical expenses were necessary and reasonable – a lot of complaints involve treatment at private hospitals, but most travel policies only provide cover for treatment in public hospitals
  • what you would have done if you had been contacted first

• When the insurer and the treating doctor disagree about treatment

  Travel insurance policies only cover emergency treatment that can’t wait until the customer returns to the UK.

  Sometimes your Chief Medical Officer (CMO) and the treating doctor will have different opinions on the most appropriate treatment.

  In these cases, we’d look at the medical evidence provided and your claims notes. We’d expect you to take into account the recommendations and advice of the treating doctor when making your decision. The treating doctor will have actually seen the patient at the time – so might be better placed to comment on your customer’s condition. But your CMO’s decision is a valid medical opinion so we’d take that into account.

• When the insurer and the treating doctor disagree about repatriation arrangements

  A customer won’t be able to return to the UK until they have a fit to fly (ftf) certificate from the treating doctor.

  We often see complaints where the treating doctor and the insurer disagree about:

  • when the customer can be safely repatriated
  • the transport which is medically appropriate for repatriation

  We’d look at the medical evidence provided and your claims notes. We’d expect you to take into account the recommendations and advice of the treating doctor. Repatriation may involve travelling at altitude, which brings its own risks. Your medical officers will usually have a specialism in aviation medicine, so their views on whether to repatriate can be persuasive.

  It’s our view that because your medical team have experience in repatriation medicine – they are well-placed to assess the customer’s repatriation needs. If there’s a difference of opinion, we’d expect to see that you’d discussed the situation with the treating doctor. You should make the decision on what is medically appropriate. If two options are appropriate, it’s not necessarily unfair for you to insist on the cheaper option, even if it does take a little longer – provided it doesn’t significantly impact the customer.

• When your customer used a private hospital but their policy only covers public hospitals

  Most travel insurance policies only cover the cost of private treatment in limited circumstances.

  A European Health Insurance Card (EHIC) entitles the cardholder to state healthcare in other EEA countries and Switzerland at a reduced cost or for free. Most travel insurance policies need the policyholder to have an EHIC card.

  If you’ve turned down a claim for medical expenses because private treatment isn’t covered, we’ll look at whether:

  • your customer was told about private treatment when they contacted you
  • your customer chose to go ahead knowing private treatment might not be covered
  • you offered your customer any help to move to a public hospital
  • we think the customer’s actions were reasonable in the circumstances

  We might think it was reasonable for your customer to use a private hospital if:

  • they needed emergency treatment that couldn’t wait
  • they were taken to a private hospital without being able to check with you first to see if this would be covered under their policy
  • the treatment they needed wasn’t available in any public hospital within a reasonable distance from them
  • the standard of care at a public hospital was so unacceptable, that it wouldn’t have been reasonable to expect the customer to remain there for treatment
  • you didn’t explain clearly that treatment at a private hospital wouldn’t be covered

• Complaints about the standard of medical care

  The standard of medical care varies from country to country. Although we’d expect you to look into any concerns raised by your customer, we’re aware that there’s very often little you can do about these concerns.

• Complaints about the payment of medical bills

  Insurers often negotiate with hospitals to reduce the amount they pay (cost containment). Cost containment is used in countries where medical costs are high. It’s also used to make sure insurers don’t face excessive fees in countries where treatment costs are low.

  We sometimes see complaints about the exchange rate the insurer has used to pay the claim. If the customer has paid the hospital bills in a different currency, we’d usually ask the insurer to calculate the settlement based on the rate of exchange on the date the customer paid the expenses.

• Delays in accepting the claim

  Customers often complain that their claim was delayed. We’ll consider your obligation under the Insurance Conduct of Business Sourcebook (ICOBS) rules to handle claims promptly and fairly.

  We’ll look at:

  • how long the delays were
  • what caused the delays
  • whether you could have reasonably done more to prevent or reduce the delay
  • whether you kept your customer updated regularly
  • the impact of the delay on your customer