ITIJ Assistance and Repatriation review October 2018

OCTOBER 2018

WORD PERFECT

BRIDGING THE CULTURAL DIVIDE

Using language and translation services

Effective and sensitive case handling

ASSISTANCE & REPATRIATION REVIEW

60 YEARS

OF AIR AMBULANCE & MEDICAL ASSISTANCE LONDON

STOCKHOLM

DUBAI

ROME

CHINA BEIJING TOKYO

DAKAR CONAKRY

DOUALA MADAGASCAR

CAPE TOWN

JOHANNESBURG AUSTRALIA

FROM AFRICA TO THE REST OF THE WORLD 24 Hour Emergency Control Centre Tel: +254 20 6992000 / +254 20 6992299 Mob: +254 (0) 733 639 088 / 722 314 239 Fax: +254 20 344170 Email: emergency@flydoc.org www.flydoc.org 2|

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contents

Case study

Eight flights, six countries, 22 hours

Bridging the cultural divide

22

From Russia with love

34

Just a touch away

38

Local assistance provision under the spotlight

4

Effective and sensitive case handling

The final journey

International funeral directors talk about their current challenges

24

Developing assistance apps

Sarah Watson Editor, ITIJ

Editorial comment

Spinning plates

10

The role of the Provider Network Manager

In ITIJ’s second Assistance & Repatriation Review of 2018, we talk to travel and medical assistance companies around the globe about some of the key topics currently under discussion in their industry.

Although technology plays a large part in how the assistance industry is evolving, the human element involved in providing care to those in need can never be underestimated. This is never more evident than when handling a medical assistance cases that involve dealing with medical staff in a wide variety of countries, and cultures. In our feature ‘Bridging the cultural divide’ (p.4), we explore the ways in which international assistance handlers navigate the nuances of different healthcare systems in order to provide effective assistance and meet customer expectations.

Another area in which technology is not quite as important as the human touch is translation and handling cases in different languages. We explore the importance of accurate and timely translations for assistance providers in our feature ‘Word perfect’ on p.16.

Elsewhere, ITIJ finds out the latest developments in the production of assistance-related apps (p38), we hear from global providers of funeral repatriation services on overcoming some of the current challenges faced by this sector of the industry (p.24), and we look at assistance provision in Russia today, with a special focus on how well the local assistance sector performed during the recent World Cup tournament (p.34). Plus, we report on a wing-to-wing repatriation by Canada’s Fox Flight and South Africa-based Awesome Air Evac (p.22) that saw a high-risk patient transferred almost 10,000 miles.

If you’d like to contribute a case study or article to ITIJ’s next Assistance & Repatriation Review, please don’t hesitate to get in touch!

Editor-in-chief: Ian Cameron Editor: Sarah Watson Copy Editors: Lauren Haigh, Mandy Langfield, Stefan Mohamed & Christian Northwood Contributors: Tatum Anderson, Femke van Iperen & David Kernek Design team: Katie Mitchell, Will McClelland & Tommy Baker Advertising sales: James Miller, Kathryn Zerboni & Tim Hall

Editorial: +44 (0)117 922 6600 ext. 3 Advertising: +44 (0)117 922 6600 ext. 1 Email: news@itij.com Web: www.itij.com Published on behalf of: Voyageur Publishing & Events Ltd, Voyageur Buildings, 19 Lower Park Row, Bristol, BS1 5BN, 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 Publishing & Events 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 firm mentioned is hereby excluded. The views expressed do not necessarily reflect those of the publisher.

Word perfect

Using language and translation services

16

Printed by Pensord Press Copyright © Voyageur Publishing 2018.

Materials in this publication may not be reproduced in any form without permission INTERNATIONAL TRAVEL & HEALTH INSURANCE JOURNAL ISSN 2055-1215

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Lauren Haigh spoke to industry experts to hear their thoughts on the best ways to tackle cultural differences when dealing with medical assistance cases >>

>>

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I

ntercultural communication can prove challenging, whatever the scenario.

But, imagine a situation that involves a sick or injured person thousands of miles from home who needs urgent care. Here, communication is paramount and could even mean the difference between life and death. Beyond the ability to communicate, elements key to providing optimal care include an understanding of the local culture and environment. So, what are the best ways to bridge cultural divides when dealing with medical assistance cases and ensure seamless care and a smooth repatriation?

First, let’s explore some of the challenges presented by medical assistance cases in different countries and cultures. Brenda Durow, General Manager of South Africa-based international assistance group MSO International, told ITIJ that some of the key issues that MSO International commonly faces are differing views with respect to death, burials, cremation and funerals, and significant differences in how people relate to serious illness and end-oflife events. “Some cultures are embracing C

We need to demonstrate acceptance and respect for their beliefs even if we may not share those beliefs of less active medical care toward the end of life, while others will wish to be very aggressive in management right up until death has occurred,” she said. “We must be very sensitive here to avoid offence and even legal risk.”

As Durow highlighted, without sensitivity and understanding, not only do medical assistance companies risk causing offence, but they also run the risk of incurring legal repercussions. This is because countries have their own sets of rules and legal frameworks. Saudi Arabia, for example, is a country deeply rooted in laws that stem from religion and tradition. Indeed, women are not allowed to interact with men to whom they’re not related or make major decisions without male permission.

These types of considerations must be kept in mind, Durow says: “In a society that is strongly patriarchal, one may find it is more effective to have a man making arrangements with regards to guarantees of payment or contracting. If the society values women as nurturers, then having a female nurse discussing care arrangements may be seen a more acceptable than a male nurse. We need to demonstrate acceptance and respect for their beliefs even if we may not share those beliefs.”

ITIJ spoke to Takaaki Chiyo, Executive

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Officer and Head of the Network Division at Emergency Assistance Japan (EAJ), a Tokyo-based Japanese medical assistance company with subsidiaries and branch offices in England, the US, Thailand, China, and Singapore, about some of the challenges EAJ faces when dealing with medical assistance cases in different countries and cultures. He highlighted the fact that, for a medical assistance company, the medical provider’s willingness to cooperate is crucial and good relationships are essential. “In comparison to some Western countries, Japan is highly culturally sensitive, and people may tend to be cautious towards people from different cultural backgrounds,” Takaaki explained. “Given such conditions, many foreign assistance companies struggle to obtain medical information from Japanese medical providers, even if they employ Japanese staff themselves.” Takaaki said that EAJ is successful in obtaining such information for its foreign clients due to its strong understanding of Japanese customs and long-term efforts to maintain trusting relationships with medical providers. Again, we hear the importance of learning about and being respectful of different cultures and customs, but also the importance of building bridges and forging relationships

over a long-term basis. In addition to maintaining regular relationships with local medical providers, such relationships can be forged via regular in country visits, establishing local business units, partnering with in-country assistance partners and networking with industry. Durow at MSO International also values establishing relationships and said that, as a Core Partner in the International Assistance Group (IAG), her company has great opportunities to do so. “We participate in bi-annual forums and the annual IAG Training Academy, which brings assistance agents from across the globe together to share their experiences and discuss similarities and differences when providing services in their countries,” she said. “This fosters an atmosphere of acceptance and puts a face to the different cultures we work with.”

Mindfulness and meticulousness Takaaki said that EAJ believes that there are three elements to be mindful of when dealing with medical assistance cases in different countries and cultures: “First, meticulously organising the planning and simulation of the assistance co-ordination; second, conducting briefing and debriefing among the operation team members to ensure the necessary information is shared and, lastly, decisions and actions are made in an accurate and prompt manner.” For EAJ, planning, sharing and timely actions are the ingredients for success in medical assistance >>

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cases in other countries. Similarly, James Page, Chief Administrative Officer and Head of Assistance and Claims for travel insurer AIG Travel in the US, believes in the importance of sharing to ensure all members of a team are up to speed and able to deliver care appropriate to the country and culture. “Having a team with a thorough understanding of the culture and environment of each major destination around the world is critical to ensure there isn’t any disconnect or misinterpretation about what the customer is experiencing,” he said. “While it seems obvious, it is important to recognise that every health system in every country is different and, therefore, a one-size-fits-all approach to delivering global medical assistance is simply untenable.” Page said that one example of this is that in China, public medical facilities do not have nursing staff; therefore, if a patient is admitted to a public facility, they will need to rely on family or friends to assist with the tasks that nursing staff might usually handle in other countries.

When it comes to delivering a smooth care pathway for a patient, Durow highlighted the importance of managing patient expectations. “Managing patient/ client expectations is always important but especially so if one is dealing with patients and care givers from different cultures,” she said. “Accessing care may be impacted by the culture or religion of the recipient

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of the care – e.g. if a female patient cannot be seen alone by a male medical practitioner – and this would need to be taken into consideration when making any arrangements. When one understands the culture of both your patient/ member and your provider it is easier to anticipate potential issues and proactively manage them.”

For EAJ, Takaaki said that collaborations with local interpreters help to effectively facilitate assistance. “We think that having interpreting services on-site is a very important factor in delivering a smooth care pathway for the patient. The travelling patient’s anxiety from the differences in the medical environment can be reduced by providing explanation,” he said. "At EAJ, that is done by not only our operation team but also our network interpreters, and such necessity occurs especially in the time of seeking medical attention when the anxiety peaks, in order to prevent subsequent anxiety-related problems from occurring.”

An additional tool for ensuring a smooth pathway, said Takaaki, is the collection of

local information by facilitators behind the operation, which includes ensuring the accuracy of the information held at EAJ.

Knowledge is power(ful) For Page, having a team that possesses a deep and thorough understanding and knowledge of the market a customer is travelling in is the most important factor when it comes to ensuring a smooth care pathway for a patient. “For AIG Travel, we address this critical need through ensuring that our eight dedicated service centres, strategically located in key regions across the globe, are equipped with a mix of local and international staff trained to provide the highest quality of service and advice (both medical and travel-related). These teams will speak the local language and are experienced with how the location’s medical system works,” he said. “Staff must be able to quickly direct a customer to the best and closest medical facility where treatment can be provided; in some cases, this could involve also arranging or communicating with family and friends back in the patient’s

Having a team with a thorough understanding of the culture and environment of each major destination around the world is critical

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home country to advise them on what has happened. Once at a medical facility, our doctors and nurses on staff who are familiar with the location, speak the language, and aware of any other cultural nuances will contact the treating physician to ascertain the condition of the patient.”

Page also highlighted how important it is for medical assistance teams to be, and indeed stay, informed of what is doing on in different markets to ensure that they can provide customers with the best advice possible. “Whether due to political unrest, economic uncertainty or other global factors, developments and advancements are constantly happening all around the world,” he said. “Depending on the circumstances, a location that was once unsafe might now be home to a high-quality medical centre or vice versa.”

A case of understanding For travellers, resources such as the World Health Organization, US Centers for Disease Control and Prevention and local government websites can be very useful in terms of education around what to expect from medical systems around the world.

“Resources and tools that provide critical information to travellers about the legal, cultural and medical differences can go a

long way toward mitigating potential issues when traveling to different countries,” said Page, who considers education and research to be key for travellers. “All travellers should be prepared by researching their destination and considering travel insurance,” he said.

“Research is even more critical for those travellers who have underlying medical conditions. Take some time to put a plan in place to mitigate potential risks that may occur while travelling. That way, less time will be spent worrying about what might go wrong, leaving more time to enjoy the trip.”

Takaaki of EAJ said that the essential points and principles when it comes to bridging the gap between different cultures when dealing with medical assistance cases are: understanding the environmental situation and culture in depth, from as many perspectives as possible; finding new partners and continuing to expand relationships with trusted partners in order to receive useful and effective local advice; forwarding all necessary information to the parties involved; and paying costs and collecting incurred fees as soon as possible.

Durow of MSO International said that when it comes to bridging the gap, her company is fortunate to have staff with a diverse array of languages cultures and religions. “This helps a great deal in assisting

us to be more sensitive to diversity within our client base,” she explained. She also said that MSO International employs local network managers in 11 key countries to ensure that when it is negotiating with providers or assisting patients, it has ‘feet on the ground’ who understand local business and cultural practices. I think most of us would agree that face-to-face communication is king and the most effective way of ensuring that messages do not become mixed or misinterpreted.

From this, we can take that the three pillars of bridging cultural divides in medical assistance cases are understanding, education and respect; understanding a culture and a country, in terms of rules, tradition, religion and language are paramount. There is also a fundamental need for those involved to educate themselves and ensure they remain in the know when it comes to developments.

Additionally, it is necessary for team members across the board to have access to the same information and knowledge to ensure consistency.

Finally, and perhaps most crucially, having respect for those encountered during medical assistance and repatriation cases, and working together to keep all parties informed via clear communication. ■

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Tatum Anderson delves into the complex and fast-paced world of provider network managers

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he first thing that hits you when you speak to a provider network manager is just how busy they are. “Every day is different – we may be re-negotiating pricing as our business grows in Mexico, identifying the best quality options for a student group in a remote location in Africa, working on an agreement with a new facility in China, developing a new offering like telepsychology,” said Laura Hilton, Director of Provider Relations at GeoBlue. “We could be doing a Personalised Recruitment to help an expat stay with the same pediatrician when moving to GeoBlue from a competitor.”

Network managers like Hilton specialise in building and maintaining networks of goodquality health facilities, so that assistance providers and insurers can be reassured they are sending their customers to a vetted and approved hospital, able to deal with >>

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international patients. They must also deal with other parts of their own organisations, said Geoffroy Remond, AXA Assistance’s Network Manager in charge of the Middle East, Africa and Europe. “We have very busy days,” he said. “When I get into the office, I can have up to five requests between heading for the cafeteria and taking my coffee to my desk! I can have the medical director requesting specific providers’ referral, the medical ops director requesting some evacuation options, or the nearest centre of medical excellence in one country or another or to ask us to source new providers.”

Fundamentals of the job Care and quality of care, negotiated prices, checking credentials and operational efficiency are the most important factors network managers look for in a good hospital. As Remond explained, assessing operational efficiency means measuring the quality and speed of the provider: “Do they know how to work with a Guarantee of Payment? Are they reactive enough on

a 24/7 basis? Are they able to deal with international companies? Sometimes it’s difficult, for example, to draft an invoice and make sure that good information is provided for an international company.

They also check if medical facilities are allowed to function, if doctors have licenses, malpractice insurance, their diplomas are kosher and they are registered with the medical board. It’s a job that is often outsourced but must be doublechecked.”

But checking the quality of care is the priority, according to the managers, with Remond explaining that it’s really important to take pictures, to allow the medical and operations teams at home to have a taste of the kinds of facilities available. He assesses not only the ER, but other hospital services, from the ICU and imaging to other specialities – and that means asking probing questions. “We ask do you have a 24/7 ER department, is your ER doctor a general practitioner or is he really an emergency doctor,” he told ITIJ. “Is she physically present the whole

night or is she on call and, if so, how long does it take to come to the ER to welcome our patient? If they have a specialist how long will it take the specialist to reach the site?”

It’s essential to do these thorough checks. Managers must be aware of drug stockout problems, how controlled drugs are handled, whether the hospital has its own blood banks or must source blood from a national centre in a different region. The checks are all-encompassing – they may even check if the hospital is providing laundry services, meals or the morgue itself, or subcontracting services to an external provider. The latter is important, particularly, should mortal remains need to be repatriated quickly. AXA even vets the security guards in more challenging parts of the world, such as Nigeria.

Hygiene is, of course, fundamental.

“In medical facilities, you can go to a laboratory and it gives you a good taste of the level of hygiene of the medical facilities most of the time,” said Remond.

Network managers are assessing not just the main city hospitals, but those in more remote areas with less infrastructure

Communication specialists International network managers must be masters of contract negotiations and procurement rules, and establish clear points of contact: if their organisation wants to arrange an admission, who should be called and who should be sending the invoice, for example?

When looking for good hospitals, Katy Youngman, AWP Regional Medical Provider Manager at Allianz Partners in charge of the Asia-Pacific region, said that she focuses on patient health outcomes, and evidence of strong clinical governance policies and procedures. Crucially, however, she looks for a good relationship with the service provider. “When evaluating a hospital, I’m primarily looking for a willingness to work in a clinically collaborative and collegiate relationship, to ensure the delivery of evidence-based bestpractice care,” she told ITIJ. The relationship with the hospital is especially vital when the good standards seen on inspections are not maintained.

Regular onsite evaluations happen every few years – but being able to work with the hospital in between these times is important too.

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providers to highlight concerns and aim for collaborative improvements.”

Collaborating with other members of her own company helps her to keep up-todate with just how well a hospital is doing as well: “I work closely with our Medical Operations teams to obtain feedback around medical outcomes with the AWP network facilities.”

Keeping a close eye There are several tell-tale signs that indicate things are not going too well at any particular hospital. Poor health outcomes, customer feedback and clinical governance are all danger signs, warned Youngman, but so is the use of inappropriate medications and clinical practices that are totally unsupported by research or evidence.

“A lack of clinical engagement with our medical teams, lack of accountability, or predatory practise leading to over servicing, is not acceptable,” she said.

Once due diligence is done, GeoBlue’s Hilton agreed that the goal is to have a long-term relationship with each contracted doctor and hospital: “It is an art, as much as a science. Clinical quality and patient experience are my top priorities, but every successful relationship has to be underpinned by win-win business terms and a solid working relationship at every level.”

That means maintaining regular contact.

“We contact each contracted doctor and facility a minimum of four times per year to maintain and grow our relationships,” she said. “In the rare instances when there is a significant issue, we make sure to get all sides of the story and then evaluate the situation internally with a multidisciplinary team (clinical, legal, provider relations) before developing a plan.”

Different levels of interaction are required too, she added, because hospitals have different needs. “Some hospitals are keen to build their business with international patients, others have been burned in the past by some company in the international space and need a lot of coaxing to actively work with a non-domestic insurer,” she told ITIJ. That’s why travelling is such a big part of the job, not just to visit hospitals, but other parts of the organisation. “Face-to-face visits with team members and key medical providers see me travelling to varied regions throughout APAC, covering multiple countries per trip,” said Youngman.

Geographical challenges Youngman’s team is spread across eight countries throughout the Asia Pacific region, which can be extremely diverse.

Indeed, the AWP Asia Pacific region consists of 56 countries with varied

14 | International Travel & Health Insurance Journal

standards, accessibility and costs of healthcare – and the network must accommodate very different travellers, including leisure, corporate and expatriate customers.

Such a broad range of countries with different cultures, economic conditions and ways of doing things requires a nuanced approach, she said: “For example, in Japan, our medical team often has to liaise with doctors to encourage pain relief medication when necessary. This is not reflected in other countries!

Japanese patients are often very stoic and appear to be tolerant of higher pain levels than their Australian counterparts [for example]. In Japan, medical doctors are highly respected and rarely questioned by patients in regard to their decisions.” In contrast, other countries within the region are more likely to overprescribe narcotic pain relief and that leads to more complications such as delayed patient mobility, prolonged length of stay and a higher risk of hospital-acquired infections, she said.

Network managers are assessing not just the main city hospitals, but those in more remote areas with less infrastructure.

“One of the great challenges is the ever more remote locations that people with significant comorbidities are travelling to – especially in ageing demographics,” said Youngman. “Locations where healthcare

options are limited for patients.”

Dubai-based Jamil Juma has seen the job from various points of view – as a provider network manager himself for 12 years at International SOS, and at Oman Insurance. He said it’s a mistake to use the same criteria for an internationally accredited hospital as one in a remote or poorer country: “In some locations, it is hard to find a facility with international standards or even with acceptable standards, but management support can facilitate this mission providing the information required.”

As a result, he looks for hospitals that have put protocols in place, are well-staffed and have an interest in good communication with their clients. Importantly, he said, they must be willing to take direction from management and provide the support required for his clients.

An interest in the world is a basic requirement

A matter of ethos Often, it’s not the international accreditation or lack thereof that may indicate a hospital is not up to scratch. It’s the ethos the hospital has. “If the hospital orientation is purely financial, this can be determined by their reluctance to share their price list, or you may learn that they have different price lists for insurance, cash and international clients,” said Juma.

GeoBlue’s Hilton agrees: “The most disappointing situations are those where a doctor or hospital puts financial or other

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interests above clinical quality and patient safety. All this makes for an extremely global and varied work environment.

Extensive experience travelling or living abroad, foreign language skills, negotiation and analytical skills, open-mindedness, effectively being a cultural chameleon, is essential for Hilton: “I often think I have seen it all, but every day is still a learning experience.”

The skillset for a provider network manager is certainly diverse. Hilton told ITIJ that her foreign language and negotiating skills have been essential. “But my own experience of being hospitalised in the Amazon at 20 years old gave me insight into what is important to patients who become sick or injured abroad,” she explained.

The managers ITIJ spoke to come from wide-ranging backgrounds; starting in critical care nursing for example. AXA’s Remond said that medical operations gave him a thorough grounding in pragmatic problem-solving in different, and sometimes difficult, situations. “One thing I always look for when I’m recruiting someone is the professional background,” he said. “If they’ve worked as an operations co-ordinator or manager, it’s always a good entry to medical network management

because they’ve been working with providers and they know the challenges.”

An interest in the world is a basic requirement, he added: “If you are aware of the foreign politics in these countries it’s always a plus because it makes the meetings with the providers easier. The chitchat before the meeting, it’s always important to keep these good relationships with the provider. Being comfortable with different cultures [is very useful]. It’s a job where you are constantly asking questions, but if you’re not curious it doesn’t help.”

Youngman believes that network managers must be flexible, but so must their organisations. “Flexibility is key in this role,” she said, “due to the multiple time zone differences. AWP is very supportive of flexible working, in the office and from home. Usually, I arrive at work around 8 a.m. and will likely be on calls as required between 8 p.m. and 10 p.m. at night to fit in family life in between.”

Additionally, passion for learning is vital, said Juma, who is, by training, a pharmacist. “There is no book or degree that you can obtain to become a network manager. It is a continuous development process,” he explained. “To succeed, you need to accept the daily challenges and find the right approach to dealing tactically with

people. You need to accept limitation of services, language barriers, the hostility of some environments, personal interests and support the team you work with.” The key, he concluded, is to ‘never underestimate communication – any communication – even a simple SMS’. ■

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Femke van Iperen assesses the need for timely and accurate language and translation services in the global assistance industry

W

hether assessing medical documents or verbally communicating with other personnel working on a case, when dealing with people in other parts of the world who speak different languages, assistance companies need translation services that are accurate and swift in order to effectively carry out their day-to-day business.

Following a recent bus crash in Buenos Aires that involved mass casualties, International SOS medical staff had to evacuate a number of foreign students and teachers – some who had walked away with mild trauma, and others who had lost their lives. On other recent occasions, they had to get a 28-week-pregnant woman to safety from a remote area in South Sudan; while over in Haiti a complex and fast security evacuation needed to be completed. These are just a few examples of testing day-today scenarios faced by the assistance sector; scenarios that rely on effective translation and language services for a successful outcome. So, how do assistance companies working on a global scale ensure they have the right people at hand to be able to respond rapidly to cases in any part of the world at any given time?

Phone a friend

At times, an assistance company may need instant support with a live interpretation. Or it may need a translation >> service for more routine

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ASSISTANCE & REPATRIATION REVIEW responsibilities such as the preparation of pre-travel advice, patient medical appointments, reports, records, insurance documentation, logistical arrangements or financial exchanges. Whether acute or more routine, in any of these circumstances there are a variety of services that can be called upon, ranging from in-house translators to external partner support and assistance apps.

For example, for its translation requirements, International SOS makes use of a pool of native speakers from assistance centres in 26 regions around the world, who together speak 99 languages. On rarer occasions, the company can make use of a global assistance network of over 80,000 medical, security and aviation providers. In addition, teams have access to a real-time ‘language line’.

When US-based company Seven Corners Assist needs support with translating medical records, foreign medical bills, policy documents, marketing materials, or with real-time interpretation during client phone calls, it makes use of its multilingual staff in-house. In the event that a particular language is not supported, the company also works with outside vendors it knows

International Travel & Health Insurance Journal

using standard outsourced translation services could be unsafe to meet these specialised needs and trusts.

An assistance company needing external support may turn to a company such as Lexxika, an expert translation service.

Lexxika explained to ITIJ that it specialises in the assistance sector and offers services in the areas of medical and accident reports, medical test results, and fit-to-fly certificates, making it a unique service.

Other companies that are used by the assistance sector may be more general but still focused on medical and financial translation. The services of Language Buró, for example, which works with financial clients as well as clinical research organisations and pharmaceuticals, are requested by the medical industry for the

translation of independent medical exams, doctor and patient notes, as well as medical journals and patient reports.

The need for speed

In the assistance sector, the need for speed on the one hand and accuracy on the other can pose a challenge. There are also time differences, complex medical or financial material, and specialist terminology to deal with. In addition, pointed out Professor Robert Quigley MD, SVP Regional Medical Director at International SOS in the US, routine assistance situations that warrant translation are far from theoretical and vary day by day.

Explaining how time is of the essence, Professor Quigley said: “By the nature of the work we do and working in a global environment with sensitive medical or security cases, most exchanges necessitate rapid communication, and therefore, rapid translation. We must be prepared to facilitate key communications, between local and our medical and security personnel 24/7/365.”

When, for example, a translation of medical reports and fit-to-fly confirmation is requested during >>

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an emergency medical evacuation, fasttracked translation is needed, because ‘the information contained in these documents is a critical component in our approving and arranging transport of a sick or injured member’, said Kellee Hinshaw, Operations Analyst at Seven Corners Assist. In the event of of a client being hospitalised abroad in a non-English speaking medical facility, “having immediate access to a live interpreter allows us to assess the situation in real time, and allows both parties to communicate expectations and provide clarification on any questions without unnecessary delay,” she added.

This is extremely important, she said, as delayed responses to those questions or requirements could directly impact a patient’s course of treatment in various ways. “A hospital may be refusing to proceed with a surgery until eligibility is [translated and] verified, or the patient is required to pay a large sum out-of-pocket, because a Guarantee of Payment cannot be issued until all supporting documents are [translated and] received,” she said.

In a remote location, a lack of the right or enough paperwork, for example, may mean that insurers may deny financial coverage, as they lack enough justification of procedures or hospital stay, and only by being able to offer real-time translated communication between the assistance company’s own team and the local medical team can it obtain the required information, Professor Quigley said.

Other than tight deadlines, medical and insurance translations depend on meticulousness. “Medical translation is a very particular field that requires a high level of precision and detail,” said CEO of Language Buró, Rodrigo Galindez. In particular, terminology and the potential for translation errors are key issues, said Galindez: “The key challenge is to find translators that are specialised in the industry and have relevant experience.”

“The global medical lexicon is definitely the biggest challenge,” said Hinshaw, explaining that in the assistance industry, a machine translation will not always suffice and should always be combined with a human editing component.

“Certain diagnoses, procedures, and even medical specialities can be referenced in different ways, depending on where services are rendered. The same can be said for insurance terminology. For example, ‘pre-certification’ is a widely used term in the US, but not really elsewhere. It’s commonly interpreted as ‘pre-approval’ in other countries, which it is not, by definition,” she said.

“The types of communications can be highly technical and, therefore, using standard outsourced translation services

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could be unsafe to meet these specialised needs,” agreed Professor Quigley.

Calling in the experts

To help speed up the process of translation and reduce translation errors, it can pay to partner with a specialist. The expert partner Seven Corners Assist choses, for example, is ‘a full-service company, not an agency that passes requests to freelancers, with projects that are proofed by a second linguist, at minimum’, said Hinshaw, who explained that they must be able to offer a 24/7 service, real-time interpretation, and a clear price structure. This, she argued, all helps to ensure a ‘more streamlined terminology between insurers and assistance providers and hospitals’.

For Tom Bool, CEO of Lexxika, a translation service should be able to offer prompt services that ‘represent the key to accelerating case-handling times’, and they should be able to facilitate the different

needs of insured parties waiting for treatment and claims handlers desperate to understand the results of a toxicology report. “The assistance industry needs a language support company who is growing

Due to our business being relatively complex, engaging a partner that has a grasp on its complexities is crucial to delivery from within it and is focused on solving industry problems,” he said, explaining the answers lie in human translation and ‘mimicking the shape and approach of an assistance company’. “By having specialist resources located all around the world,

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and a good understanding of the time pressures, it’s possible to provide a purely human solution that is always available, follows the sun and still maintains a prioritised approach to speed of delivery.”

It particularly pays to make sure the people doing the translation are subject matter experts themselves. As Professor Quigley told ITIJ: “These experts are familiar with the terminology and have an understanding of the assistance business as a whole and of how its centres operate. Due to our business being relatively complex, engaging a partner that has a grasp on its complexities is crucial to delivery.”

Other than using experts, it also pays to use native speakers, said Hinshaw: “They are more inclined to identify and understand the context, idiomatic nuances in terminology, regional accents, and cultural references and dialects, such as Castilian Spanish and Latin American Spanish.”

Apart from ensuring the most appropriate translation service, there are other things an assistance company can do to ensure perfect translations. For example, there may still be a disadvantage if the original message is not clear or specific, said Hinshaw: “If you need to know if there is any past medical history of a particular condition, or if the insurance policy covers

pre-existing conditions, communicate those needs to the linguist. This way, they know to ask those exact questions during the conversation; or look for anything that may allude to that information within the documentation, even if it isn’t explicitly indicated as such.”

On a more practical level, something like multiple translators working independently and simultaneously on different sections of the same document can be valuable, explained Galindez. Sharing a ‘glossary of common terms’ as well as a ‘translation memory’, i.e. a ‘database of previouslytranslated segments’ and a final review by another translator all work particularly well with the company’s financial clients that require translations to be done fast and ‘for understanding purposes only’. In addition, Galindez considers a ‘back translation’ useful, which he described as the ‘process of bringing a previously-translated text back to its original language without reference to the original source’.

Meeting requirements

When recently a Chinese national passed away in the US, International SOS was able to provide family repatriation support in Mandarin and another Chinese dialect.

On another occasion, by having available

a Colombian security professional from its Philadelphia security team, the assistance company was able to secure a safe, prompt release of two American businessmen who were held by Colombian police. In today’s world, with the number of people travelling to further and more remote locations growing, such scenarios are typical in the assistance sector, and its need for translation continues to increase in number, urgency and complexity.

“There is a multi-layered need for 24/7 communication, both from native speakers and from individuals who themselves are SME in medical, security, aviation and financial disciplines,” said Quigley.

“The assistance industry faces a unique set of problems when it comes to language services," highlighted Bool. "We live in a world where everything is urgent, emergencies are common place, and it is impossible to predict what challenges will arise, and therefore what resources will be required.”

However, it seems that whatever the translation requirement of an assistance company, with the right translation services, through a balance of speed, accuracy, and a knowledge of the industry and terminology, the desired outcome can be supported. ■

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Eight flights, six countries, 22 hours A wing-to-wing transfer by air ambulance companies in Canada and South Africa saw a patient being transferred almost 10,000 miles. ITIJ finds out the details of how the mission was co-ordinated The mission saw the two air ambulance operators combine to complete a journey made up of eight individual flight legs, touching down in six different countries, before terminating some 22 hours later.

The incredible logistical challenges of the transfer were compounded by the fact that the patient was categorised as high-risk, requiring ventilation throughout the flight.

The challenge In early June 2017, Awesome Air Evac was contracted to transfer a high-risk patient from a hospital in Johannesburg, South Africa to Kansas City, Missouri, US. Given the distance involved, Awesome Air Evac opted to partner on the mission with Fox Flight Air Ambulance via a wingto-wing patient transfer. The companies agreed that Tenerife South, in the Canary Islands, would be the most convenient airport to conduct the transfer due to its relative location and the airport’s extended operating hours.

In Johannesburg, the patient presented with an intracerebral bleed with a nosocomial pneumonia, which was further compounded by the patient being non-

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ambulant and fully ventilated. While both companies have experience with ventilated critical care retrieval missions, due to airport closure restrictions faced by Fox Flight at the final destination, this mission posed a time complexity concern that had to be planned for carefully. The total mission time added additional pressure on ventilation calculations as well as pharmacological quantities.

Obviously, a mission this complex presents a range of logistical challenges. The routing that was required needed to be the safest yet most direct in order to meet FDP (Flight and Duty Period) limitations, while keeping in mind the timeline needed to obtain the multiple clearances at each stop along the way.

The flight operations departments of both air ambulance firms had to ensure that all ground services were immediately available at the multiple airports where the aircraft had to make technical stops for refuelling. The timing of each leg had to line up perfectly, as this mission involved airports closing at different times and both sets of crew needed to be prepped and ready to transfer the patient from one aircraft to the other with minimal ground time inbetween.

The flight The official go-ahead for the mission was given on the morning of 15 June. Based on

Awesome Air Evac: Johannesburg-Luanda-Accra-Dakar-Tenerife Fox Flight: Toronto-St John’s, Newfoundland-Santa Maria-Tenerife Awesome Air’s anticipated flying time of 11 hours 36 minutes to Tenerife, excluding ground time for technical stops, Fox Flight proposed to make the patient exchange on 17 June at approximately 16:30 hrs local time.

A Fox Flight Learjet 36 air ambulance, carrying two pilots and a medical crew, comprised of an ICU doctor and a critical care nurse took off for Tenerife at 18:30 hrs Toronto time on 15 June. The journey included technical stops at St John’s, Newfoundland and Santa Maria in the Azores. The crew arrived in Tenerife

this mission posed a time complexity concern that had to be planned for carefully at 11:30 hrs local time on 16 June and immediately went off duty to rest up in preparation for the return journey.

The Awesome Air Evac Learjet 35 air ambulance departed from Johannesburg on the first leg of the transfer at around 02:30 hrs local time on 16 June with a two-person medical crew comprised of an ICU doctor and an Advanced Life Support Paramedic.

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The plane made its first refuelling stop about three and half hours later in Luanda, Angola. After about 30 minutes on the ground, the crew took off on the second leg to Accra, Ghana. From Accra, the jet made a stopover in Dakar, Senegal, before heading to Tenerife for its rendezvous with the Fox Flight air crew and medical team. The Awesome Air Evac jet arrived in Tenerife late in the afternoon of 16 June.

As soon as the patient was safely transferred, the Fox Flight air ambulance took off on the first leg of its journey, and the fifth in the transfer, to the Azores. After refuelling, the crew proceeded to St John’s, Newfoundland. Leg seven of the journey took the Fox Flight crew back for a brief stopover at their home base in Toronto, where two new pilots had to take over due to duty time restrictions. The final leg, number eight in total, took the patient from Toronto to Kansas City.

The patient was closely monitored and remained stable during all phases of the flight, with neither medical crew encountering an adverse clinical event.

Oxygen calculations, pharmacological quantities, patient nutritional requirements and pressure care were completed at optimal clinical levels during all phases of the mission. The patient arrived in Kansas

City in stable condition at 03:30 hrs local time, just two hours later than estimated, and was transferred to hospital by the medical crew.

COMMUNICATION IS KEY Close collaboration between flight and medical teams ensured impressive patient care continuity and the wingto-wing transition was well executed. Constant communication was the key to the success of this mission. Both aircraft were tracked via satellite by flight operations throughout, and all relevant parties were notified of departure and arrival movements to ensure both aircraft were in Tenerife on time and were parked in close proximity to ensure minimum ground time with the patient during the transfer. In addition, flight operations had to communicate with handling agents at each stopover to assist with arrangements on the ground, such as fuel bowsers being ready for aircraft refuelling, assisting with Customs and airport procedures and filing en route flight plans.

Repatriation flight: Tenerife-Azores-St Johns-Toronto-Missouri The use of multiple communication channels, in particular frequent verbal discussions, ensured that all parties were involved in decision-making and that all team members were informed of potential risks and the related mitigation.

Technologies such as aircraft satellite tracking allowed both companies to have a simultaneous live view of mission progress and appropriately manage the teams taking part in the transfer. ■ This case study first appeared in the March/April 2018 issue of AirMed&Rescue Magazine

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International funeral directors tell David Kernek that the challenges they face have more to do with bureaucratic paperwork and adjusting family expectations than the demographics of death overseas

A

big part of the vacation travel industry is based on the business of selling dreams. ‘Can you recommend a good funeral director?’ is not a question often found in foreign language phrase books for tourists. Death in Venice was one of Thomas Mann’s greatest stories, but it’s not a good look for an Italian holiday brochure.

While the vast majority of holidaymakers and business travellers return home after an uneventful trip, death turns some dream vacations and work secondments into emotional and sometimes bureaucratic nightmares. International funeral directors and repatriation companies have a business line that will never be rubbed out by technology, but how have their operations been adapted to meet demographic changes as the age range of vacation travellers widens to include more baby boomers taking their pre-existing conditions with them?

Shifting demographics “Travelling abroad has become increasingly easier, cheaper and more accessible yearon-year, and with this we’ve seen a distinct change in the demographic of those travelling,” says Samuel Tester, operations manager at UK-based international funeral repatriation company Homeland International. “The most obvious change from our perspective is due to the increase in cruise travellers.” The number of cruise passengers on Royal Caribbean lines alone has risen steadily over the last decade from 3,905,384 passengers in 2007 to 5,768,496 in 2017, says Tester, and due to this, his company has seen a rise in repatriating mortal remains (RMR) cases across cruise regions. “We often have to work out challenging routes when people pass away in small ports and villages on

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their journeys,” Tester told ITIJ. “Even in many European cruise destinations, RMR’s can prove a challenge. In the Norwegian fjords, for example, cruise liners dock at small ports. Getting access to these ports by road is often a problem.

We overcome such challenges by relying on the local knowledge we’ve built through our dedicated teams on the ground in such areas. Solutions are identified quickly enabling us to safely reach these locations to assist all of the parties involved.”

Looking at current patterns of RMR cases, Homeland International reports a decline in cases from Turkey, possibly due to the decrease in visitor numbers there over the last few years. “But this seems to be slowly rising again,” said Tester, “as it is now being considered a safer place to holiday.

Conversely, we have experienced a rise in cases from more unusual destinations such as Montenegro and Tunisia. The majority of our cases currently, however, are from the typical tourist hotspots in Europe: Spain, Portugal and Greece.”

Fiona Greenwood, Operations Director at UK-based international funeral repatriation company Rowland Brothers International (RBI) plays down the perception that ageing baby boomers are having a significant impact on the sector. “Working

with bereaved families worldwide, we have always felt that older travellers don’t necessarily represent the greatest proportion of our homebound repatriation arrangements, but it’s difficult to find international statistics to corroborate our impressions. Does retirement boost travel?

We read that between the ages of 60 and 72, people travel more intensively, but less over the age of 75, perhaps due to concerns about health issues. Old and young alike might relish the challenge of journeys to remote areas, so we must be ready to engage with relatives who have lost a family member at any time of life.”

The most recent statistics from the UK government’s Foreign & Commonwealth Office record that in 2016, consuls helped the families of 3,670 British citizens who died overseas, says Greenwood. “British travellers continue their love affair with Spain, France, Greece, Italy and Thailand, which are frequent points of origin for repatriation,” she said, “but we manage repatriation also from every corner of the globe.”

At Singapore-based Flying Home, CEO Deborah Andres tells ITIJ: “Funeral and repatriation companies are definitely working with a wider diversity, not only in countries but also with religion, culture

and traditions that go outside what their traditional communities may have once looked like.”

Rules and regulations With a more diverse range of travellers heading to a wider range of destinations, funeral repatriation companies have to keep abreast of the intricacies and logistics

Just as passengers need documentation to travel, so do the deceased of working in any given part of the world.

Andres highlights small islands and the Middle East as challenging locations from which to organise repatriations.

“With small islands, there can be a degree of difficulty in getting to them,” she explained. “In the Middle East, where there are restrictions and regulations that can hamper and delay repatriation, it really is all about working closely with >>

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government agencies and embassies. A close trusted network is extremely valuable and partnering with local people and agencies helps tremendously.”

Homeland International’s Tester agrees that the Middle East can pose problems.

“There are many different requirements for repatriation worldwide; every country has its own legislation and guidelines for departure as well as the destination country having additional requirements for entry.

Locations such as the Middle East have a lot of involvement with the employers.

There are many paperwork processes that require the employer to assist with meeting some of the regulations. The biggest difficulty is usually when registering the death; in some countries it is legal for us to register the death, in others we cannot.

In cases where the individual was a lone traveller this can create challenges as it can mean there is nobody else there who can assist with registering the death.”

Tester says that flying the deceased’s family members out to the location is not usually advisable. “It can add cost and time to the repatriation, as well as adding stress for the family. Typically, we would require a doctor from the hospital to register the death, as more often than not they are legally endorsed to do so. This can often result in delays, when we have to wait until the doctor is available to leave the hospital in order to assist.”

Good working relationships with embassies are vital, Tester told ITIJ: “They regularly update and change their regulations, and to make things even harder, their regulations are not the same in every country worldwide. They might require one set of documents in the USA while in Cambodia, for example, they want an entirely different set of papers, even though they represent the same government. We have forged many personal relationships with embassies worldwide, which means it is easy for us to work closely with them and to keep on top of all the regulation changes they make.”

Logistics are always an important part of repatriation protocols, says Greenwood

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at RBI. “The combination of location, circumstances, nationality and destination sets unique parameters for each arrangement, which we manage from start to finish. Collecting the deceased to bring them home can involve many forms of transport, from a boat to a private plane or a prolonged overland journey. We never underestimate the value of relationships built over many years with partners around the world who share our can-do approach.” She said there is no one-sizefits-all policy when it comes to national authorities and the paperwork they require.

“The documents required to complete the repatriation process, and the regulations, can change at any time, due to a change in the political situation in the country or updates on in-country regulations.

This does not generally cause a problem although in some instances it might affect the timeline for repatriation slightly. In countries considered a war zone, each case needs to be reviewed on its own merits to determine if repatriation is possible, as the situation can change daily. The worst case might involve a local burial with a view to exhuming and repatriating at a later date once the situation has changed.”

We must be ready to engage with relatives who have lost a family member at any time of life

Dominic Vernhes, CEO of Paris-based international funeral assistance group Anubis, told ITIJ funeral companies are having to deal with a wider range of countries, laws and customs than ever before. “Funeral companies need to do their research and find out if they are equipped to respond to rules and regulations in different countries as well as cultural requirements for the deceased.

Funeral formalities include obtaining the documentation that is required for transporting a body from the country where the death occurred and that for its destination. In certain cases, it is also necessary to obtain documents required for travelling through different countries during the journey, particularly when the repatriation takes place by road.

Conventions exist between certain countries that facilitate the process or limit the number of documents that are required. But it can be complicated if the relevant countries do not have a diplomatic relationship or consular representation.”

Religious requirements are also important when organizing the repatriation of a body, he said, so it’s necessary to have a wide knowledge of different rites and rituals in order to avoid making an irreversible mistake that might result in a claim for moral damages with high financial consequences.

Logistical challenges Logistical problems, Vernhes told ITIJ, are generally faced in regions such as the Caribbean, Polynesia and the Philippines, or ‘anywhere where a tourist destination is made up of a number of small islands’.

A plane will usually be chartered for repatriation of a body from somewhere that doesn’t have an international airport, but sometimes this isn’t possible when the planes that are available don’t have a cargo door that is big enough for a coffin, Tester said. The alternative in this situation is to find an aircraft that suits requirements or to organise a transfer by a public or private boat to another island or to the nearest mainland that has an international airport. This involves extra costs that >>

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REPATRIATIONS AND FUNERAL SERVICES

We provide complete transport of the deceased by a cooled hearse or by plane. We will take care of all documents and permits necessary for the transport. We will provide embalming and cosmetic treatment, plane, coffin, zinc inserts with sanitation valve, shroud, etc. With the help of Cargo Partner we can take care of the flight to the final destination or offer the most suitable flight variant.

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can add up quickly due to the logistics required for departure and arrival.

There can also be complicated logistical challenges, he says, arising from geographical and political situations, ‘often in Africa and the Middle East’. “Certain countries don’t have any specific regulations in place, he told ITIJ. “They don’t have funeral companies or regulation coffins.

These countries include East Timor, Bhutan and far-away places such as Adélie Land on Antarctica, where we assisted after a helicopter crash. Problems might also arise when a death occurs on a private boat or on a cruise or cargo ship. A logistical solution is needed to recuperate the body and this can be particularly complicated if the captain decides to continue the boat’s journey. We responded to a case recently where a man died while carrying out an inspection on a ship. His body was supposed to be dropped off in Mauritius, but we finally recuperated it in Singapore.

The same happened in another case

utilise technology to manage a number of areas including finance, cost containment, provider network and client base. It enables us to operate smoothly in all areas. The system is flexible and can be used on any operating system and device. It needs only an internet connection, which ensures we can work collaboratively wherever our teams are in the world.”

Technology, agrees Vernhes, is changing the way things work in the funeral sector, ‘but this is happening at a slow and steady pace because every country has its own regulations and every service provider has their own communications system’.

“Unfortunately, there is no such thing as an electronic visa for repatriating a body, or a one-stop information site that can deal with the range of necessary formalities," he said. “Generally, these tasks will need to be dealt with at different offices at the relevant location. In the US, it is possible to declare a death online, but all other formalities must be dealt with in person.

The majority of our cases currently are from the typical tourist hotspots in Europe: Spain, Portugal and Greece involving a cruise ship that was supposed to go back to Antigua in the Caribbean but continued its journey to the UK.” Furthermore, it’s sometimes necessary to ship vital equipment from neighbouring countries, said Vernhes. “Many years ago, for a petrol conglomerate client, we equipped a village clinic in Asalouyeh in Iran with cold chambers brought from Tehran, 800 miles away,” he told ITIJ. “They didn’t have any equipment prior to our intervention; dead bodies were put in a piece of sealed pipeline while repatriation was being organised.”

E-mail and mobile phones have enhanced processes and shortened timelines, says Flying Home, although Homeland International says that the RMR sector has been generally reluctant to take advantage of the latest kit. “Technology is certainly slowly making an impact on improving services,” said Tester, “but the sector is still far slower in this area than other medical and travel assistance operators.

Most companies in the funeral sector are very traditional, and use dated software and equipment. Off-the-shelf software for our sector is also very dated and non-user friendly, which is why we took the decision to create our own bespoke case management system. We reap the benefits from this daily, allowing us to

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In Europe, countries that signed the Berlin Convention use the same template for death certificates and repatriation transport authorisation forms, but all the other necessary documents vary from country to country.”

Technology has without doubt facilitated an easier way to exchange information and to keep a record of communication as well as keeping people up-to-date with a situation, said Tester, ‘but we cannot ignore the fact that a human presence is essential when dealing with death’.

Assistance covered Are international funeral repatriation companies seeing an increase in the number of families paying privately for their services, or does a greater proportion of their business come via travel and IPMI insurers and assistance providers?

“Our Asian platform,” says Vernhes, “is seeing an increasing number of cases in which a family pays privately for our services. I think that this is due to the fact that their insurance policies and cover are very different to the policies available in Europe or North America.”

RBI also works with both types of clients, but most of its business comes from emergency travel assistance companies.

“Occasionally, families decide to pay

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company that might not offer the same and claim if they can’t wait for a medical quality and understanding as one of the history, due to faith or other personal worldwide repatriation companies. This reasons,” said Greenwood. “For most makes the whole process a lot harder for the families, the news of a death away from family at an already tragic time and gives home is totally unexpected and, for the sector a poor reputation.” some, funding repatriation privately is Flying Home’s Andres said that the difficult. Some families expect that if a decision to pay privately for a RMR will travel insurance product was purchased, normally depend on regional, cultural cover is automatic for any emergency. and religious traditions. “For example, If cover is declined, families might turn here in Singapore, if the deceased is from to crowdfunding or to extended family, Malaysia and Indonesia, the families will friends, employer or charities to seek pay because they want their loved one help with repatriation costs. They might home the same day. Westerners, on the ask about an alternative solution, such as other hand, understand processes and will cremation in resort, if this is available and normally wait for the insurance approval compatible with their faith.”

Most of Homeland International’s missions, before proceeding.” similarly, come from assistance companies, Tester explained: “It is positive that RMR Improving communication is covered by most travel insurance policies, Are there ways in which communications as it protects families financially and gets between insurers, assistance companies them access to companies that can operate and funeral repatriation operators could be effectively wherever they are in the world. improved to make the process less stressful But we hear of too many stories about for families? families overseas who, when a loved one ‘Undoubtedly’, says Tester at Homeland who was uninsured has passed away, are International. “One of the largest issues we forced to pay the full bill themselves, face when working on behalf of assistance relying on funeralia an unregulated, low-grade local companies is the time between providing poland a5.pdf 1 21/09/2018 08:53

For most families, the news of a death away from home is totally unexpected a quote and receiving the go-ahead. While policies are being checked and prices compared with providers who have taken longer to respond, issues can arise. The first setback is that we lose time and families are left in limbo overseas.” There is little protection for families, so local funeral companies will often go to the hospital and offer support, taking advantage of a grieving family, he told ITIJ. “Unaware they are being duped, a family will sign paperwork quickly and the local company will move the deceased person to their premises without proper consultation. By the time we have been assigned to start the case, the deceased person has been moved from the hospital. The funeral home will then charge us an extortionate price to remove the deceased, making the case far more expensive for the client. Insurance and assistance companies should advise families not to sign anything at all at the first call stage. Then, when >>

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we get involved, it will all be far easier. It will save costs from rising and make the process quicker.”

Shaping the expectations of bereaved families is also important. “We feel privileged to work with assistance companies around the world,” said Greenwood at RBI. “No two arrangements are ever the same, but it is important to maintain the same standards across everything we do. Setting clear expectations, with empathy and honesty, is important to our team, our clients and the bereaved. If we can go ahead as soon as we are notified, families feel progress is being made while cover is explored.

Provided this is clearly explained to the family, this works well.”

In most cases, the relocation of a loved one is accomplished in a relatively short time, but if local protocol prolongs the arrangements, communication is crucial to reassure clients and families, explained Greenwood. “The essence of repatriation is not only managing the arrangement but also managing expectations across cultures and continents, providing a seamless service which respects family wishes and local, international and emergency assistance protocols.”

Assistance companies, thus, need to have knowledge of the processes and different regulations in different countries, explained

Flying Home’s Andres, so that their client’s expectations can be managed. “Insurance company representatives sometimes have no prior knowledge of the repatriation process and what it entails and can sometimes hinder the process by promising families a timeline that cannot be met,” she told ITIJ. “They also need to know that time zones, locations and other factors can hinder a quick response. Other challenges have been with embassies and consulates. There are sometimes people stationed there who do not have any experience or knowledge of dealing with death and of their own government’s requirements.”

Dialogue and sharing experiences and knowledge at international events helps as this creates a bond of trust within the sector, said Andres. The consolidating of operating standards has also been discussed. “Having continued conversations with the World Health Organization about an international operating standard would certainly help,” commented Andres. “Medical examiners in different countries have different processes, especially for autopsies and the issuing of death certificates. That can be a problem because insurance companies need to know the cause of death before approving the claim and allowing repatriation companies to begin the process. Faster payment by insurance companies to smaller repatriation operators would also be helpful, as they do

The biggest difficulty is usually when registering the death

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not have the means to go for long periods without payment.”

Lack of in-country knowledge and processes can be a problem, adds Andres.

“In Singapore, the Chinese expect their loved ones to arrive fully dressed. If a repatriation company is experienced and knowledgeable, it would be able to manage the family’s expectations by letting them know that a repatriation from the Middle East normally arrives in only a shroud. If a receiving family isn’t told about this, they can find this quite shocking.”

The Brexit question Both Homeland and RBI appear to be relaxed about the consequences for RMR procedures to and from the UK and the EU 27 after Britain leaves the union in March next year. “We have yet to fully understand the outcome of Brexit in any walk of life,” says Samuel Tester at Homeland International, “and this remains the case with RMR cases. There is likely to be a slight increase in costs as well as the potential for longer customs procedures for cases in and out of the UK. But it is unlikely to present any real problems for us operationally. We are working closely with the European Federation of Funeral Services to make processes within Europe easier. We are working with the EU and different airline companies to identify ways in which we can implement a similar process to the Schengen agreement, >>

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whereby we could by-pass embassy and other regulations when repatriating deceased people within Europe. Ours is a global company, so if this were to be established, it would make a lot of our cases far easier.”

RBI’s Greenwood confirmed: “We don’t know yet if there will be any customs or security changes that could affect us after Brexit, but many protocols are already observed and could be adapted where necessary. Over many years of EU membership, there have been few changes to individual EU country requirements. A small number of countries still expect the coffin to be sealed by their embassy abroad before starting their final journey home.

Just as passengers need documentation to travel, so do the deceased. Documents that accompany loved ones home authorise departure from one country and entry to another. Sometimes documents are certified where they originated, or by the foreign ministry where they will be used, or both. Attention to detail matters, as death certificates are not only important

for a funeral to take place, but also for estate matters.”

Vernhes thinks Brexit could have an impact on repatriation costs. “The services required in order to repatriate a body will not change: a coffin will be required, certain formalities will need to be carried out, and it will be necessary to organise transport.

But Value Added Tax (VAT) varies from country to country in the EU, and that could mean that a service provider invoicing a client in the UK will no longer be able to use an intra-EU VAT number to bill without VAT. This will depend on which EU zone the service provider is in and could have significant financial repercussions on repatriation costs – between 18 and 27 per cent. Service providers in the UK will be able to apply the same policy and add VAT to a repatriation invoice. However, the number of European deaths in the UK is significantly lower than the number of British bodies that are repatriated from Spain and France alone.”

While Brexit and the possible paperwork

Case history 1

changes – affecting Britain and the EU 27 – that might flow from it will have no impact on Flying Home in Singapore, Andres spoke to ITIJ about the potential global standardisation of paperwork for the industry. The international organisation representing funeral service operators – FIAT/IFTA – issues a ‘passport for the dead’, said Andres, which its members use: “However, not every funeral company is a member. It would certainly be advantageous if this passport was used by all companies worldwide.”

This ‘passport’– or what FIAT/IFTA calls its ‘indispensable’ Repatriation Document – is a free, downloadable uniform ID paper available in a range of major languages that provides the information national authorities require when human remains have to be taken across frontiers. If accepted and used universally, it could help to streamline the task of international funeral directors and RMR companies and alleviate some of the stress endured by often shocked bereaved families. ■

Case history 2

Libya to Bosnia/Herzegovina

A knifing at sea

Homeland International was requested by an assistance company to carry out a repatriation of mortal remains from an oil service location in the desert of southern Libya back to Sarajevo, Bosnia and Herzegovina. The case was urgent because there were no mortuary facilities in the vicinity. Homeland International recounts the details

A Philippian cook was injured when he was working on a cargo ship registered under a French flag. He was stabbed in the chest during an altercation with another sailor. The ship was in the Atlantic Ocean and heading for Pointe-Noire in the Congo. The man was hospitalised when the ship arrived in Pointe-Noire. Unfortunately, as is often the case in Africa, there was a power cut during the night. The patient was on a life-support machine, and he died. The shipping company and the family of deceased requested that his body be repatriated from Pointe-Noire to Manila. Anubis shares details of the repatriation

We have trusted local providers in every country worldwide, so we were able to mobilise our team on the ground within minutes. We responded to the case in the early evening, so made the decision to leave straight away as the eight-hour drive would be easier at night than in the daytime heat.

Our team was getting close to the location, about two hours away, when a sandstorm stalled progress and it was impossible to complete the journey in the vehicle the team had. We contacted another of our local agents who was in the area, and who had a more suitable vehicle for the terrain. The team changed vehicles and collected the deceased, arriving back safely in Tripoli the following morning. The Monday was a national holiday in Libya. We could not progress paperwork because government offices were closed, but as we operate 24/7 365 days a year we were able to prepare the coffin and the embalming. The government paperwork was completed the following day.

Now the process in Libya had been completed, we had to look for flights, which is tricky because of the political situation in Libya. Many airlines no longer operate from Tripoli, giving us very limited options for the outbound flight. As we needed to contain costs for our client, private aircraft was never an option. Eventually, we were able to find a route to Sarajevo via Tunis and Istanbul, which was available that evening. The family had told us about the Bosnian funeral home they wished to use. We liaised with the funeral home and supported it with the import procedures before they were able to collect and move the deceased to its premises in Sarajevo. Despite a few hurdles, the case was completed smoothly and successfully.

32 | International Travel & Health Insurance Journal

The patient died in Pointe-Noire, but his injury took place in international waters. The boat was subject to French maritime law. This meant that the body had to be repatriated to Paris in order for an autopsy to be carried out.

Transportation consent from the consulate was required in order to carry out this legal obligation. Once the autopsy had been carried out, the body was released and repatriation to the Philippines was once again requested. However, we encountered problems while putting together the documentation that was required for a transportation authorisation. The death took place in the Congo; the body was in Paris and needed to be repatriated to the Philippines. A doctor in the Congo issued the medical certificate and Pointe-Noire City Hall issued the death certificate. It took one month for us to have all the paperwork, because an original copy of the birth certificate had to be sent from the Philippines to Pointe-Noire City Hall before the file could be sent to Paris.

In order to get all of the paperwork necessary for transportation, we also needed authorisation from a French judge and a ‘free from epidemic infection’ certificate. All of the paperwork then had to be translated into English so that it could be sent to the Philippine Embassy in Paris in order to apply for authorisation to enter the Philippines. But the Philippine Embassy in Paris rejected the application because the death took place in the Congo and is outside their intervention zone. We contacted the Philippine Embassy in Nairobi, Kenya, and had to send the original documents to Kenya along with the additional paperwork from the Congo and France. Two months after his death, the sailor’s body was repatriated to his home country.

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I

n 2016, the last year for which reliable figures are available, inbound tourism to Russia grew by seven per cent, according to Russian Culture Minister Vladimir Medinsky. The number of Iranian tourists increased significantly in that year over 2015, while China, Korea, India and Spain also registered an increase. Italian and French tourist numbers were up too. Leonid Marmer, CEO of Intourist Thomas Cook, said that the country is most popular with Chinese tourists, though, as 2016 saw 1.2 million Chinese tourists visit Russia, while Germany, in second place, saw 500,000 tourists head to the country.

2018 – a new challenge In the summer of 2018, Russia hosted the FIFA World Cup, which saw vast numbers of tourists head to 11 different host cities around the country to attend football matches. State news agency TASS reported that Russia’s Black Sea resort city of Sochi saw an increase in visitor numbers of 90 per cent during the World Cup. In July, at the end of the tournament, TASS reported that more than five million tourists, of which 2.9 million were international, visited the host cities.

Arthur Zulficarov, General Manager of assistance firm GVA Russia, told ITIJ that the Sochi Winter Olympics in 2014 had

been helpful for everyone involved in the FIFA World Cup organisation process, as it allowed companies to prepare for another big influx of visitors. There were, however, changes in national healthcare provision between 2014 and 2018, which brought about ‘constant updates of changes in our network’ during the preparation phase, he explained: “About 12 months before the World Cup teams’ playoff draw held in Moscow in December 2017, we organised a massive information campaign within our network in the hosting and neighbouring

The expertise of assistance companies in the country with experience of dealing with international insurance providers allowed calls for assistance to be dealt with promptly and professionally, when the eyes of the world were on them cities to update our knowledge of changes with their organisational structure, renovation, equipment, key contact staff members, renewal of agreements, and so forth. At the same time, we focused on the potential emergency needs of Englishand Spanish-speaking FIFA fans in these locations.”

The main challenge for GVA was to find as many English- or even Spanish- speaking doctors in Russia as possible, especially outside of Moscow and St Petersburg.

“All GVA assistance co-ordinators and doctors are fluent English-speaking,” said Zulficarov, “and some are Spanish-, French- and German- speaking, so during the tournament we faced a dozen cases

in smaller cities where GVA was playing the role of a medical interpreter between an international patient and the local doctor hospital.”

Sergey Nickoulitchev is Business Development Manager for Savitar Group Ltd, which was part of a tender process for providing assistance services to European officials who were preforming site surveys before the tournament began. He explained: “Our key target was to have a clear picture of the hosting cities’ infrastructure, medical and security capabilities. Our network and medical departments arranged missions to all 11 cities during spring 2018. The results were discussed in internal meetings and accumulated in relevant reports/ presentations. Those of our clients who were interested in learning about our network received a copy of the report.” The increase in the number of visitors, inevitably, was going to put pressure on the company’s resources – namely, staffing. Nickoulitchev said: “In terms of staff availability, we were prepared quite well for a major case flow.

There is a natural, predictable increase of cases during the summer season, so the staff was employed and trained in anticipation of the growing workload. A separate subplateau was established for the FIFA cases.

This part of our team did most of the work to support foreign guests coming to Russia this summer.”

kick off As the saying goes, prepare for the worst, hope for the best. For Savitar, this came true, as Nickoulitchev explained: “We did expect a high volume of injury-related claims. However, in reality the bulk of the cases turned out to be >>

credit: GVA

Russia is the largest country in the world by area, covering more than one-eighth of the Earth’s inhabited land area. Providing assistance to the thousands of travellers who visit the country each year, then, is a challenge not to be underestimated, as Mandy Langfield explains

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simple travel-type sicknesses like flu, fever or gastroenteritis. There were no criminalrelated cases (to everyone’s relief), only a couple of lost documents/missed flight dossiers and around 12 really complex medical cases, with air evacuation or body transportation from Russia to other parts of the world.”

The level of preparedness, preventive measures, and alertness of all federal, regional and municipal security and healthcare systems across the host cities and team bases was reportedly impressive, and there were therefore no major incidents or criminal cases involving foreign fans during the tournament. GVA opened 312 cases related to World Cup tourists during the sixweek period, ranging from minor trauma to an unexpected labour and birth, and a heart attack that a fan suffered during a match.

When it comes to air medical transportation within Russia, the situation is complicated by the fact that there is not a single private jet company in the country that dedicates its entire fleet to medical evacuations. The Ministry of Emergency Situations has developed a state-managed network of air rescue planes, so medical evacuations can take place in theory, but the reality is that these aircraft are mostly dedicated to missions such as natural disaster relief.

Nickoulitchev said that Savitar has to therefore explore other avenues when medical evacuation is necessary: “If there is a necessity to bring a foreign patient home from Eastern Europe or Central Asia, we would rather search for available options from countries like Finland, Germany or

Turkey, or consider equipping a rented flight with our medical gear, depending on a patient’s condition.”

To eliminate any potential complications or delays in obtaining Russian visas for international medical escort staff, GVA finds it more effective to provide medical escort services itself for its insurance and assistance partners in other parts of the world. The company performed six commercial carrier medical escorts throughout the tournament and assisted on the ground for three air ambulance evacuations performed by foreign air ambulance teams.

“The major concern during an event like the World Cup,” pointed out Zulficarov, “is the lack of space for stretchers and ticketing for seated patients due to high air passenger traffic both incoming and outgoing as well as hotel rooms for escorting medical teams because of high demand of hotel rooms by the fans and the visitors.”

reported. “Web applications, remote access tools, online conferences, training options – all of this helps us immensely. New tools make life in our call centre easier, both on the management side with wider statistics availability and on the operational side, with more capabilities to provide fast and efficient service.”

GVA has developed its own proprietary information infrastructure and maintains it as a result of the IT team working hand in hand with assistance co-ordinators and doctors. “It is not only a database to manage cases, it is a digital eco-system embracing GVA Alarm Centers worldwide,” said Zulficarov. The smartphone era in particular, he added, has contributed a great deal to the firm’s information environment by taking formats of communication adored by younger generations and transforming them into professional tools for co-ordinators and medical professionals. “Web-based geographical tools, great geo-positioning and tracking instruments, online booking systems, instant access to medical databases, you name it – all this is heavily used in a daily routine,” said Zulficarov. The ability to communicate more effectively with clients has also had a positive impact on GVA’s operations, he said, while quality of care and customer loyalty have also both improved as a result of immediate communication with end users. There is, though, still a case to be made for more traditional methods of communicating with customers. “There are users who still prefer a conversation on the phone, particularly when it comes to a medical or critical situation. Therefore, we believe that along with new technological solutions that we are committed to testing and implementing, the role of the human touch in communication in our activity will keep playing an important role now and in the near future.”

The major concern during an event like the world cup...is the lack of space for stretchers and ticketing for seated patients

Technology updates The advent of new technology into the Russian assistance business has helped to significantly streamline the provision of such services to tourists in need. When Nickoulitchev first started out in the assistance business 13 years ago, he said there were few technical tools available – just a few adapted programmes that would help to manage the case load. “Now, in 2018, things do look quite different,” he

credit: GVA

Job well done

36 | International Travel & Health Insurance Journal

Russian organisers responded well to the challenges of holding successful – and safe – international sporting events, which is no mean feat. The expertise of assistance companies in the country with experience of dealing with international insurance providers allowed calls for assistance to be dealt with promptly and professionally, when the eyes of the world were on them.

While the Russian football team didn’t make the final, they, like their countrymen in the insurance and assistance business, certainly distinguished themselves. ■

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Mobile technology is such an integral part of our everyday lives that we rarely think about it anymore. Still, the assistance industry faces a number of challenges when it comes to engaging with customers via apps. Christian Northwood explores how these challenges are being overcome

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W

ith the app market becoming so saturated, standing out is the main challenge for assistance providers who offer an app to their customers. Users don’t just expect one or two services to be delivered via the app they are looking to be supplied with an entire suite of resources. Swedenbased company Global Warning Systems (GWS) strives to make travellers safer and was created in 2008 after its Founder Lars Lidgren experienced the SARS epidemic in 2003, the Indian Ocean tsunami in 2004, and the Mumbai terror attacks in 2008, all first-hand. Its app is part of a wider travel security platform offered by the company called Safesure, which allows both staff and the companies they are employed by to ‘quickly receive alerts and support when something serious has occurred based at their exact location’, explains CMO Jonas Brorson. “Because the app is part of the entire platform, there are many features that are designed for travel safety and tailored to business needs,” he told ITIJ. “The app is also available as a software development kit solution, which gives us a unique advantage.” As part of the package, users are able to access a wide range of services, including multilanguage translation, exchange rates, travel booking

information, location sharing, local news from ‘credible sources’ and much more.

Most importantly, however, ‘Safeture makes it possible to contact each other immediately to make informed decisions’.

Assistance firm Tangiers International, headquartered in Malta, provides ground support services for many types of companies, among them insurers.

Its app also provides a rage of features: “Customers can use their mobile phones to check a policy, submit and track a claim, investigate local healthcare options and access emergency assistance – from anywhere in the world,” explained the company’s Managing Director Jane Hegeler.

Safety features are certainly a key draw when it comes to assistance apps. Nathan Holloway, Business Development Manager at CEGA Group, in the UK, believes this is the strength of his company’s assistance app INtrinsic: “Users see the app as an essential tool that provides access to vital (and potentially life-saving) integrated medical and security intelligence, response and assistance services – tailored to their destination and needs.”

But as well as loading up on features, users want their apps to be sleek, smooth and provide quick access to the services

they need most. CEGA Group’s INtrinsic app was created in partnership with security specialist Solace Global, and Solace Managing Director Emily Roberts explains that a personal touch goes a long way in making customers use the app again: “Clients can make the app their own, including adding a client-specific button that can store important company

users want their apps to be sleek, smooth and provide quick access to the services they need most information – such as key contact details, insurance policy number and travel policy documents – encouraging users to use the app regularly.”

Holloway agrees: “We use bespoke branding of the app to encourage ownership, and work closely with clients to introduce the app to users. To date, feedback has been >>

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overwhelmingly positive.”

Hegeler stresses that, at the end of the day, a better working app means better usage and profit for the assistance company: “We bundle this [the assistance app] into our offering for our clients – underwriters, brokers or employers. If the end-user finds the app easy and effective to use, reuse goes hand in hand with renewed policies.”

Safety first With global business travel spending rising to $1.33 trillion in 2017, according to a report from the Global Business Travel Association, keeping employees safe when abroad is an ever-increasing concern.

Brorson explains that GWS’s app contains its risk management tool Instant Security Overview, which allows for the instant location of employees, plus a direct line of contact. “By being updated with real-time security information, users avoid new incidents, and companies can quickly make wise decisions to ensure the safety of their staff. Safeture also focuses on preventive work. The platform incorporates travel information on more than 200 countries and regions, local government contact information, diseases – and how to avoid them, current security threats, and monthly global health reviews,” he

International Travel & Health Insurance Journal

explained. Hegeler also states that being able to keep track of an employee’s current and future location helps them stay one step ahead of danger, and her company’s app uses notifications to make sure the user is aware of any ‘heated situations’ that they may be heading into.

Holloway stresses not only the increasing growth in business travellers, but also the increase in business travellers heading to unfamiliar locations. Furthermore, a 2017 survey from the Federation of Risk Management, the International SOS Foundation and KPMG found that for 41 per cent of companies, the current geopolitical climate is the biggest complexity of a risk manager’s task, with a further 64 per cent believing that exposure to health, safety and security risks linked to workers’ mobility has increased over the last two years. Keeping those employees located in more unstable areas in the loop and with quick access to help is, therefore, key. Holloway explains how his company’s app goes some way to helping: “The INtrinsic app helps reduce travel risks proactively via a single mobile source, avoiding the complexities associated with multiple supply chains. It ensures that employees are fully prepared for specific assignments abroad, aware of real-time

health and security risks overseas, easy to locate, and able to access integrated medical and security assistance quickly in an emergency. And that personnel, assets and vicinity risks are monitored globally by the INtrinsic team, 24/7.” The combination of this constant monitoring

If the end-user finds the app easy and effective to use, reuse goes hand in hand with renewed policies allows companies to easily monitor an employee in one place, says Holloway, and able to fulfil part of their duty of care obligations.

Although safety is a major concern, cost containment is also a key consideration for assistance companies, and their apps are created with this in mind. “The cost of an emergency abroad can spiral out of control rapidly if the right support is delayed by multiple supply chains or complicated communication,” Holloway told ITIJ. “By providing mobile access to integrated medical and security intelligence, >>

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risk mitigation and responses, the INtrinsic app can reduce the cost, frequency and severity of emergencies overseas.” For CEGA and Solace Global, the app helps users to more easily access CEGA’s existing global network of overseas partners and agents that provide on-the-ground support during events. This network is constantly being assessed and reviewed, making sure it is cost effective.

The Tangiers app also saves money by saving time, and some of these savings are passed onto the insured. “It reduces phone calls and minimises the time it takes to look for a provider,” Hegeler explained, adding that the app’s ability to give a traveller updates for the location they are in, or their destination, and on-the-spot claims processing, all helping to make the process as efficient as possible.

One step beyond Standing still is not an option with technology, and constantly looking ahead to new technologies is vital. Artificial intelligence (AI) is becoming more and

42 | International Travel & Health Insurance Journal

more prevalent in day-to-day life, and assistance app developers are looking to harness its power. “AI will also have a big role to play with how claims are handled and is already helping streamline processes and improve end user’s experience,” said Hegeler of Tangiers, while Roberts of Solace Global said that his company is exploring the ways AI can help further improve the information and support it provides to its clients.

Brorson asserted that GWS is already harnessing AI’s unique capabilities, using it to develop tools that allow the company to handle large amounts of information to make accurate assessments, and sorting that makes life easier for its analysts. “We are convinced that AI will be increasingly important in the future,” he concluded.

Wearable technology – such as smartwatches – is also increasingly becoming part of day-to-day life for many travellers, and although none of the apps profiled in this feature are currently available on tech of this kind, it is again very much on the cards. “It

definitely has potential for future assistance apps, given the capabilities of wearable tech such as heart rate monitoring and GPS tracking being built into devices,”

employees are fully prepared for specific assignments abroad, aware of real-time health and security risks overseas, easy to locate, and able to access integrated medical and security assistance quickly explained Hegeler.

In conclusion, Roberts of Solace summarises where the future of assistance apps is heading: “Technology is continuously advancing. The more we can harness these new solutions, the greater the user experience is, and the better we can help businesses manage risks quickly and easily.” ■

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