Overseas Employees at Risk
A rogue wave pulled a vacationing military contractor walking on a foreign beach into the ocean. He hit his head on a rock and was paralyzed.
Because his employer sent him on the trip for some R&R, the contractor’s Foreign Voluntary Workers’ Compensation insurance responded for his medical injuries even though he was vacationing instead of at a job site.
Luckily for the worker, his employer had the right coverage in place to forestall painful financial and health consequences.
But a substantial risk for employees and the companies they work for is that how and when coverage responds overseas often doesn’t track how coverage responds stateside, said Mary Quillen, manager, international workers’ compensation, AkesoCare.
Multinationals tend to carry many overlapping lines of insurance for their overseas business travelers, which is a help.
“You may have six or seven lines of insurance responding to a single claim,” said Logan Payne, assistant vice president, international practice, Lockton.
The primary policies are Foreign Voluntary Worker’s Compensation, Business Travelers Accident, and Kidnap, Ransom and Extortion, Payne said. Purchased effectively the coverages can be powerful. Purchased without the proper consideration, they may suffer from gaps as well as redundancies. Such gaps can cost employees dearly at a desperate time of their lives, Payne said.
To prevent that, he recommends centralizing insurance purchasing for expats instead of delegating it piecemeal to departments or regional offices. “Get all the insurance buyers in the same room to reach one comprehensive answer,” he said.
“Who does the traveler call if he loses his prescription drugs or needs medical evacuation? Who does he call if he hears gunshots outside his hotel?” — Chris Chao, senior vice president, Aon
International benefits from domestic health care insurance can range from nonexistent to “pretty good,” said Arno Chrispeels, owner, Health Insurance International. “A plan might cover emergency medical treatment but not evacuation or repatriation,” he said.
Since these are hefty expenses — $20,000 to $100,000 for a helicopter evacuation and $15,000 to $25,000 for repatriation — companies should review their domestic policies and fill in gaps by using international insurance for short- and long-term travelers.
Chris Chao, a senior vice president at Aon, said it is generally the travel assistance provider that keeps expats safe.
“Who does the traveler call if he loses his prescription drugs or needs medical evacuation? Who does he call if he hears gunshots outside his hotel?” Chao asked.
Duties of Care and Loyalty
When companies send workers out of the country, they have a “duty of care” to keep employees safe and healthy, while the expat workers have a “duty of loyalty” to follow their employers’ safety practices. Sometimes this requires workarounds and major effort. For example, said Denise Buckland, senior vice president, operations, International Medical Group, if a worker is diagnosed with an autoimmune disease, doctors will try staged medications.
“You try one, and if it doesn’t work, you try another,” she said. But the options can be very limited.
Let’s say a U.S. employee working in Thailand requires the injectable Humira to manage her condition, and no other drug gives her the relief she needs. Humira is illegal in Thailand, however. The carrier could contact the Thai and U.S. governments to help the employee get an importer’s license, but in the meantime, Buckland said, “the worker may get so sick that she has to go home.”
Especially in regions where the medical infrastructure is underdeveloped by Western standards, an acute but treatable event, such as a compound bone fracture, could quickly escalate into a life-threatening medical issue, said Alison Swanz, senior consultant, Arthur J. Gallagher & Co.
Duty of care is still an “unregulated philosophy,” said Hart Brown, senior vice president, practice leader, organizational resilience, HUB International. It depends on a number of interrelated steps, beginning with a vetted travel assistance provider and adequate insurance.
An employer “hasn’t met its duty of care” if its travel assistance provider does not have the right protocols or its expats don’t know the provider’s toll-free number, he said.
“Compliance is hard to enforce. You can’t sit on an adult to make him take his meds.” — Alison Swanz, senior consultant, Arthur J. Gallagher & Co.
Coverage gaps and potential risks should be exposed in a thorough pre-trip screening, said Rob Howard, director of corporate sales, GeoBlue, a major provider of international insurance for expatriates.
When employees need medical help while on assignment, carriers will tap their provider networks to find care equivalent to what they would get at home, said Howard.
Pre-assignment evaluations should extend beyond known health issues, said Nick Dobelbower, vice president, global benefits practice, Lockton, to include language training if necessary, and alert the traveler to cultural differences and sensitivities.
The onus is on the employee to make a responsible decision whether to go on an overseas assignment. Sometimes, employees should decline assignments, Swanz said. A worker with asthma probably shouldn’t accept an offer in Beijing, where air pollution is a health hazard.
“An executive expat assignment is a huge investment for the company,” Howard said, and may include high compensation, language training, housing, security, a driver and private schools.
To recoup that investment, companies expect an executive assignment to last three to five years, but more than 50 percent end in failure after six to nine months. Among the top reasons for failure are the expat’s benefits package and health care, according to Cigna’s “2015 Global Mobility Survey.”
Duty of care and duty of loyalty should align during pre-trip planning, said Howard. He recommends a sit-down orientation with travelers as a group before they leave to review the size and scope of risks.
Other issues such as domestic employees can arise, Chrispeels said. “Employees may think they have international coverage for the entire household [such as nannies], but they don’t.”
The organization should also consider issues such as family mental health problems. A one-on-one meeting or a follow-up phone call may bring issues to light when travelers have medical issues they don’t want to share with a group.
One aspect of an employee’s duty of loyalty applies to medical compliance, especially to taking prescribed medications for common diseases such as heart conditions or asthma.
“Compliance is hard to enforce. You can’t sit on an adult to make him take his meds,” Swanz said.
U.S. companies that send U.S. citizens overseas are subject to the Affordable Care Act, but the law is so complex — despite Congress’ attempt at guidance in the Expatriate Health Coverage Clarification Act of 2014 (EHCCA) — that “people get glassy-eyed looking at it,” said Mark Holloway, senior vice president, co-director, compliance services, Lockton.
Holloway recommends that companies write their expat coverage on U.S. paper as a practical way to satisfy the individual mandate — but to work with professionals who deal in expatriate insurance every day.
“Companies will want to work with a broker or counsel who plays in the sandbox because it’s such an arcane area of the law.”
Beyond Brussels: Employee Crisis Communications
John Persons (not his real name) was in the Brussels airport around 8 am on March 26, 2016 when two bombs detonated, killing 31 and wounding around 300.
Fortunately for Persons, his family and his employer, a large U.S. insurance brokerage, he was not among the dead or injured.
His employer knew he was safe almost immediately. Expert Care, a service of American Express Global Business Travel, saw from his itinerary that he was scheduled to be in the Brussels airport.
Risk managers confirmed it by geolocating Persons through an app on his smartphone, then sent him a Short Message Service (SMS) message.
He texted back “1,” code for “I’m OK.” Expert Care immediately forwarded the good news to Persons’ employer.
A response other than “I’m OK” — say, “2” for “I need help,” “3” for “I’m not sure” or, more ominously, no response at all — would have triggered a much different scenario, said Evan Konwiser, vice president, digital traveler, American Express Global Business Travel.
“Travelers in the red column of the dashboard may need help,” he said.
Their companies’ crisis and travel managers would next decide how to proceed: phone call, follow-up texts and/or alerts to local authorities. As responses trickle in from travelers who had no or spotty mobile broadband connection, and those who were separated from their devices or were nowhere near the trouble spots, the travel manager would focus on the smaller group who really did need help.
Emergency Notification System “Handshake”
This kind of SMS “handshake” is high among companies’ preferred methods of communicating with its employees who get caught in crisis areas, said Matt Bradley, regional security director for the Americas, International SOS, because it’s fast, requires few keystrokes and transmits more reliably in low-signal situations than more data-hungry methods such as email and social media, although they also have their place in crisis communications.
Travel risk programs and emergency notification systems should deploy on smartphones, the technology every business traveler carries, said Hart Brown, senior vice president, practice leader, organizational resilience, HUB International.
“Local employees know the crisis response plan, but travelers are often left out of the briefing.” — Matt Bradley, regional security director for the Americas, International SOS
“Travelers leave other devices in their bags or forget to charge them.”
Smartphones can contain numerous mechanisms for locating and alerting travelers: GPS, apps, a programmed or installed panic button, email, social media and voice communications, Brown said.
“Every tool has strengths and weaknesses, so we pull in as much data as we can from every source,” Konwiser said. For example, “if a traveler missed his flight to Brussels, the itinerary data might not be updated, but we’d know he’s safe if he swiped his Amex corporate card at a concession stand in Heathrow 10 minutes before the explosions.”
Although social media, including Facebook and Twitter, can help break news — the suspicious package in the Atlanta airport that led to an evacuation on March 23, 2016, for example — it can also broadcast unverified information, such as the tweet about shots fired in the Atlanta airport during the same incident from someone claiming to be there, said Bradley.
International SOS, which provides medical and travel security risk services to many Fortune 500 clients, monitors Twitter for incidents, seeks verification and then takes action if appropriate.
Action may include sending information to clients’ travel managers or directly to travelers about an incident, always accompanied by advice.
During the terrorist shootings in Paris in November 2015, for example, “we told people, ‘Seek shelter. Don’t go back to your house or hotel. Get off the street.’ ” Information without advice, Bradley said, creates counterproductive anxiety and panic.
For those times when smartphone communications fail, companies should have a backup plan that includes instructions to go to a pre-determined rally point, such as a hotel or supermarket that provides shelter against rain, is usually open for business and that cab drivers can find easily. Rally points are never monuments, train stations or office buildings, which may themselves be targets, Bradley said.
Best Practices in Mature Global Travel
Companies whose employees travel extensively should have “overarching” crisis management plans, either housed at corporate headquarters or regionalized to branches, Hart said, and travel risk management plans that include a travel portal that aggregates flights, hotels, meeting times and locations, and arrival/departure dates.
“We want to see that aggregated data bundled and visualized on a map so risk managers can see where their people are.”
Of course, preparing employees before they leave should be part of the plan, said Bradley.
“Local employees know the crisis response plan, but travelers are often left out of the briefing. Before they leave, employees should know where hospitals are. Where the rally point is. Where the backup rally point is.”
Companies should be aware of risks — political unrest, infectious diseases, cultural flashpoints, weather — before they send employees, and those with major operations in a region should also invest in a journey risk plan that probes a region’s details: Is it safe to hail a taxi on the street? Does the employee need a driver? Where does she go and who does she call if there’s an issue?
Most insurance policies that involve foreign and business travel have response capabilities embedded in them, such as who to call and how to get help abroad, Hart said, but clients aren’t always aware of the information. Brokerage houses, he said, should educate clients on what duty of care looks like and how to implement crisis and travel risk plans.
“The broker’s role is to make sure policies connect carriers with response partners so the crisis plan works efficiently from beginning to end,” he said.
Hospitals Struggle with Security Risks
A growing number of health care facilities are foregoing armed security because of insurance carriers’ concerns.
Instead, some facilities are equipping security personnel with intermediate-level weapons, such as handcuffs, TASERs, batons and pepper spray.
“The cost and availability of insurance is almost certainly a factor in the decision,” said Jeff Young, a spokesperson for the International Association of Hospital Security and Safety, and executive director, Lower Mainland Integrated Protection Services in British Columbia.
“Since pepper spray and Tasers are less lethal than firearms, they’re less risky from a liability standpoint … but they’re less effective against an assailant with a gun.” — Michael DuBose, senior vice president, workforce strategies practice, Marsh Risk Consulting
“If insurance coverage isn’t available, the corporation might not be willing to assume the risk on its own.”
Some carriers “take a negative stance on arming staff,” said Michael DuBose, a senior vice president with Marsh Risk Consulting’s workforce strategies practice, particularly internal security staff (as opposed to contracted security personnel, such as off-duty police).
In health care facilities, as in schools, “if you go ahead and arm your staff, you may find out your carrier will drop you or boost your premiums.”
“Since pepper spray and Tasers are less lethal than firearms, they’re less risky from a liability standpoint,” said DuBose.
But there’s a tradeoff. “They imply less liability and require less training, but they’re less effective against an assailant with a gun.”
Shootings at hospitals are, unfortunately, not rare.
In February, an injured man seeking aid fired a bullet into a door at the Reston Hospital Center in Northern Virginia and then fired another bullet once inside the hospital. Medical personnel eventually convinced him to lay down his gun.
In December, a Los Angeles police officer shot and killed a patient at the Harbor- UCLA Medical Center in Torrance, Calif. when he attacked officers and reached for an officer’s gun, according to reports. The patient, arrested earlier in the day, fought ferociously with police at the hospital. Officers tried using a Taser on the patient first to no avail.
That was also a case last summer in Houston, when police were unable to subdue a combative patient with a Taser, according to reports.
The patient, who struggles with mental illness, was shot in the chest by the police, working off-duty as hospital security; that shooting was not fatal.
Determining the Risk
DuBose said many facilities want to equip personnel with some means of protection for themselves and the public.
“They conduct an annual security risk assessment that considers, among other things, the prevalence of gun crime and violence in the neighborhood and the facility’s own history of violence. Then they ask, ‘Is that the right stance for our facility?’ ”
“How many local police officers would feel comfortable pursuing someone into a central sterilization area where there are toxic or flammable gasses?” — Dr. Jeffrey Ho, Hennepin County Medical Center
For example, he said, “firearms may have a role in a Level 1 trauma center that treats victims of violence, mental health patients and inmates. But you have to question very closely the need to arm a small community hospital that doesn’t have that same degree of risk.”
Barry Kramer, senior vice president, Chivaroli & Associates, a health care insurance broker, said that armed security in health care settings is more of a risk management concern than a coverage issue.
“It would be highly unusual for our clients’ liability policies to exclude claims involving security guards, whether or not they’re armed with guns,” he said.
He said many health care risk managers are not equipped to manage exposures associated with licensing and certifying guards or registering the facility’s own firearms.
For facilities that lack the bandwidth to manage, train and track certifications for in-house security staff, Kramer said,third-party vendors, such as local law enforcement or private security companies, can be contracted, since they have firearms experience as well as liability insurance coverage.
Jeffrey Ho, an emergency room physician in a busy Level 1 trauma center at the Hennepin County Medical Center in Minneapolis and a sworn deputy sheriff in neighboring Meeker County, cautioned that armed personnel must be thoroughly trained to work in a health care setting.
“How many local police officers would feel comfortable pursuing someone into a central sterilization area where there are toxic or flammable gasses?” he asked.
“How many would feel comfortable discharging a firearm or Taser, which generates an electric spark? Any weapon can be dangerous in those environments.”
Train for the Worst
“Prevention,” said Young, “is the first line of defense in potentially violent situations. You have only seconds or at most minutes to de-escalate a situation before it can go very wrong.”
Failure to recognize a potentially violent situation and take precautionary steps can lead to tension between security and clinicians.
Training – not just in lockdowns and active shooter drills but in de-escalation techniques and identifying potentially dangerous situations – is essential to preserving safety, said Ho.
Failure to recognize a potentially violent situation and take precautionary steps can lead to tension between security and clinicians, said Ho.
When his facility first undertook a comprehensive violence prevention program nine years ago that included debriefings after forceful intervention, “clinical staff pointed the finger at security and said, ‘How dare you put that patient on the floor, handcuff him, spray him with pepper spray?’ And security would say, ‘The situation was out of hand before we got there. What did you want us to do?’”
Looking back, he said, most situations never should have escalated to violence.
Eventually the entire staff – clinicians, therapists, food service and administrators – were trained to recognize stresses and talk down problems from flash points, which worked well in many but not all situations.
“Maybe the patient was hungry or thirsty or needed a blanket. Failure to recognize a simple problem often led to acting out.”
Greater force may be called for with intoxicated people, he said.
Although security seldom if ever initiates violence but rather responds to aggression, patients may perceive the situation otherwise and pursue litigation, Young said.
“Especially in a psych setting, patients may turn it around,” said Jane Lipscomb, professor at the University of Maryland Schools of Nursing and Medicine, and author of “Workplace Violence in Health Care: Recognized but not Regulated.”
“They can say, ‘I was defending myself because the staff member was being abusive,’ and the staff member is put on administrative leave.”
The most effective environments value staff safety, she said, and see that it’s inextricably linked to patient safety and quality of care.