Travel Insurance Observatory 2014

Transcription

1 Travel Insurance Observatory 2014 Research which contributes to excellence in the tourism experience

2 TRAVEL INSURANCE OBSERVATORY 2014 Acknowledgements The data on which this study is based comes from the health claims and outcomes database of MAPFRE ASISTENCIA and its subsidiary InsureandGo UK. The claims data is compared with statistics from two sources: Forward Data S.L. and its ForwardKeys.com database; and the Office for National Statistics (ONS), based on the ONS International Passenger Survey (IPS), which is the official source of statistics on UK inbound and outbound travel, and the UK Travel Trends reports for Disclaimer The analysis, interpretation and conclusions expressed in this report are based on data contained in the databases of MAPFRE ASISTENCIA and the UK ONS and do not reflect the views of any individual, organisation or institution. MAPFRE ASISTENCIA does not guarantee, and accepts no legal liability whatsoever arising from or connected to, the accuracy, reliability, currency or completeness of any material contained in this document. Readers should seek appropriate independent professional advice prior to relying on, or entering into any commitment based on, material published here, which is published solely for reference purposes. Published and printed by: MAPFRE ASISTENCIA Carretera de Pozuelo, 52 Edif. 1 Anexo Majadahonda Madrid Spain Website: [email protected] Copyright 2014 MAPFRE S.A. All rights reserved. The contents of this report may be quoted, provided the source is given accurately and clearly. Distribution or reproduction in full or in part is permitted for own or internal use only. 2

3 TRAVEL INSURANCE OBSERVATORY 2014 Contents Foreword 4 Glossary 6 Key Highlights 7 Part 1 Trends Around the World Introduction Overview of World Trends Analysis by Source Region Europe Latin America Asia Pacific Leading Source Markets: UK, Spain and Brazil Analysis of Seasonality 31 Part 2 The UK Market Background and Methodology Types of Travel Insurance Cover Non-medical Claims Medical Claims Medical Claims by Destination Region Individual Country Analysis The Link between Age and Medical Problems Seasonality of Medical Claims 51 Appendices 55 3

4 Foreword Contributing to safe travel With increasing political and social unrest in different parts of the world, not to mention the outbreak of new and sometimes untreatable diseases such as the Ebola virus or even Avian flu, travellers are understandably more and more concerned about the risks they might incur for their safety and security when travelling. But while travel advisories from governments and intergovernmental bodies such as the World Health Organization play an important role in raising awareness among the public of many of the risks involved, there is not yet any regular health monitoring system in place that can be consulted by travellers and the tourism industry. Clearly, there is still a long way to go before a universally approved, reliable system can be put in place. But in the meantime, in an effort to provide a service of benefit to the public and industry stakeholders, MAPFRE ASISTENCIA has developed its Travel Insurance Observatory (TIO), based on its own in-house travel insurance research a comprehensive database of the claims filed by travel insurance customers of MAPFRE ASISTENCIA and its partners. This 2014 Travel Insurance Observatory, the second edition of what is intended to become an annual report, contains an overview of some of the key findings taken from MAPFRE ASISTENCIA's growing database of health claims and outcomes. Not only does it highlight the main medical problems suffered by travellers in different parts of the world, but it also clearly identifies the different reasons for the medical problems and complaints in other words, those that could have affected the tourists anywhere in the world and those that are related to specific destinations or travel experiences. The 2014 Travel Insurance Observatory The first MAPFRE ASISTENCIA Travel Insurance Observatory report, published in 2013, focused only on the UK market MAPFRE ASISTENCIA's largest travel insurance customer base and covered the period July 2012 to April This edition was presented at the 20th General Assembly of the United Nations World Tourism Organization (UNWTO) held in Zambia, Zimbabwe. This year's analysis monitors a full 12-month period, May 2013 to April 2014 (hereafter referred to as 2013/14). In this 2014 edition, we provide more in-depth coverage of the UK market, highlighting, as we did last year, the destinations in which most medical claims originated, as well as the type of medical complaint affecting UK travellers in the different destinations visited. In addition, we provide some comparisons with data for the same 12-month period of 2012/13, and we take a closer look at medical claims by age group and disease type, and also at seasonal trends which months of the year account for the most claims and where. 4

5 Part 1 contains new information on a number of other markets in Europe, the Americas and Asia Pacific in which MAPFRE ASISTENCIA travel insurance policies are sold. We hope you will find the information useful as well as interesting and that it will help lead to a better and broader understanding of the risks posed by particular types of travel experiences and destinations. Happy reading! 5

6 Glossary Medical Assistance Claims Medical Reimbursements Other Personal Benefits (OPB) EHIC GEA UTI DRD ONDRD TRAUMA Claims that involve immediate assistance from MAPFRE ASISTENCIA's call centres and/or hospitalisation of the insured (inpatients). Claims from MAPFRE ASISTENCIA's insured who need to pay for medical attention in the outpatients' department of a hospital or clinic, or at a doctor's, and who are reimbursed for these expenses after their trip. Non-medical claims related to travel cancellations and to the personal possessions of the insured (e.g. the loss of personal belongings, including computers, mobile phones, spectacles, cameras, etc., and the loss of travel and bank documents such as passports and credit cards. European Health Insurance Card, valid in all European Economic Area (EEA) member countries (including Switzerland). Gastro-intestinal infections. Urinary tract infections. Destination Related Diagnoses, such as allergies, animal and insect bites, infectious diseases (of both bacterial and viral origin), gastro-enteritis, diarrhoea (GEA) and abdominal pain, respiratory infections, urinary tract infections, dermatitis, conjunctivitis, altitude and decompression sickness, sunburn and other burns, etc. Other Non-Destination Related Diagnoses, including chronic illnesses, cardiovascular diseases, anaemia, tumours, epilepsy, etc. Trauma-related disorders, such as bone fractures, strains, etc. 6

7 Key Highlights First global Travel Insurance Observatory report The 2014 Travel Insurance Observatory (TIO) report, which is based on MAPFRE ASISTENCIA's database of travel insurance claims from around the world, is the first global report to be published by the company. It looks at medical claims submitted by tourists from several source countries in Europe, Latin America and Asia Pacific travelling around the world, with a particular focus on the destinations in which their claims originate. European tourists still favour travel insurance In mature markets such as Europe, where public health care is widely available, it is still very common for travellers to take out travel insurance, even though the European Health Insurance Card (EHIC) entitles tourists from EU and EEA-member countries to the same health care throughout the EU and EEA free of charge or at a subsidised cost. This is attributed to the fact that many Europeans prefer to have a back-up, just in case they encounter problems, such as for trips involving winter sports and other sports activities. The number of associated claims received by MAPFRE ASISTENCIA is also quite high higher than would normally be expected notably during the winter sports' season and with regard to claims originating in countries with mountain resorts such as France, Spain and Andorra. even for domestic travel Travel insurance is clearly less common for domestic trips, since most travellers are covered by either national or private health schemes in their own countries. But many travellers do have annual policies, or policies included with their package tours, and some still take out insurance for independent domestic trips as evidenced by the high share of domestic claims in some source markets. In the case of claims handled by MAPFRE ASISTENCIA, the domestic share ranges from as low as 1% in Germany, or virtually 0% in the UK, to 30% in China, 31% in Spain, 33% in France, 58% in Turkey and 61% in Australia. The pattern of claims is very much in line with travel flows The results of the 2014 TIO analysis show that the incidence and share of medical claims in different destinations and in different months of the year closely follow holiday destination and seasonal travel trends, since 75% of all travel insurance policies sold are for leisure trips. The seasonality of medical claims is, not surprisingly, influenced by peak holiday periods such as the ski season, and is affected by annual shifts in popular travel periods like Easter, as well as by special events. In Brazil, for example, the main domestic peak for claims falls in February, during Carnival. One example from the UK, which highlights the impact of different events, was the sharp decline in the share of claims originating in Egypt in July 2013, the month in which a coup d'état in the country caused a sharp drop in travel demand for the destination. 7

8 Trends in medical claims by age the case of the UK The destination shares of claims by age group, for which MAPFRE ASISTENCIA has detailed information in its database on the UK market, provide some interesting insights into the type of medical problems incurred in individual parts of the world, and by whom. In the majority of regions, the highest share of medical claims comes from those aged (find out more about age ranges in the body of this document) and, contrary to common perceptions, the 65-plus age group submits the lowest share. Nevertheless, as can be seen from the following chart, the medical reasons for these claims vary considerably across the three broad age group categories indicated. Among young travellers under the age of 25, the most frequent claims by a wide margin are those involving Destination Related Diagnoses (DRD) while, among seniors aged 65 years or older, there is a higher preponderance for claims relating to Non-Destination Related Diagnoses (ONDRD). MAPFRE ASISTENCIA claims from the UK, by age group and medical diagnosis (%), 2013/14 TRAUMA cases are most prevalent among year-olds and, indeed, specifically among those aged 50-65, as will be seen in the main report. The second chart looks at claims by different types of Destination Related Diagnoses (DRD) across the different age groups. Claims for gastro-enteritis 8

9 and intestinal problems (GEA) the most common cause of DRD worldwide are most prevalent among year-olds; young people (aged 0-24 years) and seniors aged 65 and over are more likely to suffer from other types of infections, according to the respective shares of claims. Skin problems, although much less widespread, are not so prevalent among the oldest age groups; as is the case with allergies, but animal and insect bites appear to account for similar shares of claims across the different age segments. MAPFRE ASISTENCIA claims from the UK, by age group and DRD type (%), 2013/14 Regions where most (health incidents giving rise to) medical claims originate The chart overleaf shows that almost half of all MAPFRE ASISTENCIA medical claims worldwide originate in Europe, followed by North America and Latin America. The shares of claims originating in other regions are relatively modest. If domestic claims are excluded from the calculations, Europe's share falls by eight percentage points, with most other regions showing slightly higher shares as a result, but the share of claims from Oceania and Africa remains small in line with the respective regions' shares of world travel flows. 9

10 MAPFRE ASISTENCIA medical claims by destination region total and excluding domestic claims, 2013/14 Domestic claims affect top destination country ranking The destinations in which the majority of MAPFRE ASISTENCIA claims take place, are Spain, the USA and Turkey. But if domestic claims are excluded, the top two rankings reverse, putting the USA in first place, ahead of Spain, and followed by Egypt in third place. The prominence of the USA and Spain is hardly surprising given their importance as international tourism destinations ranking second and third in UNWTO's world ranking in arrivals (after France). But the reason for Egypt's third position as discussed in some detail in Part 2 of this report is its relative importance in the UK market and the overall weighting of the UK market in total MAPFRE ASISTENCIA claims. Total MAPFRE ASISTENCIA medical claims by destination country, 2013/14 17% 16% 13% 7% 9% 8% 7% 6% 5% 4% Spain USA Turkey Egypt France USA Spain Egypt Turkey France Total (Including domestic) Total (excluding domestic) 10

11 Claims from the main source regions by travel destination In order to understand better the kind of medical problems that different source markets experience in different parts of the world, we carried out a comparative analysis of the three main source regions from which MAPFRE ASISTENCIA receives medical claims i.e. Europe, Latin America and Asia Pacific. As suspected, the findings reveal some interesting similarities as well as differences in terms of where the medical claims originate. As can be seen on the chart on the following page, the vast majority of European medical claims originate in Europe, followed by Latin America and North America, with the Middle East and Asia accounting for just a modest share. If domestic shares are excluded, the difference in shares of the top three destination regions is slightly less marked, but Europe still dominates. The top three regions combined account for some 78% of MAPFRE ASISTENCIA medical claims from Europeans, or 74% excluding domestic claims. For Latin Americans, the top three destination regions in which medical claims originate are North America, Europe and Latin America generating more than 90% of total claims between them, whether or not domestic claims are taken into account. In the case of markets from Asia Pacific, however, the overall picture changes somewhat when domestic claims are excluded from the count, due to the high share of domestic claims from Australians. The top three regions in which claims originate are Oceania, Asia and Europe or an 85% share of total claims from Asia Pacific between them and, in order of importance, Asia, Europe and North America, excluding domestic claims (87% combined). Top 3 destination regions where claims of European, Latin Americans and Asia Pacific travellers took place, 2013/14 11

12 Countries accounting for the highest shares of medical problems Looking at destination countries rather than regions, the highest shares of European claims originate in Spain, Turkey and the USA or, excluding domestic cases, in the USA, Egypt and Spain. A breakdown of Latin American medical claims shows that North America dominates the overall picture because it is such an important destination for Brazilians. Indeed, Brazil is the leading outbound market from the region, generating more than one third of all trips abroad in 2013/14, according to various national and international sources (see Appendix for details) about the same as its share for medical claims. Top 3 destination countries where Claims of European travellers took place, 2013/14 19% 9% 9% 11% 11% 9% Spain Turkey USA USA Egypt Spain Total (including domestic) Total (excluding domestic) Top 3 destination countries where Claims of Latin American travellers took place, 2013/14 34% 35% 9% 6% 10% 5% USA Spain Brazil USA Spain Argentina Total (including domestic) Total (excluding domestic) 12

13 Top 3 destination countries where Claims of Asia Pacific travellers took place, 2013/14 33% 16% 11% 8% 12% 10% Australia USA Thailand USA Thailand India Total (including domestic) Total (excluding domestic) Destinations: Spain Brazil Egy pt Turkey Australia Argentina USA Thailand India In Asia Pacific, MAPFRE ASISTENCIA is established in four countries in the travel insurance business Australia, China, India and the Philippines. Australia, the USA and Thailand are the destinations in which the largest shares of claims originate again due to Australia's high share of domestic claims in the overall count. Excluding domestic claims, the USA, Thailand and India feature in the top three rankings. 13

14 Looking Forward As MAPFRE ASISTENCIA's travel insurance business expands and moves into even more markets, both organically and by acquisition, the Travel Industry Observatory report is expected to develop into an increasingly reliable and valuable source of information on trends in this key segment affecting international travel and tourism. The travel insurance market is a particularly interesting one to study as it provides a mine of information relating to customer preferences and behaviour all extremely useful for the travel industry. By way of example and to whet your appetite for next year it is interesting to note that: In the UK, 1 in 4 travel insurance policies sold by MAPFRE ASISTENCIA is bought by a young person aged years old; the respective share in Australia is 33%. 4 in 10 of the medical claims received by MAPFRE ASISTENCIA from the UK market relate to trips of longer than 1 month abroad. According to market research: In the USA, 1 in 5 policies sold is to the 71-plus age group. In the UK, under-40s are increasingly purchasing their travel insurance online; but the majority of travellers still prefer call centres because of the personal contact, and 4 in 10 call centre sales are to the 60-plus age group. Mondays and Thursdays are the most popular days for buying travel insurance in the UK; but in Ireland, the preferred day is Tuesday (17.4%). Most online transactions take place after 21:00, while call centre bookings tend to be made from 10:00-12:00, except in Ireland when the most popular time is after 16:00. 14

15 Part 1 Trends Around the World 1.1 Introduction First insights from MAPFRE ASISTENCIA's medical claims database This is the first time that MAPFRE ASISTENCIA has opened up its worldwide database of travel insurance claims following the decision to share information of interest and, hopefully, of benefit to governments, the travel and tourism industry and the travelling public. Last year's Travel Insurance Observatory covered just the UK market, which is again a major topic of this 2014 report, in Part 2. Part 1 provides a first insight into trends around the world generally, in markets in which MAPFRE ASISTENCIA and its partners are established in the travel insurance sector. The report covers primarily the 12 months of May 2013 to April 2014 (hereafter referred to as 2013/14), although there is also some comparison with the same period of 2012/13 for those markets for which MAPFRE ASISTENCIA has adequate claims data for analysis. It should also be noted that the analysis covers only medical claims both for Medical Assistance (which involve assistance from MAPFRE ASISTENCIA and/or its partners / agencies, and may require hospitalisation or repatriation) and Reimbursements (of the costs incurred, for example, from a visit to a doctor or the outpatients department of a hospital or clinic). We have followed the definitions laid down by the World Tourism Organization (UNWTO) in terms of geographical regions, with one exception. This is the case of Mexico which, as a source market, displays travel patterns and behaviour much more in line with other Central and South American (Latin American) nations, rather than with its North American Free Trade Association (NAFTA) partners, the United States and Canada. Interestingly, this definition was also adopted by UNWTO for the purposes of its 2014 report on Key Latin American Outbound Travel Markets. Data sources The data contained in Part 1 of the 2014 Travel Insurance Observatory and which forms the basis of the report comes from MAPFRE ASISTENCIA's database of medical claims originating in different countries around the world. The report looks at the main source markets in terms of the share of total claims handled by MAPFRE ASISTENCIA, and the main destination regions and countries where the claims originated in 2013/14. The more detailed analysis of the Spanish and Brazilian markets, which is also interesting to compare with the UK (where the different variables permit this), also includes a comparison of seasonal flows. The different source markets relating to MAPFRE ASISTENCIA claims are: Europe: Belgium, France, Germany, Italy, Malta Portugal, Spain, Turkey and UK; Latin America: Argentina, Brazil, Colombia, Mexico and Uruguay; 15

16 Asia Pacific: Australia, China, India and the Philippines. Belgium, Italy, Malta, Mexico, India, the Philippines and China are included in the overall analysis, but are not identified individually in the report as source markets, due to their relatively small sample of cases, but they are of course included in the overall analysis of destinations where claims originate. The claims data is set against data from the ForwardKeys database of Forward Data S.L, as well as statistics from national tourism surveys with regard to outbound trips from Brazil, Spain and the UK, and the World Tourism Organization (UNWTO) for arrivals in different countries from those markets. 1.2 Overview of World Trends The following chart demonstrates clearly the dominance of the UK and Spain, in terms of share of the medical claims handled by MAPFRE ASISTENCIA in the 12 months May 2013 to April 2014 (2013/14). The top five source markets accounted for more than 80% of total claims. Breakdown of MAPFRE ASISTENCIA medical claims by source market, 2013/14 Relative importance of claims originating in domestic markets Travel insurance is clearly much less common for domestic trips, since most travellers are covered either by national or private heath schemes in their own countries. And this is also true for travellers from European Union (EU) or European Economic Area (EEA) countries (including Switzerland) travelling within the EU and EEA, as long as they carry the European Health Insurance Card (EHIC). If they do, they are entitled in theory, at least to free or subsidised health care. However, many travellers do take out domestic travel insurance for specific travel activities, such as winter sports or just to be on the safe side as the EHIC does not cover private health care. 16

17 It is important to look at domestic claims as they account for very different shares of MAPFRE ASISTENCIA medical claims from one market to another and can, therefore, distort the overall picture. Markets in which domestic claims strongly influence the overall shares include Turkey, Australia, Portugal, France and Spain. The relative share is particularly important in the case of Spain, which accounts for such a high share of claims overall, as seen in the previous chart. More importantly, the inclusion or exclusion of domestic claims has a marked impact on trends. With all claims included, the total number of MAPFRE ASISTENCIA claims increased by 9.3% in 2013/14 but only by 0.7% if domestic claims are excluded from the count. Share of domestic claims in total MAPFRE ASISTENCIA claims, for selected source markets, 2013/14 Europe dominates the destination shares, even without domestic claims The respective shares of the destination regions in which MAPFRE ASISTENCIA claims originate both with regard to total claims and excluding domestic claims are compared in the following table. As already discussed, Europe dominates in terms of share, followed by North and Latin America. MAPFRE ASISTENCIA medical claims, by destination region, 2013/14 (%) Destination including domestic excluding domestic Africa Asia Europe Latin America Middle East North America Oceania Worldwide

18 The overall picture for claims involving foreign travel can be seen more clearly in the following chart: Total MAPFRE ASISTENCIA medical claims by destination region (excluding domestic claims), 2013/14 Middle East 9% Africa 3% Oceania 4% Asia 9% Europe 41% Latin America 17% North America 17% Similarly, an analysis by individual destination country of claims from all source markets in which MAPFRE ASISTENCIA sells travel insurance shows that the largest shares of claims originate in Spain (26%), the USA (20%) and Turkey (11%). But if domestic claims are excluded, the top spots are held by the USA, Spain and Egypt, albeit with smaller shares overall as shown in the following chart. The prominence of the USA and Spain is hardly surprising given their importance as international tourism destinations ranking second and third in UNWTO's world ranking in arrivals (after France). 18

19 MAPFRE ASISTENCIA medical claims by destination (in which claims originate), excluding claims originating in domestic markets, 2013/14 USA 16% Spain Egypt Turkey France Mexico Thailand Australia Andorra Dominican Rep. 9% 8% 6% 5% 4% 3% 3% 2% 2% Others 43% The reason for Egypt's third position in the claims ranking as discussed in some detail in Part 2 of this report is its relative importance in the UK market and the overall weighting of the UK market in total MAPFRE ASISTENCIA claims. The presence of Andorra and the Dominican Republic can be attributed in large part to the popularity of these destinations from Spain and, in the case of the latter, also the UK. 1.3 Analysis by Source Region This section compares trends across the three main source regions Europe, Latin America and Asia Pacific Europe European source markets generate the most claims As already indicated, European source markets account for the largest share of medical claims handled by MAPFRE ASISTENCIA 49% in 2013/14, or 41% of all international claims (i.e. those originating in foreign countries for the respective source markets). More than half the claims from the region also stem from medical problems that occur in Europe. The UK, in first position in the source market ranking, generates the majority of all non-domestic claims, ahead of Spain with the two together accounting for a high 86% share between them. France, Germany and Portugal, each representing only very modest share, make up the top five. 19

20 Total MAPFRE ASISTENCIA medical claims (excluding domestic) from Europe, by source country, 2013/14 UK 52% Spain 34% France Germany Portugal Turkey Other 4% 4% 4% 1% 1% The following chart highlights the destination regions in which most European medical claims originate: Europe again predominating, ahead of Latin America, North America, the Middle East and Asia. Although this study only covers claims from MAPFRE ASISTENCIA, the volume of claims amply justifies the analysis. However, this breakdown is quite surprising on at least two counts. Latin America comes well down the list of most visited destinations from Europe, according to UNWTO and national statistics certainly some way behind North America and Asia, if not also the Middle East and Africa yet it accounts for 16% of medical claims, second only to Europe in share. Africa's 4% share, meanwhile, which one might expect to be higher, is in fact very much in line with the destination's share of overnight volume out of, say, the UK (5%), or share of trips from Spain (5%) 2013 results for MAPFRE ASISTENCIA's two most important European source markets. Total MAPFRE ASISTENCIA medical claims (excluding domestic) from Europe, by destination region, 2013/14 Oceania 4% Asia 8% Africa 4% Middle East 11% Europe 45% North America 12% Latin America 16% 20

21 By way of comparison, the next table shows the respective shares of destination regions in which European claims originate with and without domestic claims. Total MAPFRE ASISTENCIA claims from Europe by destination region, 2013/14 (%) Destination including domestic excluding domestic Africa Asia Europe Latin America Middle East North America Oceania Worldwide European claims relate to a broad spread of destinations On a country-by-country basis, the highest shares of European claims originate in Spain (19%), followed by Turkey and the USA (both accounting for 9%). Spain's top place, however, is due to the high share of claims from Spaniards travelling within their own country, and the same trend also affects Turkey's position in the overall ranking. If domestic claims are excluded from the count, the top three ranking changes to the USA, Egypt and Spain, with the full top ten (see below) highlighting the variety of destinations visited by Europeans, as reflected in UNWTO and national statistics. In these top ten destinations, three are in the Americas (USA, Mexico and the Dominican Republic), one is in Asia Pacific (Australia), one in the Middle East (Egypt), and just five in Europe (Spain, France, Turkey, Greece and Andorra). MAPFRE ASISTENCIA medical claims (excluding domestic) from Europe, by destination country, 2013/14 USA Egypt Spain Turkey France Mexico Andorra Dominican Rep. Australia Greece Others 11% 11% 9% 8% 5% 4% 3% 3% 3% 3% 41% 21

22 1.3.2 Latin America The majority of claims from Latin American markets are from Brazil MAPFRE ASISTENCIA's well-established travel insurance business in Brazil, coupled with the strong growth in both domestic and outbound travel demand from Brazilians, means that a majority of claims are generated from this country for domestic as well as international trips. Nevertheless, the growth over the past 12 months in claims from Latin American travellers has not come from Brazilians, but rather from Argentinians from a much lower base, of course and, to a lesser extent (in percentage terms), Uruguayans. MAPFRE ASISTENCIA medical claims (excluding domestic) from Latin America, by source country, 2013/14 Brazil Uruguay Colombia Argentina Mexico 1% 3% 22% 19% 55% Given Brazil's dominant share of claims, however, it is hardly surprising that the market heavily influences the shares of destinations in which claims originate. Indeed, as can be seen clearly in the following two charts (both of which exclude domestic cases), North America dominates the overall picture because it is such an important destination for Brazilians, attracting more than one third of all trips abroad in 2013/14, according to various national and international sources about the same as its share for medical claims. Europe ranked second and neighbouring Latin American countries third. MAPFRE ASISTENCIA medical claims (excluding domestic) from Latin America, by destination region, 2013/14 Oceania 4% Asia 3% Africa 1% Middle East 0% Latin America 25% North America 37% Europe 30% 22

23 With claims from Brazil taken out of the equation completely, the picture changes dramatically. Not surprisingly, since most of the less mature Latin American markets like Colombia and Uruguay travelled primarily within their own region in 2013/14 as they traditionally tend to do the share of claims originating in Latin America increased sharply, to 33%, ahead of that for Europe (with 28%) and North America (with 26%). Claims originating outside those three regions were relatively few and far between. MAPFRE ASISTENCIA medical claims (excluding domestic and Brazil) from Latin America, by destination region, 2013/14 Oceania 8% Asia 4% Middle East 0% Africa 0% North America 26% Latin America 33% Europe 28% 23

24 The following chart, which helps to substantiate the findings noted above, compares the share of Latin American claims by destination region the region where the claims originated (excluding domestic cases and all cases related to the Brazilian market) to that of inbound overnight volume from those countries. The chart shows just how important intraregional travel is for Latin Americans, since the region generates two thirds of all nights spent abroad (2013/14 data). Yet the share of medical claims originating in Latin America is only half that according to industry experts, most likely attributable to the fact that many Latin Americans do not bother to take out travel insurance on short trips to neighbouring countries. MAPFRE ASISTENCIA claims from Latin Americas vs. nights spent abroad in different destination regions, 2013/14 (%) Claims Nights 65,2 28,5 32,7 25,8 21,1 4,4 0,3 0,2 0,7 12,4 0,4 0,2 7,8 0,3 Africa Asia Europe Latin America Middle East North America Oceania Source region: Argentina,Colombia, Mexico and Uruguay (excludes Brazil). Finally, it is interesting to look more closely at the individual destination countries in which claims from Americas markets originate. Since domestic claims are relatively unimportant in terms of their share of total claims from Latin American markets their inclusion or exclusion makes little different to the overall breakdown. But, once again, we compare the shares with and without Brazil as a source market. In the case of the former, the USA stands out as the number one destination by a wide margin, accounting for more than one third of claims, followed by Spain and Argentina a 50% share for the three combined. When we exclude Brazil as a source market, the top three destinations the USA, Spain and Brazil are closer together in share and together account for a lower 44%. 24

25 % shares of destinations in which MAPFRE ASISTENCIA claims from Latin America originated, 2013/14 Destination including Brazil excluding Brazil as a source market as a source market USA Spain Argentina 5 6 France 4 3 Mexico 4 - Brazil 4 8 UK 3 5 Portugal 3 - Italy 3 2 Canada 3 4 New Zealand - 6 Peru - 2 Others Total Without the influence of Brazil, which we focus on as a source market later in this report, other perhaps surprising destinations emerge in the top ten New Zealand, accounting for a 6% share of claims, and Peru, with 2% Asia Pacific A fast-growing source region, with a high share of domestic claims MAPFRE ASISTENCIA is established in the Asia Pacific travel insurance market, selling policies in four countries Australia, China, India and the Philippines and its operations are already showing signs of rapid growth. Australia as a source market for medical claims has increased by more than 200% over the past 12 months in line with the market's overall growth and there has been a similar trend in Asia. A breakdown of medical claims by source country shows the strong dominance of Australia and China, but this is partly due to the fact that both markets have a very high share of domestic claims. The respective share of domestic claims in total claims is extremely modest in the case of India and the Philippines. MAPFRE ASISTENCIA claims from Asia Pacific, by source country, 2013/14 The high share of domestic claims from Australians also distorts the overall picture in terms of the breakdown of destinations in which MAPFRE 25

26 ASISTENCIA medical claims originate. In 2013/14, one third of all claims from the region originated in Australia, 11% in the USA and 8% in Thailand. However, if domestic cases are excluded from the destination analysis, in order to remove the bias in favour of Australia and, to a lesser extent, China, it can be seen that Asia still features very strongly as a source of claims for Asian policy-holders. But Europe follows closely behind, some way ahead of North America and Oceania Australia, New Zealand and the Pacific Islands. Only a modest share of claims originates in other regions of the world. MAPFRE ASISTENCIA claims (excluding domestic) from Asia Pacific, by destination region, 2013/14 North America 18% Oceania 7% Africa 2% Latin America 2% Middle East 1% Asia 40% Europe 30% The destination country breakdown of claims is quite diverse, reflecting the wide range of destinations visited. The USA and Thailand head the list, followed by Indonesia and Spain. MAPFRE ASISTENCIA medical claims from Asia Pacific by destination country, 2013/14 USA Thailand Indonesia Spain Germany New Zealand France Japan Canada UK 5% 4% 3% 3% 2% 2% 8% 10% 12% 16% Others 35% 26

27 1.4 Leading Source Markets: UK, Spain and Brazil Europe generates a high share of claims in all three markets As already discussed, the three most important source markets in 2013/14, in terms of the share of total medical claims handled by MAPFRE ASISTENCIA (excluding domestic cases), were the UK (31%), Spain (30%) and Brazil (9%). Domestic cases have been excluded from the comparison because they are far more important as a share of total claims for Spain than for the other two markets, which would distort the findings. The following graph compares the shares of claims originating in different destination regions for the three source markets. In the case of the UK and Spain, Europe accounts for the highest shares of claims, ahead of Latin America in the case of Spain, and the Middle East in the case of the UK. Travel destination preferences are naturally different for Brazil, because of its geographical location on a different continent and in the Southern Hemisphere but Europe is still important as a claims-originating region for the Brazilian market, albeit some way behind the USA in top spot. Given the pattern of travel flows from these three markets to destinations around the world, the share of claims would seem to be more or less in line with the importance of each destination region to the specific market. But among the anomalies, or surprise findings, of our comparative analysis is the low share of Asia in the case of the UK and the lower than expected share of Latin America in the case of Brazil. % shares of MAPFRE ASISTENCIA medical claims by destination region for the three leading markets Spain, UK and Brazil, excluding domestic claims, 2013/14 Brazil Spain UK Africa Asia Europe Latin America Middle East North America Oceania More differences than similarities between the three markets The UK is the subject of more detailed analysis in Part 2 of this report. But it is nevertheless interesting to highlight here some of the key findings of the UK analysis, so as to make direct comparisons with the other two markets, particularly with Spain, a sister European market. 27

28 % share of MAPFRE ASSISTENCIA claims from Spain, UK and Brazil in top 3 and top 10 destinations, 2013/14 Let us consider the top destination countries in which UK claims originated in 2013/14. The top three Egypt, Spain and Turkey accounted for 50% of total claims made by UK travel insurance policy-holders, while for Spain the respective share (of the top three foreign destinations: USA, Mexico and Andorra) was a mere 17%. Brazil's top three destinations (USA, Spain, Portugal) generated a 54% share, closer to that of the UK. In terms of the top ten shares, the differences were equally striking 80% in the case of the UK and 77% for Brazil, but just 36% for Spain. Where MAPFRE ASISTENCIA claims from the UK originated (excluding domestic), 2013/14 UK is Europe's second largest outbound travel market As Europe's second most important outbound travel market after Germany, the UK generates some 58.5 million trips abroad annually (2013), with 22% of total trips to, and 40% of overnights in, destinations outside Europe. This is a much higher share than the average for European markets. 28

29 Spain is the UK market's leading destination, ahead of France and the USA two other destinations also featuring high up the list in terms of claims. In 2013, Spain attracted 11.8 million British tourists who stayed an average of 9.2 nights per person, or a total of 108 million nights in the country. Turkey is also an increasingly popular choice for British holidaymakers, recording 1.4 million arrivals from the UK and 16.5 million overnights in Egypt, while not featuring among the UK's leading tourism destinations, is a favourite for year-round holiday travel, especially among those looking for some winter sunshine. Despite the continuing unrest and intermittent violence in Egypt since the start of the Arab Spring, UK demand for the destination has held up reasonably well, showing growth of more than 5% in overnight volume in 2013 to around 5 million overnights from more than 400,000 British tourists. But, as will be discussed later, the coup d'état in July 2013 did cause a sharp, if short-lived, decline. Spanish domestic travel booms but outbound still lags behind According to the 'Familitur' survey conducted by Spain's Instituto de Estudios Turísticos (IET), Spaniards took 156 million trips in Of these, 145 million, or 93%, were domestic. The high level of domestic travel demand is not surprising given the vast array of tourism attractions offered by Spain, not least for summer sun & beach vacations. And the importance of domestic travel is understandably reflected in the volume and share of Spanish medical claims originating in Spain. Where MAPFRE ASISTENCIA claims from Spain (excluding domestic) originated, 2013/14 USA Mexico Andorra France Dominican Rep. UK Italy Germany Peru China Others 8% 5% 5% 4% 3% 3% 2% 2% 2% 2% 64% The Spanish outbound travel market still lags somewhat behind that of its northern European neighbours, as well as France and Italy. But it is more adventurous than many other European markets, with 22% of its 11.2 million outbound travellers in 2013 heading to non-european destinations. The Americas attracted 1.2 million, Africa 1.0 million and Asia still the least developed non-european region in terms of demand in the Spanish market around 300,

30 This helps to explain why so many non-european countries feature among the top ten foreign destinations in which Spanish claims originate the USA, Mexico, the Dominican Republic, Peru and China. However, the absence of African destinations in the claims' breakdown is somewhat surprising. Andorra, in third place in terms of share of medical claims from Spain, is especially popular as a winter destination, as can be seen in the time series charts in the following sub-section. And France, in fourth place, is a popular city break destination for Spaniards, usually visited in the shoulder months in spring and autumn. Brazilians' strong bias towards the USA With 62% of all Brazilian outbound trips generated by the Americas and first and foremost by the USA it comes as no surprise to see that the USA accounts for such a high share of Brazilian medical claims abroad. It is also a year-round destination, although the highest shares of claims originate in the peak summer and winter travel months of January (14%) and July (11%). As already indicated, Europe generates 31% of all claims, spread across a number of countries, with Spain, Portugal and France being the most important. The trend also appears to be in line with outbound travel patterns from Brazil to Europe. Where MAPFRE ASISTENCIA claims from Brazil (excluding domestic) originated, 2013/14 USA Spain Portugal France Argentina Italy UK Canada Germany Mexico Others 6% 5% 5% 3% 3% 3% 3% 3% 2% 23% 43% By way of interest, Brazilians took 53 million trips in 2013 involving overnights in commercial accommodation i.e. excluding most VFR travel. Outbound travel intensity, or the share of the population who travel abroad, is still only 4%, but these 7.9 million Brazilians took 8.7 million outbound trips. 30

31 1.5 Analysis of Seasonality Valuable insights to be gained from seasonal flows The case of the UK is presented in more detail in Part 2 of this report but, at the risk of repetition, we would like to highlight some of the differences across the three markets for comparative purposes at least in terms of their respective monthly and seasonal shares of total medical claims. The case of Egypt has already been noted the dip in claims and travel during the month of July 2013 following the coup d'état but the graph also highlights the predominance of claims during the summer months, which account for at least two thirds of all British trips abroad. The stagnation in share of claims in March and April 2014 can in part be attributed to the timing of Easter, which fell in April in 2014, boosting travel demand during that month. Records from the UK Office of National Statistics show that, in spring 2013, domestic travel demand was strong, possibly at the expense of travel abroad, which might explain the apparent stagnation in share of claims. Monthly shares of MAPFRE ASISTENCIA medical claims from the UK, 2012/ / / /14 Average 16% 14% 12% 10% 8% 6% 4% 2% 0% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr The following chart highlights the monthly breakdown of claims among the top five destinations, in terms of share. As an example, Egypt accounted for its highest monthly share of UK claims in November, a favourite month for UK tourists, but one with a lower overall share as the chart above shows. Claims originating in Spain and the USA are fairly balanced in terms of share through the 12 months, highlighting the fact that they are year-round destinations. Turkey, on the other hand, accounts for a much higher share of UK claims in summer, in line with its high share of overnights from the UK. 31

32 Monthly % shares of MAPFRE ASISTENCIA claims from UK in top five destinations, 2013/14 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Egypt Spain Turkey USA France Others Total Seasonal claims patterns in line with travel flows While domestic claims in the UK are insignificant in number, and so do not really warrant detailed analysis, Spain presents a totally different picture. In the first graph, which looks at total travel for 2012/13 and 2013/14, the summer and spring months all show a higher than average share of claims. However, the shares for the months of January through March were quite a bit higher in 2013/14 likely due in part to the later Easter, but also because of increased winter sports travel to Andorra and domestic ski resorts. MAPFRE ASISTENCIA medical claims from Spain (total), 2012/ /14 (%) 2012/ /14 Average 16% 14% 12% 10% 8% 6% 4% 2% 0% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Domestic vs. international trends There is little difference in the overall trends regarding international claims, i.e. claims originating in foreign destinations, as can be seen from the following chart. 32

33 MAPFRE ASISTENCIA medical claims from Spain, excluding domestic, 2012/ / / /14 Average 16% 14% 12% 10% 8% 6% 4% 2% 0% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr In sharp contrast to the situation in the UK, and also Brazil (see below), the top five destinations in which claims originate from the Spanish market (2013/14 data) never account for more than 50% of all claims in any one month. And the average share for the year is around one third, or 33%. The 50% is only reached in the peak winter sports months of January and February when Andorra's share rises to 20% and 26%, respectively. The USA's monthly share of claims remains steady through the winter months at around 10%, but picks up to 13-14% in the peak Spanish summer travel season, at the expense of neighbouring destinations like Andorra and France. France is the favourite summer hot spot for several European nations. But not in the case of Spain, since the majority of Spaniards still take their main summer vacations in their own country. In the case of the Spanish market, as reflected by the respective shares of medical claims originating in France on a monthly basis, the destination is less popular in the peak travel season. But, as France's tourism industry has recognised for many years, demand from Spain which is pretty heavily concentrated on city trips and short breaks is much higher, relatively speaking, in the winter and shoulder months of the year. It therefore comes as no surprise to see France's monthly share of medical claims peak at 10% in the month of December and 9% in April. Monthly % shares of MAPFRE ASISTENCIA claims from Spain in top five destinations, 2013/14 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr USA Mexico Andorra France Dom. Rep Others Total

34 The monthly shares of domestic claims present a much more dramatic picture. The two seasonal peaks can be explained by Spaniards' enthusiasm for winter sports holidays, or at least mountain holidays, which tend to peak between February and Easter no doubt resulting in a rise in cases of TRAUMA, such as skiing fractures. Monthly shares of MAPFRE ASISTENCIA domestic claims in Spain, 2012/ /14 (%) 2012/ /14 Average 16% 14% 12% 10% 8% 6% 4% 2% 0% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr The August 2013 peak may be attributed to the upturn in Spain's economic situation at about that time, motivating Spaniards to go on holiday. Statistical trends from IET's Familitur database also point to a strong increase in domestic travel in 2013, which has continued into Brazil outbound travel and medical claims show the same annual peaks Seasonal patterns from Brazil, in terms of medical claims, show a peak during the main summer holidays, in January, but also during the winter. In 2013/14, the two peaks were equally important. MAPFRE ASISTENCIA medical claims from Brazil, excluding domestic, 2012/ /14 (%) 2012/ /14 Average 16% 14% 12% 10% 8% 6% 4% 2% 0% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 34

35 This coincided with the sharp peak in medical claims in January At the start of 2013, according to the ForwardKeys database, outbound travel demand in Brazil suffered a drop of nearly 6%, resulting in a fairly flat year in terms of seasonal flows. The trend is also reflected in the spread of medical claims over 2012/13 when seasonality was somehow more flat. Interestingly, in the following year 2013/14, the share of medical claims started to fall slightly from February, with the decline accelerating in April. This was possibly due to the approach of the FIFA World Football Cup, which also saw a marked slowdown in demand for travel, especially to long-haul destinations. The following chart confirms in no uncertain terms the importance of the USA as a destination from Brazil, accounting for between 38% and 52% of total claims each month in 2013/14. Other significant destinations on a monthly basis are Spain where the share of claims peaks in February (12%) and May (10%), and France in June (10%). Monthly % shares of MAPFRE ASISTENCIA claims from Brazil in top five destinations, 2013/14 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr USA Spain Portugal France Argentina Others Total

36 Part 2 The UK Market 2.1 Background and Methodology MAPFRE ASISTENCIA in the UK Scope of analysis Since MAPFRE ASISTENCIA acquired 'InsureandGo' in October 2010, it has not only expanded the UK brand considerably, but has also exported it to a number of other countries, including the United States, Ireland and Australia. InsureandGo is now the leading UK travel insurance specialist, selling an increasing share of its policies in the UK online, as well as being the overall world leader in online travel insurance distribution, with more than 2.8 million sales in Following the parameterisation of the InsureandGo medical assistance claims data subsequent to the brand's acquisition, MAPFRE ASISTENCIA set up a Travel Insurance Observatory in The findings of the first statistical analysis, published in September 2013, covered the part-year July 2012-April 2013 (see Appendix for more details). This was the first significant period for which data was deemed sufficiently accurate for meaningful analysis, including diagnosis per claim in line with the World Health Organization's International Classification of Diseases (ICD-10). Part 2 of this 2014 Travel Insurance Observatory report, which provides a comprehensive review of the UK market, including an analysis of trends over the past 12 months, covers the travel insurance claims handled by MAPFRE ASISTENCIA through its subsidiary InsureandGo in May 2013 to April 2014 (hereafter referred to as 2013/14) claims corresponding to InsureandGo international travel policies issued in the UK. Medical claims whether for Medical Assistance or Reimbursements are handled separately from non-medical claims (Other Personal Benefits), which allows for a more accurate assessment and understanding of the diagnoses related to the medical claims that are directly linked to the destinations visited by the UK travel insurance policy-holders. Claims for Other Personal Benefits are discussed briefly, but the main focus of this report is on medical claims. In addition to a detailed breakdown by destination the region and country in which the medical problems originated the analysis looks at the types of medical problems most faced by UK travellers abroad the so-called diagnostic groups. Cases are also analysed by age and how they relate to the flow of travellers from the UK to the same regions and countries. This analysis is made possible thanks to the findings of the UK Travel Trends reports for , together with other data from the UK Office for National Statistics (ONS) International Passenger Survey and air bookings data from Forward Data S.L. and its ForwardKeys.com database. Some comparisons are also made with MAPFRE ASISTENCIA's findings related to 2012/13 the period has been updated and aligned with that of May 2013 to April 2014 to provide a full 12 months of data. 36

37 2.2 Types of Travel Insurance Cover Medical incidents account for most UK claims A breakdown of the total claims handled by MAPFRE ASISTENCIA in the UK shows that medical, or health-related, claims comprising those involving comprehensive Medical Assistance as well as those simply for Medical Reimbursements accounted for 56% of the total cases handled in the 12-month period 2013/14, while Other Personal Benefits (non-medical claims) represented 44%. The breakdown was virtually identical in 2012/13 although, due to a typing error, the respective shares for Medical Assistance and Medical Reimbursements were mistakenly reversed in MAPFRE ASISTENCIA's 2013 Travel Insurance Observatory report. Breakdown of total MAPFRE ASISTENCIA claims, 2013/14 Other Personal Benefits 44% Medical Assistance Claims 22% Medical Reimbursemen ts 34% Medical Assistance Claims are those that need immediate assistance and/or hospitalisation of the insured at the destination, or even repatriation, and for which the direct intervention of MAPFRE ASISTENCIA operators is required. Medical Reimbursements, on the other hand, relate to less serious cases, possibly requiring a visit to the outpatients department of a clinic or hospital for a medical diagnosis and prescription for medication, the costs of which will be later reimbursed. Other Personal Benefits (OPB), the non-medical cases, primarily concern trip cancellations for health issues affecting the beneficiaries prior to the start of their trip (i.e. in the country of origin), but they can also involve incidents during their trip such as lost baggage, travel delays, missed flights and other problems (see below). Medical versus nonmedical problems It is interesting to compare the respective shares of UK travellers' claims related to medical and non-medical incidents (OPB). As highlighted in the following chart, which compares the shares in the top ten destination countries in which medical claims originate, the share of OPB (which excludes cancellation cover since this is largely restricted to the country of origin) generally exceeds that of medical claims. 37

38 However, this is not at all the case in Egypt, where the share of medical claims outnumbers that of OPB by 9:1, or in Turkey where the ratio of medical to nonmedical claims is 3:1, and in the USA, where it is just under 2:1. Selected destinations' shares (%) of MAPFRE ASISTENCIA medical and non-medical (OPB) claims, 2013/14 Destination Medical claims OPB Egypt Spain Turkey USA France Greece Cyprus Thailand Canada Mexico Others Total In Spain, where the ratio of medical to non-medical (OPB) claims is reversed nearly 2:1 in favour of OPB one seemingly obvious explanation is that travellers to the European Union (EU) or other European Economic Area (EEA) member countries are entitled to free or heavily subsidised stateprovided healthcare if they carry the European Health Insurance Card (EHIC). The EHIC does not cover private medical healthcare or costs, such as mountain rescue in ski resorts, repatriation to the UK, or lost or stolen property, but it should certainly cover the majority of non-serious medical complaints from which travellers are prone to suffer while abroad. The fact that such a high share of claims in the EU and EEA still relate to medical complaints would tend to suggest that the EHIC might not be as reliable as travellers might expect in all countries. Forewarned is forearmed, the well-known idiom goes 2.3 Non-medical Claims Ten broad categories of which three account for 90% of claims Non-medical claims, or Other Personal Benefits (OPB), can be divided into ten broad categories, as shown in the following chart. As already indicated, cancellation of a trip due to health or other concerns prior to the traveller's, or the travel group's, scheduled departure is the most common reason for claiming OPB: it accounts for 48% of all OPB claims The share has risen from 42% in 2012/13. The second most frequent reason for OPB claims is lost or stolen baggage (21%), followed by lost documents or money (11%) and travel delays for different reasons (10%). These three categories represent a high 90% of all OPB claims. More significantly, the respective shares, in terms of the number 38

39 of claims for OPB overall, have shown virtually no change over the past 12 months. Breakdown of Other Personal Benefits relating to MAPFRE ASISTENCIA claims, 2013/14 10% 8% 0,5% 0,2% 1,7% 0,0% 0,0% Cancellation Baggage Documents/money Travel delays Travel changes 11% 48% Sports-related Special cover Additional expenses 21% Muggings & crime Transport 2.4 Medical Claims What kind of medical problems are the most common? Medical claims can be classified into three different categories, broadly dependent on the health risk associated with the destination or type of destination and/or travel experience. A significant share of claims can be attributed to causes more or less related to the travel destination: allergies, animal and insect bites, infectious diseases (both bacterial and viral), gastro-enteritis, diarrhoea and abdominal pain (GEA), respiratory infections, urinary tract infections, dermatitis, conjunctivitis, altitude and other decompression sicknesses, sunburn and other burns. These have been catalogued for the purposes of this monitor as 'Destination Related Diagnoses', hereafter referred to as 'DRD'. A second series of complaints can be grouped under the heading of TRAUMA. These are mainly attributable to accidents, which may or may not be related to the travel experience and/or destination. A fall or a traffic accident, for instance, may have occurred independently of the trip. A skiing accident, bungee jump or rafting accident, on the other hand, will be very much linked to the type of travel. Nevertheless, such claims may have a much weaker causal link to the destination itself than the previous group, and so are referred to in this report's analysis as simply 'TRAUMA'. Finally, the third category is linked to causes independent of the destination, or which could have occurred even if the trip had not taken place: chronic illnesses, cardio-vascular diseases, anaemia, tumours, epilepsy, etc. These are referred to here as Other Non-Destination Related Diagnoses, or 'ONDRD'. 39

40 Of the total medical claims handled in the UK by MAPFRE ASISTENCIA in 2013/14, 49% were diagnosed as DRD, 26% were TRAUMA related and 25% ONDRD. This breakdown shows little change over that of 2012/13, when the shares were 48%, 27% and 25% respectively. MAPFRE ASISTENCIA medical claims worldwide from the UK, by type of diagnosis, 2013/14 ONDRD 25% DRD 49% TRAUMA 26% UK travellers are more likely to suffer a DRDrelated medical problem outside Europe The following chart highlights the different types of health risk for UK travellers in Europe and in destinations further afield. Not surprisingly, given that many popular destinations outside Europe are in the tropics, where climate- and food-related ailments are inevitably more common, the share of DRD medical claims is much higher in these regions than in Europe (59% as against 39%). In Europe, on the other hand, TRAUMA accounts for a significantly higher share of claims (33% compared with 19% in the rest of the world), no doubt in large part because of skiing and other sports-related accidents. Although other regions, such as North and South America, Northeast Asia and Australia and New Zealand, offer fantastic conditions and facilities for winter sports, British enthusiasts are more likely to take their winter sports holidays in Europe. MAPFRE ASISTENCIA claims from the UK by type of diagnosis, 2013/14 in Europe in the rest of the world ONDRD 28% DRD 39% ONDRD 22% DRD 59% TRAUMA 33% TRAUMA 19% 40

41 2.5 Medical Claims by Destination Region Type and level of health risk vary by region As already indicated, the type of medical problems experienced by UK travellers abroad varies considerably from region to region. A more detailed analysis by region and country is provided below but, as a general rule, claims originating in the Middle East are much more likely to be destination-related (DRDs) than those originating in other regions. DRDs account for 80% of all claims originating in the Middle East. They also account for high proportions of claims in Asia (51%) and Latin America (50%), but a low proportion in Oceania (27%). The share of DRDs in Europe is also relatively low. This can of course be explained by the fact that the majority of UK residents travelling in continental Europe at least in the EU and EEA member countries carry the European Health Insurance Card (EHIC) and are able to receive medical care either free of charge or at reduced cost. % shares of MAPFRE ASISTENCIA UK claims by type of diagnosis in each region, 2013/14 DRD TRAUMA ONDRD Africa Asia Europe Latin America Middle East North America Oceania The proportion of TRAUMA cases is highest in Europe and Oceania, with Oceania also having the highest proportion of Other Non-Destination Related Diagnoses (ONDRD). Half of all claims originate in Europe Not surprisingly, given the dominant position of Europe in the UK ranking of foreign destination regions visited, a significant share of the UK claims (50%) handled by MAPFRE ASISTENCIA in 2013/14 originated in Europe. However, the share was still well below the 78% share of actual trips taken to, or overnights (60%) spent in, other parts of the European region. Again, this can be explained by the fact that most UK residents travelling in continental Europe carry the EHIC, as described just above. 41

42 MAPFRE ASISTENCIA UK medical claims by destination region, 2013/14 Latin America 5% Asia 6% Africa 2% Oceania 2% North America 14% Europe 50% Middle East 21% A comparison with the 2012/13 results shows that the breakdown has remained stable. Europe's share is down very slightly, as are Asia's and Oceania's, with North America showing the most appreciable increase, albeit a modest one, of two percentage points. High share of Middle East-originating claims attributed to Egypt In order to avoid any distortion of the regional breakdown due to the impact of the European Health Insurance Card (EHIC) on claims originating in EU and EEA countries, the following chart excludes Europe from the world breakdown. This draws attention to the relative significance of the Middle East in the overall picture, especially when the share of claims is compared with that of overnights spent in the region in 2013/14 by UK travellers. Share of nights spent abroad by UK residents vs. medical claims by region, excluding Europe, 2013/14 Claims Nights 41% 26% 28% 28% 5% 15% 12% 10% 14% 10% 3% 7% Africa Asia Latin America Middle East North America Oceania 42

43 t is therefore important to note that more than 50% of medical claims in the Middle East region originate in Egypt. Although the civil unrest and violence in Egypt over the past few years have undoubtedly taken a toll on demand for the destination, it remains a popular destination for UK outbound holidaymakers, accounting for some 4.8 million overnights from the UK in 2013/14. And, as other evidence will confirm later in this report, the incidence of DRDs is relatively high in Egypt's main tourism resorts. North America shows a close correlation between medical claims and overnights The only region in which the shares of claims and overnights appear to be well correlated is North America, although Latin America comes close behind. For the purposes of this report, Mexico has been included in Latin America rather than in North America. North America, which therefore comprises the USA and Canada for the purposes of this study, is not a region that is perceived as posing serious health risks for travellers. But because it is seen as a very expensive destination for medical treatment of all kinds, the British, like most other travellers, do pay particular attention to taking out travel insurance when visiting North America. And it would seem that the region's share of claims is in proportion to the overnight volume from the UK. For Latin America, on the other hand, the fact that the share of medical cases per overnight volume is quite modest comes as a surprise, since local tour operators and suppliers usually recommend taking out good insurance coverage for any trip to the American sub-continent. The same is also true of Africa (another region representing a small sample) and the trend also begs the question "Why?" The most likely answer is that the destinations most visited by the British in Africa pose less of a health risk than general perceptions of the continent would lead some to believe. In Oceania, i.e. Australia, New Zealand and the Pacific Islands, where the situation is similar, there is a good explanation. Under reciprocal healthcare arrangements between the UK, Australia and New Zealand, British citizens resident in the UK and travelling on a British passport are entitled to limited subsidised health services when visiting the two countries. So it makes sense to see a reduced incidence of medical claims in these destinations. 2.6 Individual Country Analysis Top ten countries account for 77% of all medical claims Of the total UK claims handled by MAPFRE ASISTENCIA in 2013/14, 77% originated in just ten countries, and a mere four countries accounted for as many as 62% Egypt, Spain, Turkey and the USA, in order of importance. The ranking remains unchanged from that of 2012/13, as do the countries in the top 20, in which more than 90% of all claims arose. 43

44 Top ten destinations in terms of MAPFRE ASISTENCIA medical claims from the UK market, 2013/14 % share Destination 2012/ / /14 Egypt 3,080 3, Spain 2,211 2, Turkey 2,090 2, USA 1,519 1, France Greece Cyprus Thailand Bulgaria Canada Others 2,925 3, Total 14,801 15, Breakdown of total MAPFRE ASISTENCIA UK claims by destination country, 2013/14 Others 23% Egypt 20% Thailand Cyprus 3% 4% Greece 4% France 4% USA 12% Turkey 15% Spain 15% In order to provide a better understanding of the relative sample size in relation to the importance of the destination, the following tables compare the shares of total claims with the respective shares of nights from the UK in 2013/14. The results should be interpreted with caution since reliable conclusions cannot be drawn without more details of total medical claims as a share of policies sold. But the exercise does provide a useful indication of the relative weight of medical claims in different destinations. The analysis has been separated into two groups the first covering European countries and the second, the rest of the world without Europe so as to take into account the differences in claims that could be attributed to the effects of the European Health Insurance Card (EHIC). Spain and Turkey account for the highest shares of medical claims Just under 50% of all medical claims handled by MAPFRE ASISTENCIA in 2013/14 originated in Europe, which generated about 60% of all nights spent abroad by UK travellers over the same period. With the notable exception of 44

45 Turkey, the destinations in which most medical claims originate among UK travellers are all members of the EU and/or the EEA, led by Spain and France the top European destinations for the British in terms of both trips and nights spent abroad. Turkey accounts for the second highest share of medical claims but is only the sixth most popular European destination out of the UK in terms of nights. This suggests that it is a destination that poses a higher health risk than average. The share of claims in France, Italy and Portugal are below what their market share would suggest, whereas in Bulgaria, Cyprus and, to a lesser extent, Greece, Austria and Malta, they are well above. Spain and Switzerland show a more moderate relationship although, in the case of Spain, the volume is significant, while Switzerland represents a very modest number of claims. Breakdown and shares of claims and nights in European destinations, 2013/14 No. of No. of % share of % share of % share of claims/ Destination claims nights claims nights % share of nights Spain 2, , Turkey 2,310 16, France , Greece , Cyprus 627 7, Bulgaria 215 3, Italy , Austria 155 4, Portugal , Malta 107 5, Switzerland 78 5, Other Europe 8,038 92, Total Europe 15, , Note: The shares of claims and nights have been rounded which causes some distortion in the calculations of % share of claims over % share of nights. Sources: MAPFRE ASISTENCIA for no. of medical claims; UK Travel Trends, UK Office of National Statistics (ONS) for overnight data. Egypt stands out as the destination posing the greatest health risks Non-European countries accounted for 50% of all the medical claims made by British travellers and handled by MAPFRE ASISTENCIA in 2013/14 the same as for Europe overall. As might be expected, however, Europe attracted a much higher share of trips (78%) and nights (60%) but the British are nevertheless adventurous travellers, with over 12.6 million of them in 2013 choosing destinations outside Europe where they spent 243 million nights. As far as medical claims were concerned, the majority of countries in the top ten (for claims) accounted for fewer claims than might have been expected, with India (0.2), Australia (0.3), South Africa (0.5) and Tunisia (0.7) heading the list. Thailand (1.6), the USA (1.4), Canada (1.3) and Mexico (1.1) registered more claims than they should have done, but in a ratio of not much more than 45

46 1.1. In sharp contrast, Egypt accounted for substantially more claims than it should have done (20.2), implying that it is a high-risk destination. Breakdown and shares of MAPFRE ASISTENCIA UK claims and nights in non-european destinations, 2013/14 No. of No. of % share of % share of % share of claims/ Destination claims nights claims nights % share of nights Egypt 3,202 4, USA 1,961 43, Thailand 474 9, Canada 266 6, Mexico 227 6, Australia , India , Tunisia 102 4, South Africa 101 6, Other non-europe 1, , Total non-europe 7, , Notes: The shares of claims and nights have been rounded which causes some distortion in the calculations of % share of claims over % share of nights. The Dominican Republic is not included as comparative data on UK overnights is not available. But these are estimated at around 1.2 mn. Sources: MAPFRE ASISTENCIA for no. of medical claims; UK Travel Trends, UK Office of National Statistics (ONS) for overnight data. Five countries account for nearly 80% of all medical claims outside Europe The following chart highlights the relative weight of the most important destinations in terms of share of medical claims. With Europe excluded from the count, Egypt's share increases to 40%, followed by the USA with 25% and, some way behind, Thailand with 6% and Canada and Mexico with 3% each. Breakdown of total MAPFRE ASISTENCIA UK claims by destination country, excluding Europe, 2013/14 Mexico 3% Canada 3% Thailand 6% Others 23% Egypt 40% USA 25% 46

47 GEA cases strongly predominate in terms of type of medical claim An analysis of medical claims from around the world shows that gastrointestinal and other abdominal problems (GEA) are the most widespread. In 2013/14, they accounted for more than half (51%) of all the medical claims handled by MAPFRE ASISTENCIA from sales of InsureandGo travel insurance policies. The second most common category was infections (34%) all types, whether bacterial or viral followed, a long way behind, by animal and insect bites (7%), allergies (4%), skin problems (3%) and altitude sickness (1%), including decompression problems. Interestingly, there has been almost no change in the breakdown of medical complaints in the 12 months since 2012/13. The shares of GEA and animal / insect bits have fallen, while skin problems and infections have risen slightly. However, the overall picture does mask a number of regional variations. While gastro-intestinal problems represent the majority of all DRDs in Mediterraneanbordering countries (notably Turkey and Cyprus), including the Middle East (64%) and Africa (67%), as well as close to 50% in Asia and Latin America, they are much less prevalent in EU / EEA Europe, North America and Oceania. Infections, on the other hand, represent some 59% of all claims in North America and 74% of those originating in Oceania, but only a small share of those in the Middle East (17%). Tropical countries show the highest incidence of insect and other animal bites, although their share in total claims is still modest. Dermatitis and other skin problems are more significant in the Middle East or Latin America. Total MAPFRE ASISTENCIA UK claims by DRD type, 2013/14 Skin problems Allergies 3% 4% Animal bites 7% Altitude sickness 1% Infections 34% GEA 51% Differences in diagnoses by destination Clearly, there are also differences in the types of infections, skin problems etc. that are prevalent in different countries. DRDs in the Mediterranean region are primarily caused by dermatitis and other skin infections. GEA is much more common among UK travellers in Africa and the Middle East, however, with the vast majority of cases in the latter region originating in Egypt in part because of the larger number of British travelling to this destination. In Asia, DRDs are primarily linked to cases of GEA, notably in the sub-regions of Southeast and South Asia. The incidence of viral infections is also much 47

48 higher in Southeast Asia compared with the other sub-regions, representing the majority of all claims with regard to infections in Asia. TRAUMA claims are most common in Europe, and especially in countries within the Alpine region, which is a popular destination for British winter sports enthusiasts. In Latin America, while DRD claims have generally increased their share since 2012/13, the share of TRAUMA has declined and there has been no change in the share of ONDRD. The trend has also been the same in North America, where DRD nevertheless accounts for 10% fewer medical claims overall than they did a year ago. In the following series of charts, we highlight a few of the more interesting individual country examples of the diagnoses linked to medical claims. The selection focuses on countries in which most of the medical claims of UK travellers originate. Egypt In Egypt, where more than 20% of all UK medical claims originate, DRDs account for as more than 80% of cases. The highest proportion of DRDs in Egypt during the period under review were due to GEA, followed by sickness resulting from animal / insect bites, skin problems and respiratory infections. Claims in Egypt by diagnosis, 2013/14 ONDRD TRAUMA DRD Spain The picture is much more balanced in Spain, which shows a fairly even split between cases of DRD, TRAUMA and ONDRD. About three quarters of the DRD cases are caused by GEA or respiratory infections. Viral, urinary infections and dermatitis cases are also quite significant. Claims in Spain by diagnosis, 2013/14 ONDRD TRAUMA 29% DRD 36% United States As in Spain, medical claims originating in the USA are fairly well balanced between DRD, TRAUMA and ONDRD. However, in contrast to the situation in other regions, respiratory and viral infections account for the most claims, ahead of GEA and skin-related complaints. Claims in the USA by diagnosis, 2013/14 ONDRD 32% TRAUMA 27% DRD 41% France and Austria These two charts show the very high share of TRAUMA cases in UK medical claims originating in France (68%) and Austria (82%). As already discussed, these are two of the most popular winter sports destinations for UK travellers, 48

49 and skiing or other sports-related accidents are bound to be a lot more prevalent than in countries without winter sports facilities. Claims in France by diagnosis, 2013/14 Claims in Austria by diagnosis, 2013/14 ONDRD 22% DRD 10% ONDRD 12% DRD 6% TRAUMA 68% TRAUMA 82% Turkey In Turkey, 55% of medical claims through InsureandGo by British travellers relate to DRD, while TRAUMA and ONDRD account for 24% and 21% of claims respectively. The three more common DRDs, as in Greece and Cyprus, are GEA, respiratory infections and dermatitis. Claims in Turkey by diagnosis, 2013/14 TRAUMA 24% ONDRD 21% DRD 55% India DRDs in India represent 49% of the total cases. And the most common diagnosis for these diseases concerns GEA (63% of DRDs), followed by respiratory infections and infections caused by viruses. Less common are cases of dermatitis, animal bites, urinary infections and bacterial diseases. Claims in India by diagnosis, 2013/14 ONDRD 30% TRAUMA 21% DRD 49% 49

50 2.7 The Link between Age and Medical Problems Medical claims by age group The following chart shows the share of UK claims registered worldwide by MAPFRE ASISTENCIA by age group in the 2013/14 12-month period under review. MAPFRE ASISTENCIA UK medical claims by age, 2013/ years 4% 0-19 years 18% years 23% years 24% years 31% Not surprisingly, the worldwide shares mask some interesting variations from one region to another. In the majority of regions, with the exception of Europe and Oceania, the age group accounting for the highest share of medical claims is the year-olds. The respective shares for this age group range from 28% in the case of Africa to 51% in Asia a region where young people are travelling more and more due to the growth of low-cost airline services. In Europe and Oceania, the year age group generates the highest shares of medical claims of 28% and 41% respectively. Claims by type of medical problem A breakdown of claims by type of disease or medical problem highlights the wide variations across the different age groups. DRD cases are most common among infants and children aged 0-4 years, with children generally and young travellers up to the age of 24 also showing a higher incidence of destination related diseases (DRD) than average. TRAUMA cases are most prevalent among year-olds, while the incidence of ONDRD is highest among travellers above the age of 70 as one might expect. 50

51 MAPFRE ASISTENCIA UK claims in each age group by diagnosis type (%), 2013/14 Age group DRD TRAUMA ONDRD 0-4 years DRD claims by problem An analysis of DRD claims by the broad categories of medical complaints highlights the wide variations across the different age groups. GEA, which is the most common cause of DRD worldwide, is most prevalent among the year-olds, while infections are most common among the very young 0-19 year-olds and the 70+ age group. Skin problems, although less widespread, tend to affect the year-olds most, and altitude sickness (also much less frequent) is most likely to affect the year-olds, while allergies are most prevalent in the year age group. Breakdown of MAPFRE ASISTENCIA UK claims in each age group by DRD type (%), 2013/14 Altitude Animal & Skin Age group Allergies sickness insect bites GEA Infections problems 0-4 years

52 2.8 Seasonality of Medical Claims Share of claims follows similar trends as for overnights As would be expected, travellers are likely to make a higher share of claims in months in which they travel the most. This is not always the case, of course, but the peak in share of claims through the Northern Hemisphere months of June through September coincides with the peak summer travel period. Note that the black dotted line refers to the monthly average over the 12-month periods May-April in 2012/13 and 2013/14 (100% 12 = 8.33%). In 2012/13, claims for DRD and ONDRD cases exceeded the monthly average from May through October, falling below average during the other months. TRAUMA cases, on the other hand, were above average in terms of share during the summer months of June September, as well as in January April. Monthly shares of MAPFRE ASISTENCIA UK claims by diagnosis type, 2012/13 DRD TRAUMA ONDRD Average 16% 14% 12% 10% 8% 6% 4% 2% 0% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Monthly shares of MAPFRE ASISTENCIA UK claims by diagnosis type, 2013/14 DRD TRAUMA ONDRD Average 16% 14% 12% 10% 8% 6% 4% 2% 0% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 52

53 While the seasonal pattern was very similar in 2013/14, some interesting anomalies emerge, begging a number of questions. By way of example, the monthly TRAUMA shares fell were much lower in January-April in 2014 than in those same months in 2013, also falling progressively through the four-month period. One likely contributing factor was the time shift of the Easter holidays. In 2013, they were in March, resulting in greater travel that month, so perhaps explaining the parallel rise in share of TRAUMA claims. While holidays in March often still involve skiing, a later Easter period typically favours other destinations such as cities or sun & beach resorts, in which cases of TRAUMA are less likely. With regard to DRD claims only medical complaints related to the destination there was a big dip in the curve in July Monthly shares of MAPFRE ASISTENCIA UK DRD claims, 2012/13 and 2013/ / /14 Average 16% 14% 12% 10% 8% 6% 4% 2% 0% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Further investigation suggests that this was almost certainly due to a sharp drop in demand for travel by the UK market as with all other European markets following the coup d'état in Egypt the same month, which resulted in widespread travel advisories warning against travel to Egypt. Arrivals overall in Egypt fell by 26% in July 2013, with the sharpest declines from western Europe, and the downward trend has continued ever since. Egypt is a particularly important medium-haul destination for UK travellers, especially holidaymakers, and 20% of total medical claims registered by MAPFRE ASISTENCIA from the UK market in 2013/14 originated in Egypt. So the impact of the coup is hardly surprising. Closer analysis confirms the assumptions, as can be seen in this final chart. 53

54 Monthly shares of MAPFRE ASISTENCIA UK DRD claims originating in Egypt, 2012/13 and 2013/ / /14 Average 16% 14% 12% 10% 8% 6% 4% 2% 0% May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr This example shows how important it is not to place too much importance on raw data without a proper understanding of the circumstances and events to which the data refers. 54

55 Appendices Methodology Time period selection The data in the 2013 report relates to a 10-month period July 2012 to April This year, the analysis covers a full 12-month period May 2013 to April 2014 (hereafter referred to as 2013/14) and any comparisons made with the previous year also refer to the same 12-month period in 2012/13, thereby expanding the scope of the 2013 report. Country selection The database for analysis was created from individual country databases of claims handled by MAPFRE ASISTENCIA travel source countries / markets in which MAPFRE ASISTENCIA's travel insurance policies are sold, both directly and through third parties. Chile was excluded from the study due to a lack of homogeneity in its database, as well as a significant volume of missing information. Data has been included for the following countries: Argentina, Australia, Belgium, Brazil, China, Colombia, Germany, Spain, France, India, Italy, Malta, Mexico, Philippines, Portugal, Turkey, the UK and Uruguay. The analysis has focused on these travel source markets grouped by region Europe, Americas and Asia Pacific and with a special analysis of the main source countries in MAPFRE ASISTENCIA's claims database: the UK, Spain and Brazil. The sample for the study consisted of 97,059 claims / cases, of which 50,695 for the 12-month period May 2013 to April Selection of variables for analysis For comparative purposes, three basic variables selected from our global database: source country, destination country / continent / subcontinent and also case date. For the UK, in addition, the diagnostics variable was of sufficient quality to allow for a more in-depth analysis. A different database containing non-medical claims 'Other Personal Benefits' (OPB) enabled us to perform an overall split analysis of the different types of OPB claims handled by MAPFRE ASISTENCIA in 2013/14. Selection of continents / subcontinents Countries were grouped by continent and subcontinent based on UNWTO's definitions of geographic regions. The exception was Mexico, which was included in Latin America in view of the Mexican market's greater similarities with other markets of Central and South America than with its North American Free Trade Association (NAFTA) partners. Another difference with the 2013 Travel Insurance Observatory (TIO) concerned Egypt, which is included in the Middle East in this 2014 TIO, according to UNWTO definitions. 55

56 Criteria for comparison Due to the big differences in individual country sample sizes, all comparisons were made using relative values (% shares). The analysis for origin markets for which there are few cases is clearly less reliable because of the random component than that for markets that present a large number of cases. The data should therefore be interpreted with caution. Comparison were limited to those source markets and destination countries In that present the highest shares of claims whether the top three, top five or top ten. Diagnostics variable The UK was the only source market selected for a diagnostics analysis, due to the high quality of information relating to the different medical diagnoses submitted for claims, as well as the large volume of claims and the very low volume of missing information. An initial problem concerning the heterogeneity of the diagnostics data was overcome by grouping disperse and descriptive values into a smaller group of specific types of diseases proposed by the medical director of this study. Time series The time series represent the share of total claims for each month, thus reflecting the seasonality of cases through the 12-month period. The time series presented as monthly shares retain the same shape as an a time series of absolute values and makes it easier to compare changes in seasonality, even if the total amounts vary over two time periods. Data Sources European Travel Commission's (ETC) including ETC's series of 'Market Insights' Forwardkeys.com Instituto Brasileiro de Geografia e Estatîstica (IBGE) Instituto de Estudios Tourísticas (IET), Spain Ministério do Turismo, Brazil / Embratur UK Office for National Statistics (ONS) including various publications such as UK Travel Trends, VisitBritain World Tourism Organization (UNWTO) various publications and statistics 56