With nearly two billion international journeys undertaken annually, fewer than 0.5% of travelers require medical repatriation. This relatively low proportion is notable given the increasing number of elderly and chronically ill individuals engaging in international travel. Outside exceptional circumstances such as pandemics or armed conflicts, the overall total number of travelers is rising steadily. Hence, the demand for medical repatriation is expected to do so as well.

When a medical emergency occurs abroad, a critical decision must be made: whether the patient can be adequately treated locally or requires transfer. Options include repatriation to the patient’s home country or transfer to a third country with appropriate medical infrastructure. The decision is influenced by clinical urgency, the nature and severity of illness or injury, available local resources, and financial considerations.

Transport modalities vary accordingly and include ground-based critical care transport, air ambulance services (fixed-wing aircraft or helicopters), and commercial airline transfers with medical escort, either seated or on a stretcher.

In most cases, medical repatriations are commissioned by travel insurance providers. As these insurers typically lack their own transport capabilities, they rely on external service providers. These range from large international organizations with dedicated air ambulance fleets to independent freelance physicians offering services through private arrangements.

Heterogeneity of employment and liability structures

The contractual and liability frameworks governing medical personnel in repatriation services are highly heterogeneous. Ideally, physicians operate within an employment structure that includes comprehensive professional liability coverage. In some cases, freelance physicians are similarly covered under the insurance policies of the contracting organization.

However, a significant proportion of service providers operate without adequate or clearly defined liability coverage. This creates a substantial risk exposure for individual practitioners.

A significant proportion of service providers operate without adequate or clearly defined liability coverage. This creates a substantial risk exposure for individual practitioners

Although the overall number of liability claims in medical repatriation is low relative to the volume of transports, the financial implications of a single case can be severe. Legal costs and damages may reach several million US dollars, particularly in jurisdictions with high litigation exposure. Even in cases where claims are ultimately unfounded, the associated legal expenses alone can be considerable.

A landmark study published in 2006 in the New England Journal of Medicine (NEJM) examined 1,452 closed malpractice claims (all specialties) and found that approximately 37% did not involve medical errors. However, the system handled these appropriately: 72% of claims without errors did not result in compensation, and only one in four received payment. Overall, claims not involving errors accounted for 13–16% of the system’s total monetary costs. For every dollar spent on compensation, 54 cents went to administrative expenses (including those involving lawyers, experts, and courts). Claims involving errors accounted for 78% of total administrative costs.

Recent literature shows that unfounded liability claims have not risen over recent years; rather, the overall rate of malpractice claims has substantially declined.

Furthermore, potential claims are not limited to patients or their families. Legal action may also be initiated by commissioning insurers, service providers, aviation companies, or third parties – for example, co-passengers exposed to infectious diseases during transport.

A structural insurance gap

In most cases, the absence of adequate insurance coverage is not the result of deliberate risk-taking by physicians (or other healthcare providers). Rather, it reflects a structural gap in the insurance market. Suitable professional liability policies for freelance healthcare providers engaged in international medical repatriation are, in practice, not available.

This issue is not widely discussed in the literature, nor does it appear to be sufficiently recognized within the industry. Nevertheless, it has significant implications for clinical practice and professional accountability.

Personal experience

In addition to part-time clinical work in a hospital setting, I have been involved in medical repatriation for more than 20 years. Throughout this period, I have been fortunate to work exclusively with organizations that provided professional liability coverage as part of the contractual arrangement.

However, I have repeatedly encountered opportunities to collaborate with other providers that did not offer such coverage. In these cases, I was forced either to decline the engagement or to accept it only under restrictive conditions, such as limiting the geographical scope of operations or excluding certain patient populations.

In an effort to secure independent coverage, I initially approached all major national insurers in my home country (Germany) that offer medical liability insurance. My request was for an international policy covering legal costs and damages of up to €5 million for work in medical repatriation – a coverage level that is, notably, below commonly recommended European standards. The responses were uniform: coverage could only be provided within the insurer’s national jurisdiction, and activities in countries such as the USA and Canada were categorically excluded.

Subsequent inquiries directed at European insurers and international brokers yielded similar results. While some indicated a theoretical willingness to provide coverage, the proposed premiums were economically unviable, exceeding the expected income from such work

Subsequent inquiries directed at European insurers and international brokers yielded similar results. While some indicated a theoretical willingness to provide coverage, the proposed premiums were economically unviable, exceeding the expected income from such work.

Attempts to obtain coverage from insurers based in the USA failed for different reasons, primarily due to the absence of local medical licensure, which is typically a prerequisite for eligibility.

I also approached internationally active specialty insurers that advertise expertise in niche healthcare sectors. Despite prolonged discussions, these efforts did not result in a viable insurance solution.

Finally, I explored the possibility of establishing a group insurance model, for example through a professional association or interest group. Given the likely number of physicians affected globally, this appeared to be a promising approach. However, insurers showed no willingness to pursue this option.

Discussion and ethical considerations

The current situation presents a paradox. Large insurance companies offer both travel insurance products and professional liability insurance, yet fail to provide integrated solutions for a field in which both are inherently interconnected.

This raises the question of whether insurers are fully aware of the gap, and if so, whether the associated risks are implicitly accepted. From an ethical standpoint, this is problematic. Insurers commissioning medical repatriations arguably share a degree of responsibility for ensuring that the services they rely on are adequately covered.

Insurers commissioning medical repatriations arguably share a degree of responsibility for ensuring that the services they rely on are adequately covered

At the same time, physicians operating without sufficient liability protection face a serious ethical dilemma. Even in the hands of highly experienced professionals, adverse events cannot be entirely prevented. The inability to provide compensation in the event of patient harm conflicts with fundamental principles of medical professionalism and accountability.

Moreover, the legal consequences for individual practitioners may be devastating, extending beyond financial loss to include reputational damage and professional sanctions.

Conclusion and call for action

The experiences described here suggest that the lack of adequate insurance solutions for freelance physicians in medical repatriation is not an isolated issue, but a systemic deficiency.

Addressing this gap will require coordinated efforts involving insurers, medical professional bodies, repatriation service providers, and regulatory authorities. Potential solutions may include the development of specialized international insurance products, the establishment of group policies, or the integration of liability coverage into standard service contracts.

Addressing this gap will require coordinated efforts involving insurers, medical professional bodies, repatriation service providers, and regulatory authorities

Greater awareness of this issue is an essential first step. Feedback from colleagues and stakeholders, as well as information on existing or emerging solutions, would be highly valuable in advancing this discussion.