A Review of Expatriate Medical Insurance Plans Worldwide

Introduction:
Following the rapid rise in "Global based companies" over the past decade, coupled to vast improvements in telecommunications and expansion of Internet services world-wide, the availability of private healthcare insurance services to the expatriate community, has never been better. However, of the 30-40 million estimated expats living or working globally, less than half of these individuals and families hold valid healthcare insurance plans. As this market for expat cover is growing at over 10% annually, globally, several new plan providers and new insurers have launched new plans over recent years, offering clients increased choices. I have listed a number of these with websites and contact phone numbers at the end of this article. Additionally, some of these insurer benefits and premiums are compared in the attached matrix sheet for review purposes.

For new ex-patriots, leaving the USA or Western Europe, to be based in a developing country, perhaps for some years, it is often a shock to discover that medical treatment of a reasonable quality is just not available, or very expensive, in their new location. Conditions can differ vastly from Baku to Beijing to the Bahamas. Many documented case histories sadly indicate the devastating experience both mentally, physically and financially of falling seriously ill when overseas, can become. Private Medical Insurance when abroad is like a parachute when flying. You may not need one but it better be there, as you and your family would may not survive without one. e.g.: Being evacuated from the Gobi desert, following a car accident resulting in broken bones, coupled to a suspected fractured skull is not an easy matter at any time.

The medical insurance plans you may need are readily available through a worldwide network of specialist Brokers, Independent Financial Advisors, or via the Plan Insurers themselves, who advertise extensively through magazines and expatriate media. Several specialist independent Brokers now have their own websites, offering multiple choices of health insurance plans. The taking of independent advice is always recommended, in order that you not only buy the right plan, but pay premiums appropriate to your new country area. Do not buy a plan without studying the policy wording carefully, particularly underwriting conditions, benefits, etc. If in doubt, ask and then complete all application forms fully, to the best of your ability.

The Premium/Benefit Trade Off:
Too frequently, a potential customer or new client will look to lowest price or premium cost comparisons, before really considering the specific benefits and area of cover they may actually need. The ex-patriot client should carefully review benefits of cover offered, check out any limits to that cover and any exclusions made by the insurer. Some plans are cheaper for a reason. Often they include large voluntary deductibles on any claim you might make in future and may severely cap the benefits received under the plan. Cover limits can vary from £50,000 total cover to as much as £5,000,000 total cover. Any major operation in the USA or perhaps an organ transplant can soon eat up a " capped cover" plan. Exclusions to the policy should also be read carefully and advice taken from an independent Advisor. Our motto is for clients to "define their needs" first, particular Area of cover they need, then their annual healthcare insurance budget. Then, they should look to premium comparisons, last of all.

Many new entrant expatriate Insurers are taking a much easier line on HIV and AIDS issues as well as offering chronic conditions cover, if such conditions develop during the plan lifetime. Post September 11th 2001, many expatriates are now considering the purchase of income replacement insurance, term life and kidnap insurance, or travel insurance, in addition to their Health Insurance Plans.

Underwriting Terms of Plans:
For the individual expatriate or family there are usually only two ways to take out international medical insurance. By means of a "moratorium" application or a "full underwriting" application. It is important to understand this rather jargonised phrases as claims can be rejected if you have inappropriate underwriting. A moratorium plan means that any "pre existing" condition, for which you have had treatment, advice or consultation upon during the last 2,3 or even 5 years in some cases, will be EXCLUDED from cover. Should you then not have any treatment, advice or consultations for such conditions for a further two years, your insurer may add that condition to your policy. Full underwriting applications mean that all medical history questions have to be completed (not needed on a moratorium plan) and that most insurers may then exclude any particular stated condition, which they feel will lead to claims upon them. Full underwriting schemes are a little more complex as sometimes confirmation and clarification letters may be needed from your Doctor in order to have a specific condition covered under your new plan, or for that insurer to offer cover at all (E.g.; HIV or AIDS conditions cover or other long-term endemic/chronic conditions.)

For larger groups of expatriates and large corporate plans, Insurers will frequently offer cover on a "Medical History Disregarded" basis, meaning that a new plan member might even be in hospital for a triple bypass, but still have that condition included in the total corporate plan. Clearly with larger numbers of people in a plan, insurers are prepared to take higher risks and offer lower premiums. Company plans can have premiums some 15% to even 40% less than individual plans, due to the larger numbers of employees and higher annual premium overall, charged by that Insurer.

Vital Questions for the Insurance Provider

1. Does the plan allow for cooling off periods, cancellation and then repayment of premium in full?

2. Does the plan offer "Moratorium" or is it "Full underwriting" and do I need to have a medical examination before joining.

3. Does the new Insurer offer a 24 hour help line, 7 days a week, available from anywhere in the World (free phone)? Most Insurers now offer this facility.

4. Are my pre-existing conditions excluded when joining and if so, for how long are such conditions excluded?

5. Or all and any Nationalities accepted or are there restrictions applying to local nationals? Some Insurers will only take expatriates abroad and not local nationals into an overseas plan (e.g.: - They may cover six British Nationals in Zambia, not the 100 Zambian local national employees)

6. Does the plan allow you to continue cover unbroken through your lifetime? In most cases insurers will continue to offer existing clients cover year on year, irrespective of age or claims history. I.e.: - Once a customer, you may remain a customer, although premium rates charged can increase dramatically with old age.

7. Does the Insurer allow for any Doctor or Consultant or Hospital within the plan? Are there any restrictions in this respect? Most international plans do not place restrictions on either hospitals or Doctors, but almost all demand that their help lines are called first prior to approval of any inpatient care. (I.e.: pre qualified claim or placing of a bond with a specific hospital by Insurance Company)

8. Does the Insurer provide for direct settlement of bills presented by hospitals worldwide, regardless of location? (Or do I have to pay first?)

9. What are the Insurers procedures for Outpatient claims? Do these require any pre authorization or if stated in the plan can I just pay and claim? How long before I get my money back from the Insurer? (14 days? 28 days?)

The vast majority of expatriate health plans DO NOT exclude certain occupations as do many UK based insurance plans. Expatriate plans do however add to premiums for such as Winter Sports or diving holidays.

Nomenclature, names and Plan Titles:
The Product Providers and Insurers delight in launching new plan names with "exclusive" qualities in their brand names over those of their direct competitors. However, international medical insurance plans broadly have three key components, which are in-patient or daycare treatment, outpatient treatment, and then and add-on options.

In this way, a basic or standard plan usually includes in-patient and daycare, but no Outpatient or other cover. Comprehensive plans mostly cover outpatient in addition to the inpatient costs, often with a capped limit, whilst "deluxe" "platinum" or "Premier Plus" plans offer a full cover range of inpatient, daycare, outpatient with routine dental. Possibly maternity, evacuation, personal accident cover and even chronic conditions cover in certain cases. (All the bells and whistles plan) We tend to ignore the names of plans but ensure we have clear ideas of benefits specifically, capping, area of cover and any exclusions, when comparing plans against a clients requirements. For example a USA passport holder living in Paris, who never needs cover in the USA apart from the occasional holiday trip, could take Area 1 European cover, which is often half the price of full world wide cover including the USA. Area 2 is usually described as Worldwide cover excluding the USA or Canada" with Area 3 being the most expensive offering global cover including the USA, all year round.

A small travel add-on option can often help with up to 30 days emergency cover in USA or Canada should such be needed. Elective care in USA can also be added for just thirty days a year too, at a substantial discount to full Area 3 cover premiums. Some Insurers now offer modular benefit packages where clients can "pick and choose" benefits, working out their own premiums, at the end of this mix and match.

Emergency, Evacuation and Repatriation:
1. Does the Plan include evacuation and repatriation and mortal remains repatriation or are these benefits add on extras?

2. What costs are included in the evacuation or repatriation cover? Some plans only cover travel costs, not accommodation; some plans only give cover one way.

3. Does the Plan cover both your outward journey and pay for you to return from where you started?

4. Does the plan cater for one person or can a business colleague or a family member accompany the Plan holder when travelling for treatment after evacuation? Emergency treatment when abroad can be very stressful at the best of times and being accompanied can be a huge comfort.

Outpatient Costs and General Practitioner Costs:
Expatriates with families and small children will know that "Outpatient costs" and visits to the local Doctor are usually the main cost area at home, but particularly whilst abroad. Expats in developing countries are more prone to ill health and most will have at least one or more visits to a GP during a tour of duty. You need to know that GP costs will be fully reimbursed, or that you know the level of deductible, which will be made from any and all outpatient claims. (Each and every claim or an amount, which cumulates annually) Read your Plan carefully.

1. Many Insurers offer a limit or budget Outpatient benefits and these issues should be carefully studied in the new plan. Note any restrictions

2. Check the wording of drugs and dressings offered to note whether "Full Cover" or financial limits are set in the plan.

3. Few plans offer "Elective" or "Well woman " Well man" checks. Most international plans cater for healthcare once the patient has symptoms or is ill. They do not offer preventative checks or Health Checks at the control of the client. (Some larger company plans do offer well man checks)

Outpatient Cover, Complementary Medicine, Dental plan or Routine Maternity plan:

If you are able to afford the premiums, Outpatient cover added to in-patient/daycare cover makes sense. In-patient care gives catastrophic cover or a hospital cost cover, but gives no cost cover if you are "walking wounded". A medium range comprehensive plan may well limit the amount you may claim on the Outpatient costs, but a deluxe or fully comprehensive will give Full Cover for this benefit.

Many plans do offer benefit for accidental damage to teeth by accident, but not routine elective dental healthcare Routine Dental treatment is mostly quoted as an optional extra, as is any option to take out routine maternity treatment. Thus, if you break a tooth you are covered but if you visit the dentist for a crown, beware, you may have to pay. Routine maternity care cover can be a valuable part of overseas family planning, yet many women and families overseas, unfortunately only contact their Broker or Insurer when already pregnant. Few Insurers will allow routine maternity costs re imbursement when a woman is pregnant actually taking out the plan. Almost all Insurers will consider an existing pregnancy as a pre-existing condition, but will cover emergency in pregnancy. If a couple have held medical insurance for one year, the Insurer may offer an option, with CO-insurance for routine maternity costs to a budget limit. Talk this over with a specialist Advisor in Expatriate Health Insurance

More Insurers are now taking a more enlightened approach to the subject of complementary care and costs of such as chiropractioners, osteopaths, homeopaths, acupuncturists and the like. These benefits are usually severely "budget capped" by the Insurers, however.

Other Cost Considerations and Options:
With the growing range of plans available across the world, across a vast premium spectrum, several new benefit cost areas are mentioned below, which are not always available from all Insurers, but can be quoted selectively in certain Plans.

Well Child care, well man and well woman checks, all can be quoted

Prosthetic Appliances, can be quoted but capped

Eyeglasses and tests quoted on many deluxe and top plans

Crowns, dentures and bridges, routine dental quoted on top plans

Death of Close Relative, round trip costs covered on many plans

Treatment in USA elective or emergency usually can be quoted

Vaccinations, quoted on some plans

Annual Health Checks, quoted on some top plans

Organ Transplants, AIDS and Chronic cover on some top plans

Hazardous Sports, quoted on some plans

Legal Costs after accidents abroad, quoted in some plans

Complaints:
All Insurer Plans should clearly stipulate the complaints and disputes procedures they follow together with any Regulator. They should illustrate how you may contact the right adjudicators in their company or contact your independent Advisor for help) There are also independent Regulatory Authorities available n most Western countries, such as the UK, who can assist you with a dispute with an Insurer (who is being difficult when settling your claim) If you have bought your Plan through the offices of an independent Broker or Specialist Advisor they will almost certainly be glad to help in legitimate disputes with an Insurer. If you are right, have proper records, the Insurers will pay up.

Overview:
Generally, as with most Insurance services, you get what you pay for. Read the documentation carefully, particularly the benefits and exclusions clauses. International Medical Insurance is a complex and difficult field. Many Insurers are competing for your long-term business. They all will argue, "Their Plan is Best." Certain strategic insurance considerations have been also affecting the expatriate market since the World Trade Centre disaster. Many ex-patriots are now looking for international term life and income replacement cover, as well as medical insurance. Time will tell how long term insurance growth is affected in this expanding expatriate global market place.

If you purchase a comprehensive plan from a reputable Insurer, via an independent Broker, you are usually not disappointed. However, if you buy what is clearly a cheap cut plan, without advice, beware when trying to make a claim. (They may well have pages and pages of exclusions in the small print)

It is also important for your budget to choose the correct geographical area of cover. Routine travel options can be taken at much less cost than full-blown USA cover, if you do not really need elective USA cover. Voluntary excesses on claims can substantially reduce premiums, as can co- insurance payments. (Sharing risk costs with the Insurer)

In the final analysis, international expat medical insurance is best to have at your side so that "you may sleep at night abroad" rather than to think of ways to claim. If both parties fully understand the contract and deal in good faith, Insurers very much want to keep clients for the long term. It is always better however, to compare and study at least three packs of brochures from differing Insurers, or have a review done by an independent Broker specializing in the Healthcare Insurance field. All the material needs attention and careful reading. Understand what you are committing to, what the contract actually states, not what you may think it states (or some salesman told you) and what geographical limitations are set giving your area do cover.

You may not need to read this contract again until the moment you need medical aid. Remember, that Brand name alone does not necessarily indicate good service, but that in 2002, many lesser-known expatriate specialist Insurers offer excellent premiums, wide benefits, good claims records and fast efficient electronic client services. Professional support teams are vital in overseas emergencies. Your Helpline card is the key to medical help and assistance 24 hours a day, whilst Overseas. Make sure that you have it to hand and that you know how to use it. With most Insurers now offering toll free global lines 24 hours a day, these vital help-lines are the first port of call, prior to any treatment being arranged, with the exception of emergencies. Establish contact as soon as you can, then let the Insurers assistance teams do the rest.

Article Prepared By:

J Leslie Smith B Sc Econ Honours Associate IEE
Founder
Medibroker Limited
December 2000