What If I Get Sick Abroad? — an update

By Philip Wagenaar, Md
This item appears on page 49 of the February 2017 issue.
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In my December 2016 column, I answered questions that readers had after reading the account of my April 2016 emergency room visit in Naples, Italy (Sept. ’16, pg. 51)

One reader, Joyce Perry of Los Angeles, California, also wrote, “As an 86-year-old, I would like to know my options if I become too ill to be treated by a cruise ship’s doctor. Unfortunately, the article that detailed your experiences in Italy did not tell us how to be better prepared for an unexpected stay.”

My recommendations for Joyce are detailed below along with travel insurance recommendations and excerpts from, and updates to, my May 2014 article “What If I Get Sick Abroad?” plus items paraphrased from wwwnc.cdc.gov/travel and other CDC sites.

INSURANCE

1. Never buy travel insurance from a tour operator or cruise line that handles the tour because if the company goes bankrupt, you will not get reimbursed. You also should not buy it from a travel agent because he or she might be selling you a policy that pays the highest sales commission rather than the one that’s best for you.

2. Always buy a primary-payer policy. With primary insurance, the insurance company will pay for all your expenses up front. 

With some primary-payer plans, the company will pay the hospital in advance for the insured’s admission to the hospital. Examples of primary coverage plans that will provide advance payment are the Deluxe plan from Allianz; the Platinum (Cruise, Tour & Travel) and Gold plans from Travel Guard and all of the plans from Travelex.

If you have a secondary-payer policy, you or any other insurance company that you are covered by must pay all medical expenses up front, after which you will be reimbursed by your secondary insurance company. You must get in touch with those other health insurance companies and get proof from them that you are not covered (or not fully covered) because you had been traveling outside the US. This process might take months.

Also, if you have overseas coverage on your Medigap plan, the secondary insurance might force the Medigap plan to pay before it will pay a penny, and you may lose part or all of your Medigap overseas coverage.

I gave up on getting reimbursed by the secondary coverage plan I had, as it was not worth the time I had to spend on it.

There is not much difference in cost between primary- and secondary-payer insurance plans.

3. Ensure that you are covered for preexisting conditions. (Look for what is commonly called “a waiver of preexisting conditions.”)

Getting such a waiver usually, but not always, is accomplished by paying your first insurance premium within a set time after making your first deposit for your trip.

Note that an airline ticket that you bought months before your trip deposit was due and that you might have forgotten about may be considered your first deposit. Since this airline ticket would be your first payment on the trip, by the time you make your cruise or trip deposit, you would have exceeded the time limit to qualify for a waiver of preexisting conditions.

4. To buy your insurance, I recommend going to SquareMouth.com, where you can compare the travel policies of many companies. In addition…

A. Read each policy in its entirety and refer to the Certificate of Insurance for all details.

B. Be sure that all issues that are important to you are covered. (e.g., trip cancellation in case of a terrorist attack in a country you plan to visit).

C. If you have no need for trip-cancellation coverage, save yourself some money and buy a policy with zero trip-cancellation insurance.

D. Make sure the policy covers a minimum of $100,000 for emergency medical evacuation (EME) coverage, or buy the evacuation coverage separately. 

E. Ensure that if you are evacuated, the insurance company will return you to your residence or to a hospital of your choice closest to your residence instead of to the nearest hospital, if at all feasible and possible.

F. If possible, purchase a policy with enough medical coverage (absolute minimum, $50,000). If the policy you’re considering purchasing does not offer enough medical insurance, buy supplemental coverage. (I have used the insurance company Travelex [800/228-9792, www.travelex
insurance.com]
for this purpose. I have bought their Travel Max plan and have been satisfied with the company.)

G. Sometimes, if traveling on back-to-back tours, you  might have extra days between tours that may not be covered by the trip insurance you have bought. In that situation, ensure that every day you are overseas is covered. Double-check this with the insurance company before departing.

H. Some tour companies have the following policy. They ask you to make a deposit. If you have an emergency and you ask for a return of your deposit, they often make some excuse and refuse to refund part of your deposit. In that scenario, you won’t get your money back unless you have taken out full insurance on your deposit.

I. Ensure that the policy will reimburse you for the transportation of a relative as soon as you are an inpatient in a hospital. Some companies won’t pay for the transport of a family member until after you have been in a hospital for at least seven days.

J. Ensure that all provisions that are important to you are in writing. Do not rely upon reps’ verbal assurances.

WHAT IF I GET SICK ABROAD?

What would you do if you got sick or your previously stable medical condition worsened while overseas?

Below, I will indicate the steps you can take to ensure the best medical care while abroad.

Phone and/or contact card

Inscribe in your phone the email addresses, physical addresses and phone numbers of the following persons or resources or prepare a contact card with this information:

• At least one family member or close contact who is physically present in the US or Canada at the time of your travel or with whom you can easily get in touch at any time.

• US embassy or consulate in the destination country (or countries).

• The US State Department’s Smart Traveler Enrollment Program, or STEP (https://step.state.gov/step), which is a service of the bureau of consular affairs. 

This free service allows any US citizen or national traveling abroad to enroll his trip with the nearest US embassy or consulate and enables the traveler to receive important safety information from the embassy in the destination country, which helps when making informed decisions about travel plans and assists the US embassy and family and friends in contacting the traveler in an emergency.

Area hospitals and/or clinics in countries to be visited.

• Health-care providers at home.

Vaccinations, etc.

• Inquire about needed immunizations and booster shots at least three months before traveling. Get a tetanus shot every 10 years, even if you don’t travel.

• Read the appropriate articles on the website wwwnc.cdc.gov/travel.

• Study your disease(s) on such websites as www.mayoclinic.com, medicinenet.com, etc.

• Read appropriate chapters in the reference “CDC Health Information for International Travel 2016” (commonly called the Yellow Book) online at the following CDC site: www.cdc.gov/features/yellowbook.

• Consult a travel health clinic or your local health department or contact the Centers for Disease Control & Prevention (CDC) at 800/232/4636.

• From your doctor, get a letter with your diagnoses and the medications you take with their generic names. (Include over-the-counter drugs.)

• Note that outside the US, Tylenol® (acetaminophen) is known as paracetamol. (FYI, the maximal 24-hour dose of paracetamol is 3,000mg.)

• Talk to your doctor about the most likely scenarios that might occur in the course of your disease and which medicines you might need if your condition worsened.

• Ask your physician for the appropriate antimalarial drug, if indicated. For the best preventive advice and care, visit a travel health clinic.

Telephone help

It is vital that you know the location of the nearest phone in every place where you spend the night. You also should have the coins or a telephone card specific for that phone.

If you use a cell or smartphone, make sure you have service at your accommodation. Test the phone as soon as you enter each lodging. If an emergency should occur, you will be happy that you can call for help. 

Ensure that you are in possession of the local number to call (such as “911”) in the event of an emergency.

Preventive measures

• Postpone air travel if you suddenly are short of breath or develop a communicable disease. Do not travel to an area far from appropriate medical care.

• Reexamine your insurance coverage and increase amounts of coverage where necessary.

• Keep in mind that air carriers may decline the boarding of an obviously sick passenger.

• Before leaving, locate physicians and health-care facilities abroad by contacting one or more of the following:

A. The US Department of State at www.state.gov/misc/1016.htm.

B. The International Society of Travel Medicine — For a worldwide directory of ISTM travel health professionals, go to www.istm.org, click on “ISTM Activities” and then on “Global Travel Clinic Directory.”

C. The American Society of Tropical Medicine & Hygiene, or ASTMH (www.astmh.org), which maintains a worldwide directory of providers specializing in tropical medicine, medical parasitology and travelers’ health.

D. A number of countries have national travel medicine societies that maintain websites related to travel medicine and that also provide access to clinicians, including the following:

• In Canada, “Travel Health” at the Public Health Agency of Canada (www.phac-aspc.gc.ca/tmp-pmv/index-eng.php).

• In Great Britain, the National Travel Health Network & Centre (www.nathnac.org) and the British Global & Travel Health Association (www.bgtha.org).

• In South Africa, the South African Society of Travel Medicine (www.sastm.org.za).

• In Australia, the Travel Medicine Alliance (www.travelmedicine.com.au).

• In China, the China International Travel Health Care Association (http://en.itha.org.cn). The China ITHA website only shows a number of travel clinics in various large cities. The provided information is in English.

E. Emergency travel-related medical care and medical evacuation may also be accessed through a number of private companies. One example is International SOS (www.internationalsos.com), which operates throughout the world. Provider locations and details may be found at the website.

F. In addition, travelers who obtain evacuation insurance before travel will have access to a 24-hour hotline for help in any medical emergency. This is your best bet for getting the appropriate specialist for your particular condition.

G. In other countries, travelers may also get information about local health care from the local US embassies and consulates as well as from hotel doctors, credit card companies and, lastly, multinational corporations, which may offer health-care services for their employees.

H. Those with underlying medical conditions may want to take extra precautions. They should choose a medical assistance company that allows customers to store their medical history before departure so that it can be accessed from anywhere in the world, if needed. An example is the MedicAlert Foundation®(www.medicalert.org).

Travelers should each carry a letter from their physician listing underlying medical conditions and all current medications (including their generic names). If possible, travelers may want to carry with them the names of their medical conditions and medications written in the local languages of the areas they plan to visit.

Accreditation of health facilities

To get the best possible care, you may want to ascertain whether an overseas health facility is accredited. To do this, go to the website of Joint Commission International (www.jointcommissioninternational.org).

Obtaining pharmaceuticals abroad

It is, of course, best to take all needed medications with you.

Alternatively, if you do need additional medication, your insurance provider should be able to get the medicine to you or will be able to steer you to the right pharmacy.

If you are on your own, be careful what you buy. Even a brand-name drug having the same name as a US drug may have an entirely different formulation and may be used for entirely different conditions. Ask the local pharmacist for advice.

Take your own injection supplies. If you do not have your own injection supplies, ask if the equipment to be used is disposable and insist that a new needle and syringe be used.

Except in the case of life-threatening situations, refuse blood transfusions in countries where the blood is not tested for contaminants and infections.

Getting instant emergency care abroad

When you have an important health issue on a cruise ship, invariably the ship’s doctor will move you to a hospital on shore, as the ship does not have the facilities to deal with major medical issues. 

Try to ensure that you will be sent to a hospital where somebody will speak your language and where you can get appropriate medical care. Otherwise, insist on being evacuated to a hospital where you can get suitable care. Therefore, it is important that emergency medical evacuation (EME) is a part of your insurance policy or that you have a separate EME policy.

In the event of an emergency…

• Contact your travel insurance and/or emergency-medical-evacuation insurance company.

• Ask hotel staff or expatriates for recommendations for the best hospital and/or physician.

• Be sure to have access to a workable phone and/or phone card and/or cell or smartphone with an accessible network.

As I indicated before, have the local 911-equivalent number available.

• Note that although Medicare does not pay for medical expenses outside the US except in very well-defined conditions, some private Medigap plans available to people enrolled in the original Medicare plan provide limited coverage for emergency care abroad. 

To see if you are covered for care outside the US, read your private Medigap policy or call your Medigap insurer.

REFERENCES

FYI, I include the following references.

A. Destination-specific webpages — The CDC’s Travelers’ Health website wwwnc.cdc.gov/travel/destinations/list.aspx features destination-specific pages with information on current CDC assessments of disease risk and recommendations for healthy travel. 

Destination pages contain information about endemic diseases and health risks, with links to travel notices.

B. The following are the titles of a few Web articles and where to find them:

“Plan Ahead for Illnesses or Injuries During Your Trip,” at wwwnc.cdc.gov/travel/page/plan-ahead.

“Know What to Do If You Become Sick or Injured on Your Trip,” at wwwnc.cdc.gov/travel/page/sick-during-trip.

“Pay Attention to Your Health During Your Trip,” at wwwnc.cdc.gov/travel/page/health-during-trip.

I hope that I have answered most of the questions that ITN readers may have had.

Dr. Wagenaar welcomes questions but may not be able to answer them individually. Write to him at 116 Fairview Ave. North #1028, Seattle, WA 98109, or email pwagenaar
2002@gmail.com.

Please login or subscribe to ITN to read the entire post.

In my December 2016 column, I answered questions that readers had after reading the account of my April 2016 emergency room visit in Naples, Italy (Sept. ’16, pg. 51)

One reader, Joyce Perry of Los Angeles, California, also wrote, “As an 86-year-old, I would like to know my options if I become too ill to be treated by a cruise ship’s doctor. Unfortunately, the article that detailed your experiences in Italy did not tell us how to be better prepared for an unexpected stay.”

My recommendations for Joyce are detailed below along with travel insurance recommendations and excerpts from, and updates to, my May 2014 article “What If I Get Sick Abroad?” plus items paraphrased from wwwnc.cdc.gov/travel and other CDC sites.

INSURANCE

1. Never buy travel insurance from a tour operator or cruise line that handles the tour because if the company goes bankrupt, you will not get reimbursed. You also should not buy it from a travel agent because he or she might be selling you a policy that pays the highest sales commission rather than the one that’s best for you.

2. Always buy a primary-payer policy. With primary insurance, the insurance company will pay for all your expenses up front. 

With some primary-payer plans, the company will pay the hospital in advance for the insured’s admission to the hospital. Examples of primary coverage plans that will provide advance payment are the Deluxe plan from Allianz; the Platinum (Cruise, Tour & Travel) and Gold plans from Travel Guard and all of the plans from Travelex.

If you have a secondary-payer policy, you or any other insurance company that you are covered by must pay all medical expenses up front, after which you will be reimbursed by your secondary insurance company. You must get in touch with those other health insurance companies and get proof from them that you are not covered (or not fully covered) because you had been traveling outside the US. This process might take months.

Also, if you have overseas coverage on your Medigap plan, the secondary insurance might force the Medigap plan to pay before it will pay a penny, and you may lose part or all of your Medigap overseas coverage.

I gave up on getting reimbursed by the secondary coverage plan I had, as it was not worth the time I had to spend on it.

There is not much difference in cost between primary- and secondary-payer insurance plans.

3. Ensure that you are covered for preexisting conditions. (Look for what is commonly called “a waiver of preexisting conditions.”)

Getting such a waiver usually, but not always, is accomplished by paying your first insurance premium within a set time after making your first deposit for your trip.

Note that an airline ticket that you bought months before your trip deposit was due and that you might have forgotten about may be considered your first deposit. Since this airline ticket would be your first payment on the trip, by the time you make your cruise or trip deposit, you would have exceeded the time limit to qualify for a waiver of preexisting conditions.

4. To buy your insurance, I recommend going to SquareMouth.com, where you can compare the travel policies of many companies. In addition…

A. Read each policy in its entirety and refer to the Certificate of Insurance for all details.

B. Be sure that all issues that are important to you are covered. (e.g., trip cancellation in case of a terrorist attack in a country you plan to visit).

C. If you have no need for trip-cancellation coverage, save yourself some money and buy a policy with zero trip-cancellation insurance.

D. Make sure the policy covers a minimum of $100,000 for emergency medical evacuation (EME) coverage, or buy the evacuation coverage separately. 

E. Ensure that if you are evacuated, the insurance company will return you to your residence or to a hospital of your choice closest to your residence instead of to the nearest hospital, if at all feasible and possible.

F. If possible, purchase a policy with enough medical coverage (absolute minimum, $50,000). If the policy you’re considering purchasing does not offer enough medical insurance, buy supplemental coverage. (I have used the insurance company Travelex [800/228-9792, www.travelex
insurance.com]
for this purpose. I have bought their Travel Max plan and have been satisfied with the company.)

G. Sometimes, if traveling on back-to-back tours, you  might have extra days between tours that may not be covered by the trip insurance you have bought. In that situation, ensure that every day you are overseas is covered. Double-check this with the insurance company before departing.

H. Some tour companies have the following policy. They ask you to make a deposit. If you have an emergency and you ask for a return of your deposit, they often make some excuse and refuse to refund part of your deposit. In that scenario, you won’t get your money back unless you have taken out full insurance on your deposit.

I. Ensure that the policy will reimburse you for the transportation of a relative as soon as you are an inpatient in a hospital. Some companies won’t pay for the transport of a family member until after you have been in a hospital for at least seven days.

J. Ensure that all provisions that are important to you are in writing. Do not rely upon reps’ verbal assurances.

WHAT IF I GET SICK ABROAD?

What would you do if you got sick or your previously stable medical condition worsened while overseas?

Below, I will indicate the steps you can take to ensure the best medical care while abroad.

Phone and/or contact card

Inscribe in your phone the email addresses, physical addresses and phone numbers of the following persons or resources or prepare a contact card with this information:

• At least one family member or close contact who is physically present in the US or Canada at the time of your travel or with whom you can easily get in touch at any time.

• US embassy or consulate in the destination country (or countries).

• The US State Department’s Smart Traveler Enrollment Program, or STEP (https://step.state.gov/step), which is a service of the bureau of consular affairs. 

This free service allows any US citizen or national traveling abroad to enroll his trip with the nearest US embassy or consulate and enables the traveler to receive important safety information from the embassy in the destination country, which helps when making informed decisions about travel plans and assists the US embassy and family and friends in contacting the traveler in an emergency.

Area hospitals and/or clinics in countries to be visited.

• Health-care providers at home.

Vaccinations, etc.

• Inquire about needed immunizations and booster shots at least three months before traveling. Get a tetanus shot every 10 years, even if you don’t travel.

• Read the appropriate articles on the website wwwnc.cdc.gov/travel.

• Study your disease(s) on such websites as www.mayoclinic.com, medicinenet.com, etc.

• Read appropriate chapters in the reference “CDC Health Information for International Travel 2016” (commonly called the Yellow Book) online at the following CDC site: www.cdc.gov/features/yellowbook.

• Consult a travel health clinic or your local health department or contact the Centers for Disease Control & Prevention (CDC) at 800/232/4636.

• From your doctor, get a letter with your diagnoses and the medications you take with their generic names. (Include over-the-counter drugs.)

• Note that outside the US, Tylenol® (acetaminophen) is known as paracetamol. (FYI, the maximal 24-hour dose of paracetamol is 3,000mg.)

• Talk to your doctor about the most likely scenarios that might occur in the course of your disease and which medicines you might need if your condition worsened.

• Ask your physician for the appropriate antimalarial drug, if indicated. For the best preventive advice and care, visit a travel health clinic.

Telephone help

It is vital that you know the location of the nearest phone in every place where you spend the night. You also should have the coins or a telephone card specific for that phone.

If you use a cell or smartphone, make sure you have service at your accommodation. Test the phone as soon as you enter each lodging. If an emergency should occur, you will be happy that you can call for help. 

Ensure that you are in possession of the local number to call (such as “911”) in the event of an emergency.

Preventive measures

• Postpone air travel if you suddenly are short of breath or develop a communicable disease. Do not travel to an area far from appropriate medical care.

• Reexamine your insurance coverage and increase amounts of coverage where necessary.

• Keep in mind that air carriers may decline the boarding of an obviously sick passenger.

• Before leaving, locate physicians and health-care facilities abroad by contacting one or more of the following:

A. The US Department of State at www.state.gov/misc/1016.htm.

B. The International Society of Travel Medicine — For a worldwide directory of ISTM travel health professionals, go to www.istm.org, click on “ISTM Activities” and then on “Global Travel Clinic Directory.”

C. The American Society of Tropical Medicine & Hygiene, or ASTMH (www.astmh.org), which maintains a worldwide directory of providers specializing in tropical medicine, medical parasitology and travelers’ health.

D. A number of countries have national travel medicine societies that maintain websites related to travel medicine and that also provide access to clinicians, including the following:

• In Canada, “Travel Health” at the Public Health Agency of Canada (www.phac-aspc.gc.ca/tmp-pmv/index-eng.php).

• In Great Britain, the National Travel Health Network & Centre (www.nathnac.org) and the British Global & Travel Health Association (www.bgtha.org).

• In South Africa, the South African Society of Travel Medicine (www.sastm.org.za).

• In Australia, the Travel Medicine Alliance (www.travelmedicine.com.au).

• In China, the China International Travel Health Care Association (http://en.itha.org.cn). The China ITHA website only shows a number of travel clinics in various large cities. The provided information is in English.

E. Emergency travel-related medical care and medical evacuation may also be accessed through a number of private companies. One example is International SOS (www.internationalsos.com), which operates throughout the world. Provider locations and details may be found at the website.

F. In addition, travelers who obtain evacuation insurance before travel will have access to a 24-hour hotline for help in any medical emergency. This is your best bet for getting the appropriate specialist for your particular condition.

G. In other countries, travelers may also get information about local health care from the local US embassies and consulates as well as from hotel doctors, credit card companies and, lastly, multinational corporations, which may offer health-care services for their employees.

H. Those with underlying medical conditions may want to take extra precautions. They should choose a medical assistance company that allows customers to store their medical history before departure so that it can be accessed from anywhere in the world, if needed. An example is the MedicAlert Foundation®(www.medicalert.org).

Travelers should each carry a letter from their physician listing underlying medical conditions and all current medications (including their generic names). If possible, travelers may want to carry with them the names of their medical conditions and medications written in the local languages of the areas they plan to visit.

Accreditation of health facilities

To get the best possible care, you may want to ascertain whether an overseas health facility is accredited. To do this, go to the website of Joint Commission International (www.jointcommissioninternational.org).

Obtaining pharmaceuticals abroad

It is, of course, best to take all needed medications with you.

Alternatively, if you do need additional medication, your insurance provider should be able to get the medicine to you or will be able to steer you to the right pharmacy.

If you are on your own, be careful what you buy. Even a brand-name drug having the same name as a US drug may have an entirely different formulation and may be used for entirely different conditions. Ask the local pharmacist for advice.

Take your own injection supplies. If you do not have your own injection supplies, ask if the equipment to be used is disposable and insist that a new needle and syringe be used.

Except in the case of life-threatening situations, refuse blood transfusions in countries where the blood is not tested for contaminants and infections.

Getting instant emergency care abroad

When you have an important health issue on a cruise ship, invariably the ship’s doctor will move you to a hospital on shore, as the ship does not have the facilities to deal with major medical issues. 

Try to ensure that you will be sent to a hospital where somebody will speak your language and where you can get appropriate medical care. Otherwise, insist on being evacuated to a hospital where you can get suitable care. Therefore, it is important that emergency medical evacuation (EME) is a part of your insurance policy or that you have a separate EME policy.

In the event of an emergency…

• Contact your travel insurance and/or emergency-medical-evacuation insurance company.

• Ask hotel staff or expatriates for recommendations for the best hospital and/or physician.

• Be sure to have access to a workable phone and/or phone card and/or cell or smartphone with an accessible network.

As I indicated before, have the local 911-equivalent number available.

• Note that although Medicare does not pay for medical expenses outside the US except in very well-defined conditions, some private Medigap plans available to people enrolled in the original Medicare plan provide limited coverage for emergency care abroad. 

To see if you are covered for care outside the US, read your private Medigap policy or call your Medigap insurer.

REFERENCES

FYI, I include the following references.

A. Destination-specific webpages — The CDC’s Travelers’ Health website wwwnc.cdc.gov/travel/destinations/list.aspx features destination-specific pages with information on current CDC assessments of disease risk and recommendations for healthy travel. 

Destination pages contain information about endemic diseases and health risks, with links to travel notices.

B. The following are the titles of a few Web articles and where to find them:

“Plan Ahead for Illnesses or Injuries During Your Trip,” at wwwnc.cdc.gov/travel/page/plan-ahead.

“Know What to Do If You Become Sick or Injured on Your Trip,” at wwwnc.cdc.gov/travel/page/sick-during-trip.

“Pay Attention to Your Health During Your Trip,” at wwwnc.cdc.gov/travel/page/health-during-trip.

I hope that I have answered most of the questions that ITN readers may have had.

Dr. Wagenaar welcomes questions but may not be able to answer them individually. Write to him at 116 Fairview Ave. North #1028, Seattle, WA 98109, or email pwagenaar
2002@gmail.com.