A traveller who needed a medical evacuation after falling seriously ill in Thailand has been awarded $195,223 to cover the costs under a complaints authority ruling.

The 74-year-old was placed in intensive care in Bangkok about August 9 2022, having been diagnosed with acute gallstone pancreatitis and heart failure. He was moved to a general ward when his condition improved but went back to intensive care after his diagnosis was changed to necrotising pancreatitis. 

The insured’s family contacted Lloyd’s Australia’s emergency assistance team on August 20 after moving to bring the man back to Australia. The insurer told them it required more detail about the man’s condition before further consideration was given.

The complainant said a family friend followed up on Lloyd’s request and outlined that the man had a small “window” to return to Australia because his condition had stabilised. They said an air ambulance was the “only viable option” for him to return. 

The insured said he believed the insurer had agreed to this and arranged air transport for August 23. However, the insurer did not respond to the family friend’s email. 

Upon returning to Australia, the policyholder remained in a life-threatening condition and stayed in hospital for more than four months. He said if he had stayed in Thailand, he probably would have been in hospital for a similar time and incurred medical costs that exceeded the transport cost. 

Lloyd’s partially accepted the man’s claim to cover costs but declined to cover the evacuation expenses, noting the claimant had not received the insurer’s prior approval for the transport.

The insurer argued the transport was not required. It said its emergency team spoke with doctors at the Bangkok hospital, who said the man’s condition was improving but he was likely to stay for some time.

Lloyd’s said it tried to contact the man and his family to advise it did not think the air ambulance was necessary and the policy would not respond, but it did not hear back.

The claimant said the Lloyd’s decision was based on an “incorrect diagnosis of acute gallstone pancreatitis and not the more serious necrotising pancreatitis”. The insurer said the man’s condition had not been misdiagnosed and there was no suggestion from its emergency assistance team that it would have agreed to the transport for a necrotising pancreatitis diagnosis.

In its ruling on the dispute, the Australian Financial Complaints Authority accepts that a letter provided by the hospital recommended the patient return to Australia by ambulance plane, as he required a medical escort. 

It also notes a report from a consultant gastroenterologist in May last year, which agreed it “was imperative and in his best interests that he be urgently evacuated to Australia”. The doctor said transport on a commercial flight would have been “highly improbable” given the man’s condition.

AFCA says the complainant provided “persuasive information to show it was medically necessary to evacuate him back to Australia at that time”.

It acknowledges Lloyd’s was not provided with all available medical information, but does not believe it would have recommended a different course of action. It also says the insurer is not permitted to limit its cover, because it would have cost the complainant more if he had stayed at the Bangkok hospital. 

“I accept there is cover under the policy for medical evacuation and the insurer has not shown the costs incurred would have been avoided or minimised if the complainant had first contacted [the insurer’s emergency assistance team] or followed its guidance,” the authority’s adjudicator said. “The insurer has otherwise not shown the expenses are excluded.”  

Click here for the ruling.