Medical treatment of seafarer’s on board the world’s ocean-going vessels, and ashore if they require additional medical care, often involves a class of specialized insurance firms, Protection and Indemnity (“P&I”) Clubs, especially if the costs are likely to be high. P&I Clubs are mutual associations that provide insurance to shipowners, operators and charterers facing third party liability claims from a number of diverse parties, including seafarers, passengers, stevedores, nautical pilots and others.
Seafarer medical cases represent the largest single category of people claims handled by the P&I Clubs. There are roughly twice as many illness cases as injuries and only a small proportion of these result in death.
Seafarers come from all parts of the world. However, the majority are Asian, with Filipinos representing the largest single group by nationality. As any type of medical event could potentially occur at sea, P&I Clubs must be generalists when responding to emergent events on board and be ready to work with medical service providers who take the lead in treatment, medevac when necessary (and possible) or disembarkation to the nearest hospital or clinic when the vessel reaches port.
D.13.2 A Small, Specialized Insurance Community
The P&I clubs that underwrite this business are limited in number and pool their risks under the auspices of EU law, in order to reinsure jointly very large liabilities on an as needed basis. Presently there are thirteen P&I Clubs operating in what is known collectively as the International Group of P&I Clubs, ‘The IG’. Eight are based in the UK, three in Scandinavia, one in Japan and one in the United States. Together they insure roughly 94% of the world’s ocean-going tonnage. Many individual Clubs also insure local fishing fleets, small coastal tonnage and even fresh water fleets.
It is important to remember that there is no direct insurance relationship between the people who may require medical attention and the Club. The Club simply insures the liability that the Member, that is the ship owner or operator, has to each individual when illness, injury or death occurs on or near the vessel. The Club becomes involved with medical care issues because it will inevitably pay for them when the Member submits its reimbursement claim. Additional information on liability is available in Ch.2.10.
Additionally, the shipowner often does not have the staff or expertise to deal with an unfolding medical event in real time, so the Club is brought in from the outset to handle the matter as it unfolds and to follow up with medevac companies, tele medical providers, clinics and hospitals, as necessary.
The IG Clubs have staff who specialize in handling medical issues on board vessels and who work with medical providers when incidents occur. But the insurance cover extends beyond crew and passengers to other persons who board merchant ships world-wide. For instance, there is P&I liability cover for stevedores, pilots, inspectors, security guards and the many other third parties who board working vessels. It even extends to stowaways on vessels who may be injured, become sick, or die while on board.
A typical day for a claims handler at a P&I Club might include responding to a stevedore injury in Japan, a seafarer’s heart attack in New Orleans, an injured stowaway off the coast of West Africa and a passenger illness in the Caribbean. Each Club has a world-wide network of correspondents working in ports around the world who act locally on their behalf.
Thus, the hospital or clinic receiving the patient will, on most occasions, work directly with the local correspondent rather than with the P&I Club itself. It is not uncommon, however, for Clubs to become directly involved with medical providers if and when necessary and depending on the part of the world where the incident is unfolding.
P&I Clubs and ship operators have access to medevac providers world-wide, both private and public. How the event will be handled depends on the seriousness of the medical incident, the need to launch a helicopter or fast sea-launch and the location of the vessel at the time of the incident. Further information on the evacuation of a sick or injured seafarer is available in Ch. 5.9.
The costs associated with a medical evacuation vary greatly. Many Coast Guard authorities do not charge for their services, while others may charge ‘full rates’. When charges are billed to the shipowner, the liability is covered by the P&I Club.
D.13.4 Treatment in overseas port
Treatment will vary to a large degree depending on the type and extent of the illness or injury, on whether the hospital or other medical facility is a private or state-owned facility, on the methods of treatment employed, and on the country where treatment and care is provided. This can range from acute treatment, diagnostic measures, surgery, post-surgery treatment to nursing care and medicines. However, insurance cover is available for the costs of the level of medical treatment and maintenance which is necessary to ensure that the crew will receive proper treatment and care bearing in mind the type of illness and injury, the location of the vessel when the need for medical treatment arose, the urgency with which immediate treatment must be given, and the standard of treatment available in the country where the crew is domiciled. Proper treatment and care is a relative term, but the medical treatment facility where it is given should be certified and accredited for the type of treatment that is needed unless the urgency of treatment combined with the particular location makes it impossible to find such a facility. More information on medical care around the world is available in Ch 5.9.6.
Many physicians who are unfamiliar with the standard of care in foreign countries are sometimes reluctant to release a patient who has suffered serious injuries or is being treated for a significant illness to their homeland for continued care. In response, the P&I Club can appoint a local healthcare professional to act on the Club’s behalf and who can be in direct communication with the treating physician.
Working as a team, the three parties arrange in advance for the receiving hospital to be ready for the repatriated seafarer when he or she arrives and so that treatment can begin immediately. This helps streamline the medical care and alleviates the first responding physician’s concern as to whether the patient will receive proper care once repatriated. Further information on the repatriation of seafarers is available in Section xxx.
D.13.6 Contractual Benefits for Disability and Death
After the immediate medical concerns are addressed and the seafarer is repatriated home, P&I Clubs remain involved with follow up care and the assessment of disability. This is important work because most employment contracts contain disability compensation clauses which pay out a US dollar amount to the seafarer depending on the extent of the disability and whether it is temporary or permanent.
Often there is a difference of opinion on the disability rating provided by the treating physician and the ship owner or employer. In this situation, the case may end up in arbitration or the local court system depending on the jurisdiction involved. When a ship owner or employer is forced to defend a legal claim from a seafarer, the costs and expenses associated with the defence are covered under the P&I cover.
D.13.7 Sick Wages
Seafarers are also entitled to the payment of sick wages for a contractually defined period of time following the medical incident. Once repatriated, the payment of sick wages is based upon confirmation from the treating physician/clinic that the patient remains sick or injured, i.e. not fit for duty. P&I Clubs (through their network of local correspondents) therefore also work in close cooperation with these medical providers to ensure that the seafarer is reporting to the clinic and that wages are being paid by the local manning agent.
In short, the Club acts as a type of manager, not only in relation to the treatment but also of the financial restitution resulting therefrom. This helps the entire system run smoothly and is of great benefit to the industry as a whole.
A majority of the world’s ocean-going ferry, passenger and cruise vessels are insured by the IG Clubs. Insurance for liability to this category of persons, whether arising under statute, contract or in tort, is important for vessel owners and operators. This category of vessels represents an enormous risk for P&I Clubs as many modern vessels can carry up to a thousand passengers and crew, and some carry even more.
Responding to passenger incidents can be quite different from seafarers on merchant cargo vessels because many passenger ships have doctors and nurses on board who attend to the matter on an immediate basis. As such, immediate medevac may not be necessary and the vessel operator tends to take the lead in the medical case management.
However, if the medical incident is life threatening, involving many people or otherwise complex, the Club may be contacted to assist in the management. Injured or sick passengers, especially in cases involving ship-wide infections can be quite litigious. Resulting medical malpractice lawsuits against medical staff almost always include the vessel owners as a defendant. Clubs therefore work closely with medical professionals and other expert witnesses when defending cases in court.
There are numerous other people who work or attend on board merchant vessels and who thereby expose themselves to risk while doing so. Most P&I Clubs divide these groups into three: those carried on board, not carried on board and ‘saved at sea’. The main distinction between the first two groups is whether the vessel is moving or not. If moving, then such persons are ‘carried on board’. If not, then such persons are ‘not carried on board’.
Persons carried on board
Navigational pilots are a good example of persons carried on board. When a merchant vessel enters the waters surrounding a port it must radio ahead to the port authorities and request a pilot join the ship in order to take command of further navigation. In order for the pilot to gain access to the vessel, he must take a small pilot boat alongside the ship and climb a long Jacob’s Ladder to reach the deck of the vessel.
During this time, the vessel is either drifting or at slow speed, and the pilot boat is constantly maneuvering to maintain its position under the ladder. Unfortunately, many accidents occur when the pilot is ascending or descending the ladder. More information on pilots is available in Ch 3.2.9.
Persons Not Carried On Board
When the ship is tied up at berth all third parties who board are not carried on board. The most well-known group in this category are the stevedores who load and discharge the cargo.
Many different types of accidents can happen when the stevedores are working the cargo. As the vessel is already in port, land-based medical first responders will be called to the berth immediately, thereby increasing the probability of a successful outcome. P&I Clubs are almost always called soon after the incident. The Club will then notify the local correspondent. Many hospitals will want to know within 24 hours who is going to be paying the medical bills for the injured person. The local correspondent will confirm that there is a P&I Club involved who will pay on behalf of the vessel owner and this tends to have a positive effect on subsequent medical case management. More information on health care in ports is available in Ch. 5.10
Persons Saved at Sea
Ocean going vessels are required by law to alter course and attempt to save life at sea when they are near a marine casualty or other marine incident. This usually involves orders from the nearest coast guard or other maritime authority. It could also involve an injured or seriously ill person aboard a nearby vessel which does not have the ability to land a medevac helicopter or steam quickly enough to the nearest port in order to save the person affected.
In these types of cases, the vessel may make direct contact with its P&I Club. Many of the costs and expenses associated with saving lives at sea are covered by the P&I insurance policy, so it is natural for the Club to be closely involved from the outset. More information on such incidents is available in Ch. 5.8 and on the requirement to respond in Ch. 9.10.
Stowaways, refugees and migrants
Stowaways too may fall ill or suffer injury while on board. Indeed, it is not uncommon for stowaways to be seriously injured or killed on board, for instance when hiding in enclosed spaces with limited air supply or being crushed by heavy equipment or anchor chains. Additional information on stowaways is discussed in Ch. 9.10.
Refugees and migrants often take unsafe pathways due to large numbers of people setting out to cross the sea in overcrowded and unseaworthy vessels. Many who survive need medical treatment for injuries or conditions which have arisen during the transportation, such as hypothermia and gastrointestinal illnesses. Additional information is available in Ch. 9.10.