Indemnity or Insurance on Expeditions

Dr Alex Taylor / Adventure Medic Editor / Emergency Medicine Trainee / Bristol, England

The process of acquiring indemnity or insurance for expeditions has become increasingly opaque. Whilst medics are still gaining indemnity or insurance without issue, anecdotally the pandemic brought expedition work under scrutiny and refusals are occurring. As individuals who are passionate about adventure medicine in all its forms; Adventure Medic has produced this guide to help with the indemnity process. This is the second in our ‘Masterclass’ series designed to help practicing expedition medics navigate some of the roadblocks we all encounter.

Whilst this is UK-focused, it highlights considerations relevant to those worldwide. Be mindful that this guidance is dynamic and specific advice will likely change. Please continue to enquire with indemnity organisations and let us know if updates are required.

What is indemnity?

Indemnity is designed to provide financial protection to medics against legal and compensation costs that may arise out of claims due to negligence, mistakes, or malpractice. In practice, on expedition, if you make a clinical call and that patient comes to harm because of this, they can claim against you. An extreme example would be allowing a patient with overt signs of heat illness to continue to run a jungle marathon, who later collapses and has a seizure.¹

In the NHS, doctors’ indemnity is provided through clinical negligence schemes.²

“Under the law, a doctor must have cover against liabilities that may be incurred in practicing medicine having regard to the nature and extent of the risks. The type and level of insurance or indemnity a doctor requires depends on factors including where a doctor works, whether they are employed (and, if so by whom and for what services) or self-employed, and the nature of work they do.”

Often this indemnity is extended through an additional policy with a medical defence organisation. The defence organisation can assist with a wider range of legal and ethical issues relating to professional practice. The scope of this is more extensive, for instance, the Medical Protection Society states members can request assistance with;

“clinical negligence claims, complaints, medical and dental council inquiries, legal and ethical dilemmas, disciplinary procedures, inquests and fatal accident inquiries.” ³

For GPs state-backed indemnity provides indemnity for clinical negligence claims arising from primary care within the NHS in England or Wales. The scope of this is, again, specific and does not extend to other areas such as guidance with coroners’ inquests.⁴

How does indemnity compare to insurance?

Medical malpractice insurance is usually provided as a stand-alone policy and is tailored and specific to the job (e.g. an expedition medic role).⁵ It usually comes from a commercial insurance company unlike indemnity which is provided by membership-based not-for-profit medical defence organisations. Further information can be found at this link.

Why do I need indemnity or insurance on expeditions?

Expedition medicine and voluntary work often cover areas of practice extending beyond those specified in day-to-day indemnity protection. As such, expedition medicine and voluntary work fall under the remit of private practice. They therefore require additional indemnity or an extension to existing protection. This is true regardless of whether the work is in the UK or not, as for many hospital doctors their indemnity confines their work to within their state (e.g. NHS) hospital in alignment with their job specification.

Failure to acquire indemnity or insurance could lead to claims that may not be covered. This could impact practitioner finances, security, and medical registration significantly. This is often cited as one of the arguments that supports fair remuneration for doctors on expeditions.

Adventure Medic provides further information on the remit of an expedition medic and why this is pertinent here. Adventure Medic is also currently producing an article on pay for expedition medics – please look out for this publication shortly.

How do I acquire indemnity or insurance?

Acquiring indemnity or insurance can be a complex process and it is advisable to start early. This ensures there are no surprises and it allows you to confirm with the expedition company that you can cover the trip. Quotes acquired can be held on file by some companies for purchase at a later date.

Doctors

Defence unions
Indemnity covering expedition work can be an extension of indemnity protection you already hold or obtained through a new provider. This is achievable with the following not-for-profit medical defence organisations:
– Medical Protection Society – MPS
– Medical Defence Union – MDU
– Medical and Dental Defence Union of Scotland – MDDUS
The MDU has advised that all applications will be considered individually. They will endeavor to cover expedition medics where possible. They have offered this article to any seeking MDU indemnity.

Expedition company
Alternatively, the expedition company or other companies supplying healthcare practitioners may be able to subcontract the practitioner covering them under their own insurance.

Insurance providers
Insurance for expedition cover and approaching insurance companies directly is an option where other avenues have failed. Two companies which can provide this are:
– Saepio
– Beazley – contactable directly or through ADF insurance

Societies
Additionally, gold members of the British Mountain Medicine Society can access indemnity or insurance as part of their membership provided they:
–  Have paid for ‘gold membership’
–  Hold the Diploma in Mountain Medicine (DiMM)
–  Cover has been confirmed with the society
–  Are not undertaking an expedition in the USA

Gold members must complete a short declaration form which is sent to the insurers to confirm their eligibility and to grant indemnity insurance. Silver members can also access indemnity insurance, but the applications must be individually vetted to ensure their experience is adequate. Prices can currently be found here.

There is some consideration of equivalent qualifications to the DiMM. Recently the Diploma in Expedition and Wilderness Medicine has been authorized as holding equivalence to the DiMM by the Society and therefore is eligible with gold membership for indemnity insurance. For other qualifications, the final decision lies with the BMMS underwriters.

Paramedics

For paramedics we have been told cover is often automatic because the remit of their work allows them to work in pre-hospital environments. This is mostly provided by the College of Paramedics. Further information for expedition paramedics can be found here. It is worth being mindful that a pre-hospital environment in the UK streets may not hold equivalence with that in a jungle or polar environment (for example). Aim to clarify with the college your cover and disclose trip details before departing.

Nurses and allied healthcare practitioners

Our insight into indemnity for nurses and physiotherapists is currently lacking. If you’d like to share this information and support Adventure Medic in supporting your fellow practitioners, do get in touch.

How do I ensure the policy covers what I need?

It is essential to thoroughly read and confirm the protection offered will cover the remit of your work. For example; some may state that protection ends on the last day of your expedition and therefore claims falling after this are not covered! Clarify this fully with the company to ensure there are no exceptions. Check if the cover includes your pre-screening – which will fall prior to the start date of the expedition.

How do indemnity or insurance providers assess if they can provide cover?

After providers have collected details from you they make an assessment called the ‘rating factor’ based on the activities and details given. This is dynamic and can change throughout the year. For instance, since COVID-19, medical cover on seafaring vessels that cross oceans and are not within easy reach of land has increased in risk. The new rating factor means many indemnity organisations or insurers will not provide indemnity or insurance. However, where your application has been made to an insurer, rather than an indemnity organisation, these are businesses. They may adjust rating factors and risk assessments if they see demand and that there is money to be made. Never be shy about asking for quotes as requests can alter the market for the good of all.

If your case is being deliberated or is complex, which, often expedition requests are, then it may be sent to the underwriters for the organisation. They will make a case-by-case assessment of whether they feel they can offer protection for the role. They may request additional information to ensure they have a full understanding of the role you are undertaking. In some organisations they are not directly contactable over the phone and prefer to come back to you via email. They will often offer the final say on whether indemnity is provided.

Beware; this process can take 2-3 weeks so it is strongly advisable to try and acquire a quote for indemnity or insurance well in advance of your trip. This can be held on file and paid for later. It also allows time to approach other organisations if adequate protection cannot be provided.

What things will the indemnity providers or insurers need to know to assess me?

Short list

The information which indemnity providers or insurers will require to assess eligibility:

• Destination
• Dates of trip
• Organisation you are working with – charity, institution, company, hospital, etc
• Details of your seniority, experience, training, or relevant qualifications
• Whether you have shared or overall clinical responsibility
• Will there be any supervision of the role?
• Is this supervision remote or on-site?
• A brief description of your work and role on the expedition
• Whether the role is paid (and if paid how much)
• A brief description of those you will care for (nationalities, ages, celebrities, pregnancies)
• Any indemnity or other insurance you already hold, or if any indemnity or insurance is provided by the event organiser/company

Destination

The legalities of what cover can be provided and in what locations are nuanced. By and large a license to practice in the UK is accepted by indemnity organisations and insurers as a sufficient qualification to allow you to cover your own group on expedition. However, different countries have different legal, insurance, regulatory, or licensing requirements to practice in their countries. Ideally, these should be known. It is essential to explore this where your work includes any of the following:

• Involves caring for the local population
• Is humanitarian work
• Is officially paid (as opposed to voluntary)

This is illustrated by the arrest of Sarah Kemp,⁶ an Australian doctor who was working in a travel clinic in Nepal attending to foreign diplomats, tourists, and aid workers. Allegedly she was arrested along with 17 other foreign doctors as she did not hold a license to practise medicine within Nepal. Following this one charity operating in Nepal, the International Porter Protection Group (IPPG), began registering its volunteer doctors in Nepal. A process that initially took 35 days. This is a lengthy time to build into a trip if required to safeguard your work and is on the shorter end of the spectrum with some registrations taking 3-6 months.

Different countries may have different legal, regulatory or licensing requirements that need to be met to allow a doctor to practice medicine in that country. It remains the medic’s responsibility to ensure that they meet any such requirements. For example, if insurance is a legal requirement in the country you are travelling to (rather than discretionary indemnity), you may be advised to seek an alternative provider.

Provider specifics
At the time of writing  MDDUS specializes in the separate legal jurisdictions that exist within England, Scotland, Wales, Northern Ireland, the Channel Islands, and the Isle of Man, and does not offer membership benefits outside of these jurisdictions, other than in respect of GoodSamaritan acts, humanitarian work and limited voluntary or expedition medicine. Upon request and subject to underwriting review, membership can be extended to provide access to indemnity for bona fide humanitarian work. This work can take place globally but access to indemnity is provided on the basis that claims must be brought in a court within the UK, Channel Islands, or Isle of Man.

Saepio requires a pre-agreement to provide cover in the USA and Canada.

There may be some flexibility in registration requirements where you work in a supervised or ‘fellowship’ position under the guidance of a senior in-country doctor who can sign off your practice. This must be clarified with the provider of the indemnity cover.

Duration of trip and cover

For some indemnity providers indemnity costs will vary based on whether the medic has overall clinical expedition responsibility or shared clinical responsibility. The former is considered higher responsibility and risk. Cost is mostly decided on a case-by-case basis, and due to fluctuations organisations could not offer further insights with long-term accuracy.  

It is important to clarify the duration of protection required for the indemnity or insurance, as different companies may have different limits. Most indemnity organisations offer occurrence-based protection. MPS members for example:

“remain entitled to request advice and assistance for any matters arising from their expedition work at any time, even if they have since left MPS membership or ceased practicing.”

Saepio covers a year post-expedition by default but can extend this on asking.

This is not true of all providers and the utility of a policy that ends on the day your trip finishes is debatable!

Experience and responsibility

These are both extremely nuanced. Some indemnity or insurance companies more readily understand seniority in terms of career progression or profession. For example; a registrar doctor may be treated as more independent and experienced in seniority even if working with a senior prescribing nurse who has done multiple expeditions and has multiple expedition-related qualifications. This is because these qualifications are not always considered by indemnity providers.

Some organisations prefer to consider cover based on the number of years post-graduation and will set a threshold before you can be considered for more senior roles such as overall clinical responsibility.

Provider specifics
MPS advises that it reviews each application for indemnity for expeditions on a case-by-case basis and takes into account multiple factors, including clinical experience, relevant training and qualifications, and level of responsibility/supervision.

One organization, the MDDUS, advises that for UK-based expeditions it would consider work on a case-by-case basis looking at the trip, and the practitioner’s qualifications and experience. This usually requires referral to the underwriters – the process for which is detailed below.

Lastly, Saepio will utilise your CV to make a personal assessment of your request.

Supervision

For some practitioners, supervision may be required to obtain indemnity or insurance. This varies on a case-by-case basis and may require a supervisor to be sourced of a certain seniority. This person often needs to be sourced by the practitioner if one is not immediately linked to the role. The supervisor may be remote or on-site depending both upon what the indemnity or insurance provider requires, and what the employing company can subsidize. Ensure, if you are sourcing your own supervisor, that they have full awareness of what you are doing, are happy to be on-call to advise at all hours, and feel comfortable advising within the remit of your expedition. For instance, an altitude expedition will benefit from a supervisor who has altitude illness experience.

Nationalities

Some indemnity or insurance companies will not indemnify care provided to attendees of certain nationalities. Usually, this pertains to citizens of countries where legal cases against practitioners are common and expensive, for example, the USA and Canada. This often requires clarification with the provider but can be an expensive minefield.

Most policies contain a clause that navigates this by stating that indemnity or insurance will be provided only if claims are made in the country of “ membership.” This refers to the country in which a member holds membership for the purpose of their regular medical/clinical practice.

The nationality of the expedition company should not affect the support indemnity providers can deliver, so long as the claim is made in the practitioner’s home jurisdiction/country of core membership.

If a claim is made out of the practitioner’s home jurisdiction then some indemnity providers will assist in moving it to the home jurisdiction. Not all will do this.

Special populations

MDDUS and BMMS memberships advise that they can indemnify for the care of participants of any age. Saepio will make an assessment based on ratios – if your trip is predominantly children, it is unlikely to be covered, but if the trip is predominantly adults (60:40) it may be covered. 

Pregnant women and high-profile participants may not be covered by policies or will incur vastly increased costs.

Dual insurance

If the expedition company or your own insurer is already providing insurance then this may invalidate further policies which are taken.

Subcontracting

If you are working for another company, for instance, a production company that has subcontracted you on behalf of another provider, then you need to ask your indemnifiers if they offer ‘company indemnity to principle’. This determines if your insurance for negligence will extend to the company subcontracting you. If it will not, then technically the company you are working for could also sue you for negligence if you leave them exposed.

Additional questions may be asked:

• Will the work involve any new or experimental treatment?
• Will the work involve prescribing any drugs off-license?
  – For instance penthrox in under 18s – widely used on expeditions but not officially licensed
• Confirming if you will be undertaking any of the following:
  – An expert demonstrating a procedure for the benefit of local practitioners
  – An expert providing treatment to a patient or patients that would not otherwise be available in that country
  – Cosmetic medicine/surgery
  – Highly paid work in a developed country
  – Neurosurgery
  – Obstetrics
  – Orthopaedics
  – Teaching/educational work
• Confirming that local indemnity cannot be sourced in the destination country
• Providing a CV
• Are any of your patients or clients elite or professional athletes?
• Are any of your clients high profile? – these participants can be especially hard to cover

Are there limits and excesses to this insurance?

Often excesses are not a feature of indemnity, but do ask as one insurance provider has an excess of £1000 per claim. 

Limitations should be specified by the provider. For instance, an example would be: :
– Indemnity covers only members of the organised group you are accompanying
– Assistance is provided only with claims brought against you in your home jurisdiction
– You must act within your competency. For assessing this and an expedition opportunity please see here. (hyperlink article for assessing an expedition opportunity)
– You need to meet legal, regulatory, or licensing requirements to practice in the country you are travelling to
– You are not managing any declared pregnancies

Can medical directors be covered?

Some companies (e.g. Saepio) will grade cover for medical directors based on the trip and rating factor and can supply it on a case-by-case basis. Other organisations should be contacted directly with inquiries. 

Are local guides and people employed by the expedition company covered?

The assumption is that anyone who is present solely for the purpose of the expedition should be counted as part of the team and therefore covered under indemnity.⁷ Saepio and MPS confirmed this is their policy.

What if I have been refused indemnity insurance?

Previous refusal for trips should not stop you from being granted expedition indemnity insurance from the same company in the future. Nor should it prevent you from approaching other companies for quotes.

Provider specifics
However, some companies, such as MPS, require you to have held core membership with them for 6 months prior to acquiring expedition protection. MDU, MDDUS, and BMMS also require membership (BMMs members must be gold). Some organisations will also require disclosure if you have had previous refusals. Saepio does not require membership and is happy to consider all requests.

Where these usual avenues have been exhausted, exploring subcontracting or private quotes for insurance through Beazley or ADF insurance can reap rewards.

Summary

The world of indemnity and insurance can be complex and a headache for many expedition medics. We hope this guide will help you navigate indemnity and insurance in the future to safeguard your own practice in adventurous medicine. Please utilise it and share it widely with others who could benefit. Above all, don’t be afraid to approach indemnity organisations and private insurers and ask. Assessments for indemnity are ever changing, and requests are often considered on a case-by-case basis. Your request may open doors for others in the future. 

We are acutely aware that information regarding indemnity and insurance for humanitarian work, dentists, nurses, and physiotherapists is lacking, although, many indemnity organisations are willing to provide protection for these roles.  As people who are passionate about protecting our future in this field, if you have found any information you feel would be useful to the community, please do get in touch.

References

1) Insurance, indemnity and medico-legal support. General Medical Council.
Available from: https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/information-for-doctors-on-the-register/insurance-indemnity-and-medico-legal-support
Accessed [26/03/2023]

2) What is indemnity insurance? Securenow_insuropedia
Available from: https://securenow.in/insuropedia/what-is-medical-indemnity-insurance/
Accessed [26/03/2023]
Updated 28/11/2022

3) About us. Medical Protection Society. Available from:
https://www.medicalprotection.org/uk/about
Accessed [ 26/03/2023]

4) State-backed indemnity. The Medical Defence Union
Available from: https://www.themdu.com/mindthegap#:~:text=What%20does%20the%20state%2Dbacked,duties%20in%20England%20and%20Wales.
Accessed [26/03/2023]

5) Medical Defence Organisations vs. Insurance Companies for Medical indemnity – Which is right for you? Medicas
Available from: https://www.medicas.co.uk/resources-guides/medical-defence-organisations-vs-insurance-companies-for-medical-indemnity-which-is-right-for-you#:~:text=One%20of%20the%20main%20disadvantages%20of%20medical%20malpractice%20insurance%20is,need%20to%20make%20a%20profit.
Accessed [26/03/2023]
Last updated 1/3/23

6) Australian doctor Sarah Kemp arrested in Nepal for practising without proper accreditation. Heanue S,
Available from https://www.abc.net.au/news/2018-02-01/australian-doctor-sarah-kemp-arrested-in-nepal/9381862
Accessed [26/03/2023]
Updated: 1/2/2018

7) Moore J and Winser S. Caring for people in the field. In: Johnson C, Anderson S, Dallimore j, Imray C, Winser S, Moore J, Warrell D. (eds) Oxford Handbook of Expedition and Wilderness Medicine. 2nd Ed. Oxford University Press; 2016. p.81-110