Factors affecting cost and patient choice of travel insurance in cardiac disease: a web-based case-control study

Introduction

Travelling abroad is common for many people living in the UK, with 45 million holiday trips taken in 2016.¹ Cheaper flights and greater choice has made flying more accessible with greater expectations to travel across all social strata.² These benefits should be available to those with medical conditions who should be supported in being able to choose affordable travel insurance.

Individuals with cardiac conditions face a number of barriers to travel as a direct result of their disease. Guidance created by the British Cardiovascular Society to assess an individual’s fitness to fly³ aids cardiologists in assessing a person’s suitability to fly; for example, the need for available on-board aircraft oxygen therapy in those with New York Heart Association (NYHA) functional class IV heart failure. In addition, people with cardiac conditions can find it difficult to obtain appropriate travel insurance, due to cost.⁴ Travel insurance is recommended for all individuals who travel and reduced access for cardiac patients can be a barrier to their ability to travel.

The European Society of Cardiology recommends that healthcare professionals should provide patients with information about travel insurance⁵ to aid travel, but with a distinct paucity of research into how cardiac conditions affect travel insurance, this task is dependent on common sense advice. Pickup et al. surveyed a group of patients with adult congenital heart disease and found that 83% felt that travel insurance had not been fully discussed in clinic,⁶ suggesting there is a need to provide more information.

This study explored the influence of three cardiac conditions on cost and choice of travel insurance quotes. The broader aim of this study was to gather information about travel insurance for cardiac patients in order to support patient-centred care with regard to travelling abroad.

Methods

Selection of insurance companies

Travel insurance companies were initially identified from a list of sympathetic travel insurance companies previously published by the British Heart Foundation (BHF)⁷ and a list recommended by NHS Choices for patients travelling with a cardiac condition.⁸ Of these 21 insurance companies, seven required a lengthy telephone consultation and due to time constraints were excluded from our study. Two popular insurance comparison websites, GoCompare and MoneySupermarket, were included, giving a total of 16 sources for our analysis (see Appendix A). Each travel insurance website was analysed to ascertain the information required to complete a quote. Initial trial runs were completed to test whether fully anonymised patient data had any impact upon insurance premiums.

If patients had co-morbid medical conditions, then necessary information to complete the travel insurance application was collected and input.

Standardising the level of cover was important to ensure that the quotes from different insurance companies were comparable. To achieve this, a standard minimum dataset was constructed to represent a typical adult travelling to Spain for a ten-day holiday (vacation).¹⁰ The proposed travel included no extra cover (e.g. cruises, expensive digital equipment), no maximum excess, cancellation cover >£500, medical cover >£1 million and baggage cover >£500. The impact of timing of travel on cost and choice following an acute hospitalised event was assessed for each condition.

Patient data

Fully anonymised data sets of 40 patients from local electronic health records were identified with three different cardiac diagnoses: myocardial infarction (MI, n = 20), Marfan syndrome (MFS< n = 10) and dilated cardiomyopathy (DCM, n = 10). MI patients were identified at time of discharge from a cardiology ward and MFS and DCM patients were randomly selected from a cardiology outpatient clinic (see Appendix C for patient demographics and condition details). A nominal set of age-matched case controls were created using the patients used for the primary study, minus all their medical conditions.

Costs and choice of quotes

Data on the cost of travel insurance premiums and the number/choice of insurance quotes (as a measure of choice) were collected and collated for each cardiac condition and compared with data obtained for case controls for each condition. Due to wide variation in cost and availability of travel insurance, especially in the patient group, the median was used as it is more resistant to outlier values. A Welch’s unequal variances t-test was used to assess the significance of change in cost and in availability for the patients and the controls.

Clinical factors affecting cost and choice of quotes

To establish which individual clinical factors influence travel insurance cost and choice within MI, MFS and DCM, a data set for a single patient with each condition (see patients 1, 21 and 31 respectively in Appendix C) was used and specific factors changed in a systematic way to assess their impact. This was completed on the insurance comparison websites only (see Appendix A). The fold change was determined by calculating the relative increase in cost or decrease in availability for the patient compared with the control for each insurance comparison website. A median and interquartile range were taken from these values (see Table 1). A Welch’s unequal variances t-test was used to assess the significance of changing the individual factors.

Ethical approval

All data were anonymised from the time of extraction and no formal ethical approval was required. The local data protection officer was consulted and agreed that the data extraction required only audit-level permissions from the local Quality Improvement Team.

Results

In total, over 1600 travel insurance quotes were obtained from 16 travel insurance companies and comparison websites.

Median cost of insurance premiums

All three conditions were associated with significantly increased cost of travel insurance premiums. The time of year and the time period between booking and the travel date had no significant impact on cost or quote choice. The median cost of each insurance website for MI, MFS and DCM patients compared with controls are demonstrated in Figures 1a, 1b and 1c respectively.

Figure 1 Cost of travel insurance (£)

Cost of travel insurance (£, median; IQR and range) for each condition and appropriate age-matched controls by travel insurance company/website.

Figure 1A Myocardial infarction

Figure 1B Marfan syndrome

Figure 1C Dilated cardiomyopathy

A2T: Able2Travel; AC: AllClear; FC: Flexicover; FS: Free Spirit;
FD: Freedom; GJS: G.J. Sladdin; GC: GoCompare; GTG: Goodtogoinsurance; ISETI: It’s so easy travel insurance; JTC: JustTravelCover; MaKS: Makesure; MonS: MoneySupermarket;
SA: SAGA; SS: Staysure; TI: Travel insured; WFI: WorldFirst

MI patients had a significantly higher median insurance cost across all travel insurance websites for trips occurring within three months of the MI compared to the control group (Median cost; IQR; Range, p value) (£233.07; IQR = £222.95–£245.47; £162.56–£281.48 versus £24.29; IQR = £11.99–£34.09; £5.29–£42.61, p = <0.001).

Similarly, patients with MFS had a higher median insurance cost across all travel insurance websites compared to controls (£37.43; IQR = £23.61–£58.83; £14.47–£71.03 versus £19.20; IQR = £9.09–£27.31; £5.29–£42.61, p = 0.0378).

These trends in median cost were seen in patients with DCM across all travel insurance websites (£166.87; IQR = £129.71–£198.62; £105.42–£236.85 versus £23.96; IQR = £11.99–£32.44; £6.30–£42.61, p = <0.001).

Choice of insurance quotes

Choice was significantly constrained as demonstrated by the reduced number of available travel insurance quotes associated with each condition (Figure 2). Only eight of the 16 travel insurance websites offered online travel insurance quotes to MI patients. The eight companies which didn’t offer a quote either would not offer insurance or required a telephone consultation – typically because they required the results of investigations or the outcome of a non-routine outpatient appointment. Of the five comparison websites, JustTravelCover and G.J.Sladdin did not offer cover for MI patients. The difference in choice of quotes (n) for MI patients compared with controls (median number of quotes; IQR; range, p value) were significantly reduced on MoneySupermarket (5; IQR = 2–5; 2–5 versus 113.50; IQR = 110–117; 71–120, p = <0.001), GoCompare (5; IQR = 2–5; 2–5 versus 94; IQR = 89–99; 58–102, p = <0.001) and AllClear (14; IQR = 14–14; 12–16 versus 26; IQR = 25–26; 24–26, p = <0.001) compared with the control patients respectively.

Figure 2 Choice of insurance quotes

Number/choice of quotes (n, median; IQR and range) for each cardiac condition and age-matched controls for comparison insurance websites/companies.

Figure 2A Myocardial infarction

Figure 2B Marfan syndrome

Figure 2C Dilated cardiomyopathy

AC: AllClear; GJS: G.J. Sladdin; GC: GoCompare;
JTC: JustTravelCover; MonS: MoneySupermarket

For MFS, all travel insurance websites offered cover except SAGA as this company only offers insurance to people >50 years old and the sample of MFS patients were all younger. MFS was associated with a significant reduction in choice of quotes compared to respective controls on MoneySupermarket (83; IQR = 69-86; 35–88 versus 110; IQR = 95–113.5; 80–117, p = 0.004), GoCompare (76.5; IQR = 53–82.5; 34–83 versus 105; IQR = 104–106; 101–107, p = <0.001), AllClear (25; IQR = 21.5–26; 20–27 versus 26; IQR = 25–26; 25–27, p = 0.032), JustTravelCover (16.5; IQR = 11–17; 1–17 versus 17; IQR = 16–17; 16–18, p = 0.024) and G.J.Sladdin (16; IQR = 12–18; 9–18 versus 17; IQR = 16.5–17; 16–18 p = 0.042).

All travel insurance websites offered quotes to patients with DCM; however, World First and AbleToTravel only offered online quotes to two of ten patients. JustTravelCover required a telephone consultation for three patients who had a history of mental health problems. DCM was associated with a significantly reduced choice on MoneySupermarket (23.50; IQR = 18.5–29.5; 9–86 versus 117; IQR = 102.5–117; 71–120, p = <0.001), GoCompare (25.50; 18–31; 15–83 versus 99; IQR = 83.75–99; 58–102, p = <0.001), AllClear (16; IQR = 15.5–16.5; 11–24 versus 26; IQR = 25–26; 24–26 p = <0.001), JustTravelCover(8; IQR = 7–8; 2–10 versus 17; IQR = 16–17; 16–18, p = <0.001) and G.J.Sladdin (9; IQR = 9–9.5; 3–18 versus 18; IQR = 17–18; 14–18, p = <0.001) compared to controls respectively.

How do individual factors affect the cost and choice of travel insurance?

Individual clinical and demographic factors which changed the cost or choice of travel insurance on the ‘comparison websites’ were assessed for all three conditions using one exemplar patient and inputting different variables (Tables 1 and 2).

Poorly controlled and more severe symptoms had a significant effect on the cost of travel insurance. Angina (p = 0.001) and shortness of breath when walking 200 m (p = <0.001) were both associated with considerable increases in the cost of travel insurance for patients who had an MI. With MFS, the presence of an arrhythmia (p = 0.008) and orthopnoea (p = 0.001) led to an increased premium cost. In DCM, increasing numbers of admissions to hospital (p = <0.001) as well as orthopnoea (p = 0.008) were associated with a higher cost. Patients with a higher NYHA classification showed the greatest increase in cost (p = 0.016). The absence of left ventricular systolic dysfunction (p = 0.021) and arrhythmia (p = 0.030) led to lower costs.

Recent acute medical events, recent interventions, being on a waiting list for investigation or intervention were each associated with increased premium cost. For example, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) within six weeks of a planned holiday date were associated with significantly increased cost (p = 0.002). For a patient with MFS, awaiting surgery for valve replacement was associated with a significant increase in cost (p = <0.001). If this surgery was planned within eight weeks of the holiday, the cost of the premium was also greater (p = 0.005). For all three conditions awaiting further investigation or management, including a non-routine appointment with a specialist, there was an increased cost (MI p = 0.002, MFS p = 0.002, DCM p = 0.003).

More severe disease and advanced symptoms were associated with reduced choice of travel insurance quotes. If a patient had suffered multiple MIs choice was reduced by 38.5 (IQR = 25.5–44.5, p = 0.028) and if there were ongoing symptoms of anginal chest pain or orthopnoea then choice was reduced by the same factor. If a patient sought hospital care three times or more this led to reduced choice for DCM by 4.5 (IQR = 4.3–10.1, p = 0.015).

The need for further investigation or medical intervention, including seeing a specialist at a non-routine appointment, led to a reduction in the choice of travel insurance (number of quotes reduced by MI 13.7, IQR = 11.2–14.1, p = 0.006; MFS2.1, IQR = 2.0–2.7, p = 0.034; DCM 3.0, IQR = 2.8–7.2, p = 0.047). Undergoing a cardiac procedure, such as having a PCI or CABG within six weeks of the holiday led to a reduction (4.8, IQR = 3.3–5.2, p=0.044) for a patient who had suffered an MI, and in a patient with MFS having a surgical operation within eight weeks of travel, reduced choice of travel insurance (2.9, IQR = 2.2–3.3, p = 0.045).

Postcodes were input from the highest and the lowest areas of Scottish Index of Multiple Deprivation,⁹ and we found no difference in premium cost or choice of travel insurance quotes. Similarly, gender had no impact on insurance cost or choice of quotes.

Table 1 Impact of clinical factors on cost of travel insurance in myocardial infarction (MI), Marfan syndrome (MFS) and dilated cardiomyopathy (DCM)

Condition	Factor altered	Fold increase of median compared to age matched control with IQR	p-value
MI	Age matched control with no MI diagnosis or medical condition	1	-
	MI diagnosis with no symptoms or comorbidities	1.9 (1.8–2.2)	0.043
	Patient 1 (P1) (see Appendix C)	27.2 (20.4–29.1)	0.010
	Had PCI w/ angioplasty/stenting/CABG >6/52 (P1 had no surgical intervention)	2.8 (2.8–3.1)	0.036
	Not on waiting list for investigation/management, including non-routine appointment with specialist (P1 is on waiting list for investigation/management)	7.1 (6.5–9.1)	0.012
	MI occurred <3/12 ago (P1 had MI >3/12)	35.7 (25.2–39.3)	0.002
	Had PCI w/ angioplasty/stenting/CABG <6/52 (P1 had no surgical intervention)	19.4 (15.6–21.3)	0.002
	Angina symptoms present after MI (P1 had no angina)	46.4 (38.0–66.8)	0.001
	>1 MI suffered (P1 had only 1 MI)	57.3 (37.5–65.7)	0.001
	Breathlessness or chest pain present when walking 200 m on the flat (P1 was asymptomatic)	86.2 (71.7–96.6)	<0.001
MFS	Age matched control with no MFS diagnosis or medical condition	1	-
	MFS diagnosis with no symptoms or comorbidities	1.1 (1.1–1.2)	0.034
	Patient 21 (P21) (see Appendix C)	4.8 (4.5–5.7)	0.001
	No abdominal or thoracic aneurysm present (P21 had thoracic aneurysm)	1.6 (1.4–1.8)	0.043
	Dissecting aneurysm not under supervision (P21 was under supervision)	2.8 (2.2–3.1)	0.021
	Arrhythmia present (P21 had no arrhythmia)	6.7 (5.9–7.2)	0.008
	Surgical correction of non-dissecting aneurysm <8/52 (P21 had a thoracic aneurysm but had not undergone surgical correction)	5.9 (3.4–6.9)	0.005
	Further investigation of cardiac valve disease with no previous surgery, including non-routine appointment with specialist (P21 needed no further Ix)	10.6 (8.3–11.1)	0.002
	Orthopnoea present (P21 did not suffer from orthopnoea)	12.4 (11.4–16.0)	0.001
	On waiting list for surgery/ stent (P21 was not on a waiting list)	32.7 (23.9–34.8)	<0.001
DCM	Age matched control with no DCM diagnosis or medical condition	1	-
	DCM diagnosis with no symptoms or comorbidities	1.3 (1.2–1.4)	0.022
	Patient 31 (P31) (see Appendix C)	8.3 (6.1–9.3)	0.013
	No symptoms of impaired contractility (P31 had left ventricular systolic dysfunction)	5.0 (4.7–5.4)	0.021
	No arrhythmia (P31 had Left bundle branch block)	6.2 (3.3–7.6)	0.030
	NYHA class 3 (P31 was NYHA class 2)	13.4 (12.1–17.5)	0.016
	1–2 unplanned visits to hospital in the last 12 months due to impaired contractility (P31 had not been hospitalised in the last 12 months)	11.3 (11.2–14.6)	0.010
	Orthopnoea present  (P31 did not suffer from orthopnoea)	15.4 (15.1–21.2)	0.007
	2 or more unplanned visits to hospital in the last 12 months due to arrhythmia (see question 26)	13.7 (13.4–18.1)	0.008
	Further investigation or management required, including non-routine appointment with specialist (P31 did not need further investigation/management)	16.9 (12.4–20.4)	0.003
	≥3 unplanned visits to hospital in the last 12 months due to impaired contractility (see question 26)	19.9 (18.4–32.0)	<0.001

 

Table 2 Impact of clinical factors on choice of quotes of travel insurance in myocardial infarction (MI), Marfan syndrome (MFS) and dilated cardiomyopathy (DCM)

Condition	Factor altered	Fold decrease of median compared to age matched control with IQR	p-value
MI	Age matched control with no MI diagnosis or medical condition	1	-
	MI diagnosis with no symptoms or comorbidities	1.2 (1.1–1.2)	0.016
	Patient 1 (P1) (see Appendix C)	17.8 (10.8–19.9)	0.002
	Not on waiting list for investigation/management, including non-routine appointment with specialist (P1 is on waiting list for investigation/management)	2.2 (1.9–2.5)	0.006
	Had PCI w/ angioplasty/stenting/CABG >6/52 (P1 had no surgical intervention)	1.3 (1.1–1.3)	0.044
	MI occurred >3/12 ago (P1 had MI <3/12 ago)	1.2 (1.1–1.3)	0.031
	Had PCI w/ angioplasty/stenting/CABG <6/52 (P1 had no surgical intervention)	4.8 (3.3–5.2)	0.011
	Angina symptoms present after MI (P1 had no angina)	38.5 (25.5–44.5)	0.001
	>1 MI suffered (P1 only had one MI)	38.5 (25.5–44.5)	0.001
	Breathlessness or chest pain present when walking 200m on the flat (P1 was asymptomatic)	38.5 (25.5–44.5)	0.001
MFS	Age-matched control with no MFS diagnosis or medical condition	1	-
	MFS diagnosis with no symptoms or comorbidities	1.2 (1.1–1.2)	0.049
	Patient 21 (P21) (see Appendix C)	1.2 (1.1–1.5)	0.042
	Arrhythmia present (P21 had no arrhythmia present)	1.9 (1.7–2.0)	0.031
	Further investigation of cardiac valve disease with no previous surgery, including non-routine appointment with specialist (P21 required no further Ix)	2.1 (2.0–2.7)	0.034
	Surgical correction of non-dissecting aneurysm <8/52 (P21 had a thoracic aneurysm but had not undergone surgical correction)	2.9 (2.2–3.3)	0.045
	Symptoms of breathlessness or impaired contractility present (P21 had no such symptoms)	2.7 (1.9–2.9)	0.017
	Orthopnoea present (P21 did not have orthopnoea)	3.2 (3.0–3.9)	0.009
	On waiting list for surgery/ stent (P21 was not a waiting list for surgery)	6.0 (5.7–13.3)	0.004
DCM	Age-matched control with no DCM diagnosis or medical condition	1	-
	DCM diagnosis with no symptoms or comorbidities	1.1 (1.1–1.3)	0.046
	Patient 31 (P31) (see Appendix C)	2.2 (2.0–3.2)	0.039
	No arrhythmia (P31 had Left bundle branch block)	1.5 (1.4–1.7)	0.052
	No symptoms of impaired contractility (P31 had left ventricular systolic dysfunction)	1.2 (1.1–1.3)	0.042
	1–2 unplanned visits to hospital in the last 12 months due to impaired contractility (P31 had not been hospitalised in the last 12 months)	2.4 (2.2–2.9)	0.035
	NYHA class 3 or greater (P31 was NYHA class 2)	2.3 (2.1–4.0)	0.028
	Further investigation or management required, including non-routine appointment with specialist (P31 did not need further investigation/management)	3.0 (2.8– 7.2)	0.047
	2 or more unplanned visits to hospital in the last 12 months due to arrhythmia (See questions 25)	2.8 (2.2–6.3)	0.0.28
	Orthopnoea present (P31 did not have orthopnoea)	2.8 (2.2–6.3)	0.023
	≥3 unplanned visits to hospital in the last 12 months due to impaired contractility (See question 25)	4.5 (4.3–10.1)	0.015

 

Time from acute events

The median cost of travel insurance fell to a stable level six months after MI and after an acute event associated with MFS (Figure 3). Insurance cost for MI fell by nearly 50% and MFS by 75% at three months after an acute event. For DCM the cost fell more gradually reaching its lowest median cost at 12 months following an acute hospital admission. The choice of quotes mirrored the changes in cost with a peak increase for MI and MFS at 6 months and DCM at 12 months.

Figure 3 Impact of ‘time after event’ on cost and availability

Impact of ‘time after event’ on cost (filled lines) and availability (dotted lines) of travel insurance quotes over 15 months following an acute event for MI (n = 5) patients; a planned surgical correction of a non-dissecting aneurysm in MFS (n = 5) patients and an unplanned hospital admission in 5 DCM (n = 5) patients. Key timepoints in clinical care are highlighted as 1, 2 and 3 with issues described below.

Timepoint 1: 0 months: - MI patients have just had an acute coronary event and are awaiting non-routine outpatient appointment (scheduled at 6 months) or echocardiogram. – MFS patients are awaiting a surgical correction or stenting of their aneurysm (scheduled at 3 months). - DCM patients have been admitted to hospital due to an acute worsening of their heart failure.

Time point 2: 3 months: - MI patients are awaiting clinic (scheduled at 6 months). – MFS patients have had their surgical procedure and have a non-routine appointment (scheduled at 6 months). – DCM patients are awaiting a non-routine appointment or investigation due to previous exacerbation (scheduled at 6 months).

Timepoint 3: 6 months: - MI patients have outpatient appointment and are discharged or enter into routine follow-up. – MFS patients have outpatient appointment and are discharged or enter into routine follow-up. – DCM patients have outpatient appointment and are discharged or enter into routine follow-up.

 

Discussion

This small study of three specific cardiac conditions clearly demonstrates significantly increased cost and reduced choice in travel insurance services for patients with MI, DCM and MFS compared with disease-free, age-matched controls. While the findings are not unexpected, the more striking feature is the wide variation in cost and choice between travel insurance companies suggesting that the risk assessment algorithms and processes applied to these patients vary considerably between companies. The reasons for this are unclear and could not be addressed within this relatively small observational study.

Two widely used comparison websites, GoCompare and MoneySupermarket, which are not currently recommended by the BHF, were used in this study. Both offered cheaper insurance than most other websites recommended by the BHF, although the quality of insurance product offered varied greatly, demonstrated by different quality ratings.¹¹ In contrast, GoCompare and MoneySupermarket showed the greatest reductions in choice of quotes for our patients. This may be because they offer quotes from many insurers, which may insure individuals with medical conditions but some may not. This is consistent with BHF guidance which recommends insurance companies that have a track record of being sympathetic to cardiac patients.

MFS patients showed the least difference in cost and choice of quotes compared to their age-matched controls. While MFS patients were younger (mean age 35 years) than MI and DCM patients (mean age 59.5 and 60 years respectively), the disparity in cost and quote choice is unlikely to be due to age alone. As MI patients were selected at the time of hospital discharge following their acute coronary event, most patients required further investigation or an outpatient appointment. These specific factors increased cost for all three cardiac conditions and are likely to be a key reason for the observed difference in cost and choice between MFS and MI patients, presumably due to the perceived high-risk time period of three months following an acute cardiac event. For patients with DCM, echocardiographic evidence of impaired left ventricular function, and ongoing breathlessness had a significant impact on cost and choice of quotes.

Factors associated with increased cost were associated with a reduction in choice of travel insurance quotes across all travel insurance websites and were more marked when associated with new or deteriorating symptoms. For example, the development of arrhythmia in either MFS or DCM or the presence of progressive anginal symptoms after MI were each associated with significantly reduced choice of insurance quotes.

The time at which travel insurance is purchased after hospitalisation or a surgical procedure had a significant effect on cost. If a patient simply delayed their travel plans for eight weeks after a surgical correction of an aneurysm in MFS or three months after MI, then the cost is greatly reduced and there is a much greater choice (Figure 3). The cost of insurance also falls if there is a routine outpatient appointment planned in contrast to a non-routine appointment. A summary of clinical factors affecting cost and choice of insurance is provided in Table 1. Patients should therefore simply be advised to defer their holiday plans beyond these time periods and by doing so could increase choice and save a considerable amount of money. However, since patients can sometimes wait for up to six months for a follow-up appointment in the National Health Service, telephone reviews or other methods of review that allow more timely decision-making could supports patients to obtain travel insurance more readily.

Insurance policy documents were reviewed to understand better the details and quality of medical cover provided in each policy. Features common to all policies included cover for emergency care with repatriation back to the individual’s home country if required. Elective or preventative care or care that can wait until the patient has returned to their home country is not covered. The care they receive should be within a public or state hospital and not a private facility. If an investigation or treatment costs more than £500, the patient may need to contact the travel insurance company to authorise payment before a care plan is undertaken. A patient cannot usually claim for regular medications that they were taking for their cardiac condition prior to embarking on holiday, including lost, forgotten or insufficient supply. The patient should retain medical certificates and bills to provide evidence for any claims. The patient’s regular doctor may be contacted in the event of a claim to provide supporting medical information.

Accurate details of medical illnesses are critically important when purchasing insurance, including details regarding prior cardiac diagnoses and acute coronary events. Certain scenarios can invalidate a purchased insurance, such as if the patient develops an acute illness related to undisclosed existing health problems or if an individual travels against medical advice. There are significant differences in policy details and cover between companies and it is recommended that an individual reads the policy carefully before purchase.

The approach used in this study could be applied to other disease conditions and if extended in this way could provide a highly valuable resource for a wide range of clinicians and patients regarding travel insurance. Previous research has explored the attitudes of patients with adult congenital heart disease towards travel insurance and there is certainly scope for further work in this area to guide patients’ needs.⁶

While this study should help clinicians advise cardiac patients about how their condition will affect their travel insurance, there are limitations to the findings which merit further discussion. All patients with MI required further investigations or had plans for specialist review, which had a significant effect on the cost of premiums. The sample size is relatively small and only one patient was used from each condition to explore the effects of changing individual factors. Although 16 travel insurance websites were used, including comparison websites which include multiple insurers, there are other travel insurance websites that were not included in this study.

This study has explored the relationship between cardiac conditions and travel insurance and the relevance to patient care. A patient leaflet for each cardiac condition has been produced presenting the findings of this study (see Appendix B). Communication between healthcare professionals and patients is vital and the information in this study should facilitate better patient–healthcare provider discussions. Whilst the consideration of travel insurance may not feature prominently in the minds of clinicians when assessing and managing a patient’s cardiac condition, this study has highlighted some key considerations to support decisions regarding travel and travel insurance. Knowledge of how cardiac conditions affect travel insurance costs and quotes justifies the importance of this study in providing patient-centred care.

References

1  Office of National Statistics. Travel Trends: 2016. https://www.ons.gov.uk/releases/traveltrends2016. (accessed 01/05/18).

2  Low JA, Chan DK. Air travel in older people. Age Ageing 2002; 31: 17–22.

3  Smith D, Toff W, Joy M et al. Fitness to fly for passengers with cardiovascular disease. Heart 2010; 96: ii1–6.

4  British Heart Foundation. Insurance for Heart Conditions. https://www.bhf.org.uk/heart-health/living-with-a-heart-condition/money-... (accessed 01/05/18).

5  Lainscak M, Blue L, Clark AL et al. Self-care management of heart failure: practical recommendations from the Patient Care Committee of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2011; 13: 115–26.

6  Pickup L, Bowater S, Thorne S et al. Travel insurance in adult congenital heart disease—Do they declare their condition? Int J Cardiol 2016; 223: 316-7.

7  British Heart Foundation. Insurance: Insurance for heart patients. https://www.bhf.org.uk/~/media/files/publications/medical-information-sh...(2).pdf (accessed 02/03/18).

8  NHS Choices. Travelling with a heart condition. https://www.nhs.uk/live-well/healthy-body/travelling-with-a-heart-condition (accessed 02/03/18).

9  Scottish Government. Scottish Index of Multiple Deprivation. http://www.gov.scot/Topics/Statistics/SIMD (accessed 01/05/18).

10  Office of National Statistics. Travel trends estimates: UK residents’ visits abroad. https://www.ons.gov.uk/peoplepopulationandcommunity/leisureandtourism/da... (accessed 12/02/18).

11  Defaqto. Travel Insurance (Annual). https://www.defaqto.com/star-ratings/travel/travel-insurance-annual/?id=... (accessed 02/05/18).

 

Appendix A  List of travel insurance companies used in study (*= comparison website)

Able2Travel	It’s so easy to travel insurance
AllClear*	JustTravelCover*
Flexicover	Makesure
Free Spirit	MoneySupermarket*
Freedom	SAGA
G.J. Sladdin*	Staysure
GoCompare*	Travel insured
Goodtogoinsurance	WorldFirst

 

Appendix B Patient information leaflets relating to travel insurance for myocardial infarction, Marfan syndrome and dilated cardiomyopathy

Patient Information Leaflet

Do I need travel insurance if I am travelling abroad?

It is recommended that you buy travel insurance before travelling abroad. Travel insurance usually covers costs due to cancellation, lost or stolen bags or any emergency medical expenses whilst abroad. These can be expensive, so having travel insurance offers you security whilst travelling.

I have a European Health Insurance Card (EHIC), do I need to take out travel insurance?

Countries covered by a European Health Insurance Card: Austria,   Belgium,   Bulgaria,   Croatia,   Cyprus,   Czech Republic,   Denmark,   Estonia,   Finland,   France,   Germany,   Greece,   Hungary,   Iceland,   Ireland,   Italy,   Latvia,   Liechtenstein,   Lithuania,   Luxembourg,   Malta,   Netherlands (Holland),   Norway,   Poland,   Portugal,   Romania,   Slovakia,   Slovenia,   Spain,   Switzerland.

An EHIC allows you to have the same level of medical care provided for by the government in that country as a resident of that country. For example, if someone were travelling to the UK from Spain it would allow them to use NHS Healthcare services. It can be used in all countries within the European Economic Area and Switzerland (see below for a full list of the countries).

Although you can use the government provided hospitals whilst abroad, these may not be of the same standard as in the UK and if people in that country usually pay for part of the cost of treatment, then you would have to do the same. In addition, if you need to be flown back to the UK after a medical accident then this cost would not be covered and this would be expensive. If you want to find out more information about EHIC, the you can at: https://www.gov.uk/european-health-insurance-card.

As the UK is leaving the European Union it is unclear what the future of the EHIC will be. It will remain valid until at least December 31^st 2020 whilst the UK goes through a transition period. What will happen to the EHIC after this date will be decided by negotiations between the EU and UK.

It can be worth having an EHIC but it is strongly recommended you get travel insurance, which includes medical cover, as well.

When can I fly after a heart attack?

The British Cardiovascular Society recommends that people who have very low risk of having another heart attack may be able to fly as early as three days after having a heart attack.¹ Things that put you at a low risk are:

• this is your first heart attack
• you are under 65
• you have no complications
• no further treatment is planned

• The UK Civil Aviation Authority recommends that people with no complications, who are at low risk of another event, can fly seven to 10 days after a heart attack.¹ 

  If you are to fly soon after having a heart attack and are not sure, ask your GP or cardiologist and they will be able to provide you with more advice about travel.

   

  I have had a heart attack; do I need to declare this on my travel insurance form?

  Yes, you should say that you have had a heart attack when filling out your quote. Not doing so may make your policy invalid, which can cause problems if you need to make a claim.

  If you have other medical conditions then it is also necessary to mention these when filling out the travel insurance application.

   

  I have had a heart attack; will this stop me from being able to get travel insurance?

  No, you should still be able to get travel insurance to cover for you trip abroad. There will be some companies that may not offer cover, but the majority of companies will.

  Will my insurance be more expensive after I have had a heart attack?

  Yes, it will cost more than someone who is your age and has no health problems and has not had a heart attack. Travel insurance quotes can be higher because they are calculated on the chance of you needing to make a claim. Some travel insurance companies will not offer quotes relating to pre-existing medical conditions, and some insurers may offer cover but at an additional cost.

  How much am I likely to have to pay?

  A recent survey conducted by a medical student on 20 patients who had suffered a heart attack in the last three months, showed that the cost of travel insurance for a 10 day holiday in Spain, for example, ranged from £162.56 to £281.48 for a minimum of £1 million of medical cover. This compared with a cost of £11.99 to £34.09 for someone of similar age who had not had a heart attack. However, the cost does not stay at this level and there are factors that may help to reduce the cost of your insurance.

  What factors may make my travel insurance more expensive in relation to my heart attack?

  The following things are likely to increase the cost of travel insurance after a heart attack:

• Your heart attack occurred within the last 3 months
• You are waiting for the results of tests or investigations
• You need additional investigations or treatment
• You are waiting for an out-patient clinic review
• You are continuing to experience symptoms of chest pain or breathlessness after your heart attack
• You have other medical conditions, or develop new health issues over time
• You have a further heart attack soon after the first one

•  

  So I have had a heart attack, when is a good time to go on holiday and buy travel insurance?

  After you have a heart attack, it is likely your doctor either will want to do an investigation to look at the heart, or will want to see you as an outpatient in clinic. Once these tests have been completed and your doctor decides that they do not want to do further tests or procedures it is a good time to book a holiday. The cost of travel insurance can fall to £42.49 within one year of having a heart attack if you book after tests and appointments have been completed, compared to £162.56 if you were to book before. If the doctor wants to see you on a regular basis, for example every 6 months, then this will not affect the cost of your insurance.

   

  So I want to buy travel insurance for my holiday, where should I look?

  There are many different travel insurance companies that offer a wide number of different options and if you are looking for something in particular (i.e. cruise cover, winter sports) then it can be useful to look around. It is also worth checking that the travel insurance policy you are thinking of purchasing has the correct level of cover for things like medical expenses, lost baggage or cancellation that you want. Whilst some companies are listed below, they are not endorsed and it is important to make sure that an insurance policy meet your individual circumstances and needs.

  The British Heart Foundation has a list of specialist medical insurers that they have found can be useful for people with heart problems. Of these, the ones we would recommend looking at first are:

• Flexicover (www.flexicover.co.uk)
• AllClear (www.allcleartravel.co.uk)
• Freedom (www.freedominsure.com)
• StaySure (www.staysure.co.uk)

• There are more insurers that they suggest, which can be found on their website at: https://www.bhf.org.uk/heart-health/living-with-a-heart-condition/money-....

  Some of the larger travel insurance comparison websites like GoCompare (www.gocompare.com) and MoneySupermarket (www.moneysupermarket.com) offer cheap insurance from a large number of insurance companies, so it is definitely worth looking at these websites if you are looking to get travel insurance.

  I am unsure about filling out my travel insurance form, what can I do to make sure I am doing it correctly?

  Firstly, you can ring up the travel insurance companies directly and they will be able to advise you, or they will be able to complete the purchase of travel insurance over the phone. If you have any questions then they can answer them for you directly.

  If you are unsure about the answers to any of the medical questions, then your GP or cardiologist should be able to help you answer the questions.

  Are there any websites I can look on for more information?

  Yes there are. These are listed below and should hopefully provide you with useful information before you travel.

  NHS – “When can I fly after a heart attack?” https://www.nhs.uk/chq/Pages/2576.aspx?CategoryID=70&SubCategoryID=174

  NHS Choices – “Travelling with a heart conditions”                                            https://www.nhs.uk/live-well/healthy-body/travelling-with-a-heart-condit...

  British Heart Foundation – “Insurance for heart conditions”                                     https://www.bhf.org.uk/heart-health/living-with-a-heart-condition/money-...

  British Heart Foundation – “Holidays and Travel”                                         https://www.bhf.org.uk/heart-health/living-with-a-heart-condition/money-...

  References

• NHS Choices. “When can I fly after a heart attack?”. Last reviewed 03/08/2016 (cited on 23/05/2018). Available from: https://www.nhs.uk/chq/Pages/2576.aspx?CategoryID=70&SubCategoryID=174.

 

 

Appendix C – Patient demographics with outline of cardiac disease and comorbidities   P No.	D.O.B.	Sex	Cardiac Diagnosis	Cardiac Disease Features	Medications	Comorbidities	Smoker?
1	18/02/1956	Female	MI	NSTEMI, mild plaque LAD, medical management with DAPT, no previous MI	Aspirin, clopidogrel, atorvastatin, bisoprolol, GTN spray	COPD, hyperlipidaemia	Yes
2	09/09/1958	Male	MI	STEMI, diffuse three-vessel disease, patent grafts X3 by formal coronary arteriography (RA graft to LAD, SVG to PDA and OM), 1 previous MI treated with CABG to 2 vessels	Aspirin, clopidogrel, atorvastatin, bisoprolol, GTN spray, Isosorbide mononitrate, nicorandil, ramipril, lansoprazole, GTN spray, Co-codamol	Hyperlipidaemia, hypertension, arthritis, previous peptic ulcer	Yes
3	22/02/1952	Male	MI	NSTEMI, PCI with balloon angioplasty and deployment of DES X1 to RCA, no previous MI	Aspirin, clopidogrel, atorvastatin, bisoprolol, lisionopril, salbutamol inhaler, symbicort inhaler, GTN spray	Hypertension, COPD	Ex-smoker (quit 3yrs ago)
4	26/10/1949	Male	MI	Type II MI secondary to community acquired pneumonia and congestive cardiac failure, managed with antibiotics and heart failure treatment, no previous MI	Atorvastain, aspirin, clopidogrel, bisoprolol, candesartan, furosemide, metformin, gliclazide, lansoprazole	Moderate LVSD, PVD with limiting claudication, CKD stage 3A, Type 2 diabetes mellitus	Ex-smoker (quit 40yrs ago)
5	09/09/1964	Male	MI	NSTEMI, unsuccessful radial cannulation, medical management with DAPT followed with lifelong aspirin, no previous MI	Aspirin, ticagrelor, atorvastatin, bisoprolol, GTN spray	Hyperlipidaemia, hypertension, Type 2 diabetes mellitus	Ex-smoker (quit 30yrs ago)
6	24/07/1961	Male	MI	STEMI, PCI with deployment of DES X1 in LAD, no  previous MI	Aspirin, clopidogrel, atorvastatin, bisoprolol, GTN spray	Hypertension, hyperlipidaemia	No
7	06/08/1953	Female	MI	NSTEMI, medical management with DAPT, 1 previous MI which was managed with PCI with deployment of DES X2 in LAD 2010	Aspirin, clopidogrel, atorvastatin, bisoprolol, GTN spray, metformin, gliclazide	Hypertension, Type 2 diabetes mellitus	Ex-smoker (quit 6yrs ago)
8	14/03/1954	Female	MI	NSTEMI, PCI with deployment of DES X1 in RCA, no previous MI	Aspirin, ticagrelor, atorvastatin, bisoprolol, ramipril, lansoprazole, GTN spray	Gastro-oesophageal reflux disease	No
9	19/02/1952	Male	MI	STEMI, PCI with deployment of DES X2 in LAD and DES X1 in RCA, no previous MI	Aspirin, clopidogrel, atorvastatin, bisoprolol, GTN spray, salbutamol	Asthma	Yes
10	29/10/1953	Male	MI	NSTEMI, Medical management with DAPT, no previous MI	Aspirin, clopidogrel, atorvastatin, bisoprolol, GTN spray, levothyroxine, insulin	Hypothyroidism, Type 1 diabetes mellitus	Ex-smoker (quit 4yrs ago)
11	19/07/1962	Male	MI	NSTEMI, Medical management with DAPT, no previous MI	Aspirin, clopidogrel, atorvastatin, bisoprolol, lisinopril, GTN spray	Hypertension	No
12	28/11/1964	Male	MI	STEMI, PCI with deployment of DES X2 in LAD, no previous MI	Ticagrelor, spironolactone, ramipril, paracetemol, lansoprazole, GTN spray, furosemide, bisoprolol, atorvastatin, aspirin, salbutamol inhaler, Ivabradine	Heart failure with severe LVSD, COPD, hypertension	Ex-smoker (quit 9yrs ago)
13	19/03/1947	Female	MI	STEMI, Initial failed thrombolysis with heparin and tenectoplase followed by PCI with deployment of DES X2 in RCA	Aspirin, clopidogrel, valsartan, atorvastatin, amlodipine, GTN spray	Hypertension	Ex-smoker (quit 1yr ago)
14	04/06/1952	Male	MI	STEMI, PCI with deployment of DES X3 in RCA and DES X1 in LAD, paroxysmal AF, no previous MI	Aspirin, apixaban, ticagrelor, atorvastatin, ramipril, GTN spray	Abdominal hernia, hypertension	No
15	28/03/1958	Male	MI	NSTEMI, Medical management with DAPT, 1 previous MI which was managed with CABG 2005	Aspirin, ticagrelor,iIvabradine, furosemide, isosorbide mononitrate, GTN spray	Previous CVA, COPD	Yes
16	06/02/1958	Male	MI	NSTEMI, PCI with deployment of DES X1 in RCA and DES X1 in CFX/OM, no previous MI	Atorvastatin, clopidogrel, aspirin, GTN spray, ramipril	Nil	Yes
17	17/03/1973	Male	MI	STEMI, PCI with deployment of  DES X2 in LAD, no previous MI	Aspirin, ticagrelor, atorvastatin, bisoprolol, ramipril, GTN spray, eplerenone	Nil	Yes
18	12/12/1960	Female	MI	STEMI, PCI with deployment of  DES X1 in LAD, Post-STEMI cardiogenic pulmonary oedema, LV thrombus, no previous MI	Furosemide, ramipril, carvedilol, GTN spray, spironolactone, atorvastatin, ticagrelor	Nil	No
19	29/11/1965	Male	MI	NSTEMI, PCI with deployment of DES X1 in RCA, no previous MI	Aspirin, ticagrelor, atorvastatin, bisoprolol, ramipril	Hypertension	Ex-smoker (quit 2yrs ago)
20	09/06/1955	Male	MI	NSTEMI, PCI with deployment of DES X2 in LAD, no previous MI	Aspirin, clopidogrel, bendroflumethiazide, GTN spray, metformin, ramipril, calcichew	Hypertension, type 2 diabetes mellitus, prostate Cancer	No
21	11/01/1972	Female	MFS	Fibrillin gene mutation, metal aortic valve and root replacement 2016, type A aortic dissection 2015, good LV function, no aortic root dilatation, good prosthetic function	Bisoprolol, warfarin, tiotropium	Surgically repaired vocal cord palsy	No
22	03/05/1986	Female	MFS	Aortic root dilatation of 4.6cm, good LV function, mild aortic regurgitation	Atenolol	Nil	No
23	18/06/1981	Male	MFS	Bioprosthetic aortic valve and root replacement 2013, paroxysmal atrial fibrillation, good LV function, mild left aortic dilatation, good prosthetic function	Bisoprolol, losartan, amiodarone, aspirin, concerta, methylphenidate	Nacrolepsy	No
24	24/09/1986	Female	MFS	Fibrillin gene mutatuion, Good LV function, aortic root measurement of 3.6cm	Propanolol	Bilateral inferior lens colobomas	No
25	25/07/1985	Male	MFS	Metal aortic valve and root replacement 2002, good LV function, no aortic root dilatation, good prosthetic function	Losartan, warfarin	Allergic rhinitis	No
26	09/08/1983	Male	MFS	Metal aortic valve and root replacement 2007, LV function normal with LV ejection fraction >40%,  no aortic root dilatation, good prosthetic function	Bisoprolol, warfarin	Nil	No
27	31/12/1995	Male	MFS	Metal aortic valve and root replacement 2016, with rereplacement of aortic root following aortic root abscess, permanent pacemaker inserted 2017	Losartan, warfarin	Nil	No
28	06/12/1972	Male	MFS	Metal aortic valve and root replacement 2002, normal LV function,  no aortic root dilatation, good prosthetic function	Losartan, atenolol, warfarin	Nil	No
29	23/11/1979	Male	MFS	Metal aortic valve and root replacement 2003, normal LV function, no aortic root dilatation, good prosthetic function with very minor regurgitation	Losartan, bisoprolol, warfarin	Previous bilateral retinal detachments, obstructive sleep apnoea, generalised anxiety disorder	No
30	18/04/1977	Female	MFS	Aortic root dilatation 4.8cm, mild to moderate aortic regurgitation	Atenolol, oxyContin, ibuprofen	Migraine, joint pain	No
31	22/06/1962	Female	DCM	Cause: probable viral aetiology, LBBB, Cardiac resynchronisation therapy pacemaker in situ, NYHA class II, LV ejection fraction 44%	Enalapril, spironolactone, bisoprolol, fluticasone, paroxetine	Depression	Ex-smoker (quit 12yrs ago)
32	29/08/1969	Female	DCM	Cause is Lamin mutation, previous VF cardiac arrest, cardiac resynchronisation therapy defibrillator 2014, paroxysmal AF, NYHA class I, LV ejection fraction 46%	Candesartan, carvedilol, warfarin, amiodarone	Nil	No
33	24/07/1958	Male	DCM	Cause is secondary to muscular dystrophy, LBBB, moderate to severe LVSD, NYHA class III	Bisoprolol, candesartan, spironolactone, zopiclone, fluoxetine	Limb girdle muscular dystrophy type II	No
34	14/05/1945	Male	DCM	Cause is unknown, permanent AF, moderate to severe LVSD, NYHA class II	Simvastatin, digoxin, bisoprolol, ramipril, warfarin, furosemide, eplenerone	Hypertension	Ex-smoker (quit 7 years ago)
35	18/01/1950	Male	DCM	Cause is subacute bacterial endocarditis, moderate mitral regurgitation, severe LVSD, NYHA class II	Lisinopril, furosemide, spirinolactone, ivabradine	Recurrent depression, traumatic brain injury	Ex-smoker (quit 16yrs ago)
36	06/11/1960	Male	DCM	Cause is myotonic dystrophy, previous atrial flutter ablation, cardiac resynchronisation therapy defibrillator in-situ, severe LVSD, NYHA class I	Furosemide, apixaban, simvastatin, bisoprolol, ramipril, metformin	Myotonic dystrophy, hypertension, type 2 diabetes mellitus, parathyroidectomy	No
37	11/03/1967	Male	DCM	Cause is myocarditis related to an endomyocardial biopsy, frequent right ventricular outflow tract ectopics treated with ablation, moderate LVSD, NYHA class I	Atorvastatin, ramipril, bisoprolol, omeprazole	Gastro-oesophageal reflux disease	No
38	27/08/1955	Female	DCM	Cause is unknown, previous rheumatic fever, permanent AF, cardiac resynchronisation therapy pacemaker in situ, NYHA class II	Bisoprolol, furosemide, simvastatin, ramipril,  spironolactone, tiotropium inhaler, levothyroxine, metformin	COPD, hypothyroidism, type 2 diabetes mellitus	Ex-smoker (quit 7rs ago)
39	09/11/1961	Female	DCM	Cause is alcohol-related, moderate LVSD, NYHA class I	Lisinopril, furosemide, bisoprolol, atorvastatin, aspirin, omeprazole, gabapentin, venlofaxine	PVD, Chronic depression	Yes
40	29/12/1944	Male	DCM	Cause is unknown, permanent AF, moderate LVSD, NYHA class I	Bumetanide, eplenerone, ramipril, bisoprolol, digoxin, metformin, warfarin, salbutamol inhaler	COPD, type 2 diabetes mellitus, hypertension	Ex-smoker (quit 3yrs ago)