From St Philip's to St Luke's - a tourist's 'nightmare' trip

A British holidaymaker had a nightmare holiday in Malta last month, one she would not easily forget.

Pamela Grace Page is a working mother in Arbroath, a small town on the north east coast of Scotland, 17 miles away from Dundee. She is 58 and a diabetic.

When she flew to the island for one of her regular holidays here last month, little did she think that this time it would be different to the glorious stays she has spent here before. But it was different, very different.

This time she fell ill and had to be hospitalised. She recounts what happened to her in a letter she wrote to The Times.

When she fell ill at the apartment where she was staying in Qawra, the doctor called to see her, Dr Adrian Vella, sent her to a private hospital, St Philip's, where she was seen by Dr Louis Bughaiar.

The trouble for her began when she was told that the firm she had been insured with would not pay and that she had to foot the bill for the hospital and other expenses herself.

Within minutes that she consented to be taken to St Luke's, the drip was disconnected from her arm.

On arrival at St Luke's, her temperature was 103. She says she was left in the corridor for seven hours - a claim that is denied by the hospital.

For the 36 hours she spent at St Philips, she received a bill for Lm674.60, which includes Dr Buhagiar's fee of Lm138.

Her story has much wider implications as the hospital is accusing her insurance firm of reneging its legal responsibility. On its part, International Medical Rescue is claiming that the hospital is charging excessive rates.

More than that, it is accusing Dr Vella, Dr Buhagiar, Dr Portelli and St Philip's Hospital of exploiting British visitors and their insurance companies by diverting them into the private sector and thereby maximising their own revenues.

In an editorial on the matter today, The Times is calling on the Medical Council to investigate the matter. The Times has also sought a reaction to Mrs Page's story from all the parties concerned - St Philip's, Dr Buhagiar, Dr Vella, St Luke's Hospital, the Health Minister, Dr Louis Deguara, International Medical Rescue Limited and White Horse Insurance Ireland Limited.

Their contributions, being carried in The Times today, reveal the extent of the problem.

But how does Mrs Page feel now?

Is she bitter about her experience?

"I love your country and the people, and find the historical aspects fascinating. I hope to spend far more of my time in Malta in the future."

Mrs Page is married with two children and has nine grandchildren. She works part time in the education department of Angus Council. But over the past 10 years, she returned to study and now has an HND in Business and Secretarial Studies and an MA with honours in history, which she obtained from Dundee University.

They have holidayed in Malta for the past four years. On the last occasion before taking her holiday here, she broke a bone in her foot and had to wear a surgical boot, which added to the medical problems experienced throughout the holiday.

My story - 'dreadful'experience

by Pamela Grace Pace, Arbroath, Scotland

I recently visited Malta and read The Times during my holiday. I was interested to read and learn from local people that there have been fewer visitors to Malta this year than usual.

I have just returned from Malta, saddened that I have experienced an aspect during my visit that I have not encountered in the past. My experience was as follows:

On August 4, Dr Adrian Vella, of Qawra and Bugibba (Medicare), visited my apartment as I was very sick. After being paid Lm25, he asked to see my insurance policy and said I must go to hospital and that he would make the necessary arrangements.

He ordered a taxi (Westminster Taxi, Qawra), which took me to St Philip's Hospital (the charge was Lm10).

I am a diabetic, and was very sick; it was the early hours of the morning and I knew nothing of Maltese hospitals. The administration asked to see the insurance policy and said that, as a 'formality', my husband would need to sign a Visa form but he was assured that the insurers would pay the bill.

On Monday, Dr Louis Buhagiar visited me at St Philip's and we again showed our insurance policy.

He then expressed the opinion that our insurers would not pay the bill and that we would have to pay the bill ourselves.

We explained that we could not afford it, and it was then put to us that we could go to St Luke's Hospital.

Dr Buhagiar asked if we wanted him to arrange for the transfer and we agreed.

Within minutes, the drip was disconnected from my arm and we were on our way to St Luke's.

On arrival at St Luke's, my temperature was 103 and after seven hours of waiting I was put into a bed in a corridor.

I was not discharged from hospital until the following Thursday and am now at home in Scotland, where I am still undergoing medical tests. The diagnosis in St Philip's was salmonella.

I am enclosing the bill for the 36 hours of care I received at St Philip's Hospital.

Dr Buhagiar told my husband that he reduced his charge for "humanitarian" reasons.

Please note the charge of Lm50 for transfer to St Luke's in one of St Luke's ambulances.

We were not told of this; had we been told, we would have taken a taxi. I would be happy if you would publish the bill.

I feel there are many questions that need to be answered here.

Has this happened to other tourists?

Why was I sent to St Philip's without being made aware of St Luke's?

Are local doctors aware that there is a choice of hospitals?

Why did it take 36 hours for us to be told that our insurers would not pay? We showed the policy every step of the way, and Dr Buhagiar was able to tell us at a glance that the insurers would not pay.

Is it common practice to 'evict' patients within minutes of finding out they could not pay, regardless of their medical condition, especially as I was charged for two nights' accommodation? Why did no one tell me that I could have stayed longer?

Are the costs the same for all nationalities?

We asked for a list of basic costs, such as ambulance to St Luke's, accommodation etc., but could get no information.

Who are the directors, managers, financial backers of the Golden Shepherd Group Limited? Again we asked administration staff but these could give no information.

We visit Malta often and this year we brought our extended family with us.

We had hoped to bring a larger group next visit, but in view of this, I don't know if this will happen. My experience of becoming ill in Malta does nothing in my opinion to enhance the tourist trade.

We must, however, extend our heartfelt thanks to Antoni of Anici Apartments, Bugibba, the staff at the Mavina, Qawra, and Joanne Smith, who all made a dreadful experience bearable and, of course, many of the medical staff at St Luke's.

I have sent copies of this letter to the British Medical Association, Edinburgh and London, Michael Refalo, Minister of Tourism, and the British Consul, Malta.

Insurance firms 'reneging' legal responsibility

by Dr Frank Portelli, Director and CEO St Philip's Hospital

I can confirm that some British insurance companies are reneging on their legal responsibility towards clients covered under these policies.

Ms Page is one of these unfortunate victims. She had what appears to be a valid insurance policy underwritten by White Horse Insurance Ireland Ltd, which purportedly covered her up to a maximum of £1,000,000 for emergency medical treatment.

However, when Ms Page fell ill while on holiday on August 4, the medical assistance company, International Medical Rescue, refused to cover her essential medical expense and insisted that Ms Page be transferred immediately to a government hospital to exploit the reciprocal health agreement.

Ms Page is right to complain and she would do well to complain initially to Aon Sure Travel, The Pavilions, Kiln Park, Epsom, KT 17 1EF.

If she is not satisfied, she should write to the underwriting manager, White Horse Insurance, 14 Clyde Rd, Balls Bridge, Dublin.

When a British visitor requires emergency medical service in Malta, these insurance companies are refusing to cover the costs of this emergency medical treatment and instead are transferring patients to St Luke's Hospital invoking the reciprocal health agreement.

We have built up a dossier of these patients and I have written to the competent authorities in Malta about this state of affairs.

The pattern that emerges from these cases is as follows:

1. British travellers coming to Malta are " encouraged" to purchase a travel insurance policy, which includes cover for emergency medical treatment. Hefty premiums are charged particularly when pre-existing medical conditions are declared and admitted.

2. Many of these insurance policies are being sold over the telephone or through the internet without adequate clarification to the purchaser.

3. Some companies which sell these policies act as sellers, brokers and finally as assistance companies. One of these is IMR - International Medical Rescue - which is in a dominant position in this market and is now owned by Aon Ltd.

Your readers should be aware of the size of the problem.

1. The number of foreign patients receiving in-patient treatment at St Lukes Hospital has averaged 1,400 per annum over the last three years (government statistics).

2. More than 800 of these in-patients are British visitors. Their stay in hospital is equivalent to 22 beds being occupied every day of the year at a calculated cost to the government, and ultimately to the taxpayer, of Lm1.6 million per annum.

3. Meanwhile British insurance companies are collecting £28 million per annum against estimated claims of less than £5 million in toto.

4. Needless to say their modus operandi needs examining by the British authorities.

5. Meanwhile, the end result is that these British insurance companies are making huge profits when selling these policies - while leaving the Maltese government and the Maltese taxpayer to pick up the bills.

6. Needless to say private health providers in Malta are also being adversely affected as insured British patients are being made to ride piggy back on the local NHS.

In my view the following steps have to be taken:

1. British tourists coming to Malta for a stay less than 30 days are covered by the reciprocal health agreement; they do not require to purchase medical insurance cover. When a British tourist is sold travel medical insurance it should be made obligatory on the operator to inform the tourist of the existence of the reciprocal health agreement.

2. All tourists covered by medical insurance when treated in any government hospital should be charged for their medical treatment. This should ensure that insurance companies do not continue to wax rich at Maltese taxpayers expense. It should be noted that the 38 beds in St Luke's Hospital are occupied every day of the year by tourists who fall ill while on holiday in Malta.

3. Insurance companies selling travel insurance to tourists coming to Malta should be regulated. After all private hospitals are regulated and have to comply with various regulations.

These insurance companies should be made to comply with the Business and Insurance Act. At present they do not do so, and when claims are presented by local hospitals no means of redress is available locally.

We can, of course, do nothing and allow these companies to keep sucking the Maltese taxpayer dry.

The right to choose

by Dr Louis Buhagiar

I feel that Ms Page's letter is timely as it gives many of your readers the opportunity of seeing how some British travel insurances are abusing their clients and failing to keep their commitments, to their clients' dissatisfaction.

May I start by pointing out that a reciprocal agreement exists between Malta and the United Kingdom whereby British tourists who become unwell while on holiday are able to make use of our medical facilities free of charge.

This applies to all British tourists irrespective of whether they have a travel insurance or not. Nearly all British tourists take out a travel insurance with medical cover before they travel.

For this they pay out handsome sums of money running into the hundreds of pounds as premium. In their turn these insurance policies boast of millions of pounds of medical cover.

Nearly all British travel insurances live up to their word and cover their clients when they need medical assistance. A few of these do not and try out all sorts of silly excuses to exit scot-free.

Unfortunately, Ms Page had one of these insurances. Her insurance medical assistance company is International Medical Rescue.

The doctor that referred Ms Page to St Philip's Hospital did well in asking for her insurance papers. He knows that if she has insurance papers she should be given the right to choose between local hospitals. He knows about the shortcomings of St Luke's Hospital and what our patients go through before and after being admitted.

Ms Page in fact came to know of these gross inconveniences to her own expense and dissatisfaction.

What is pitiful is what goes on at St Luke's, and tourists are giving us a bad name. She was referred to a private hospital since this is considered a preferred destination for patients who were promised medical insurance cover.

Before going on further, I am itching to know how the Department of Health is going to explain to your readers why this lady and thousands of similar Maltese and foreign patients have to wait for seven hours with a temperature of 103 in the emergency department only to be admitted later in the middle of a corridor. I trust that you have asked the department of health for such an explanation.

To go on with our story, the referring doctor was right in sending this lady to a preferred hospital once he thought that she had cover. Unfortunately, as it turned out this British lady had one of those insurances which took her money, promised the earth and expected the Department of Health in Malta to shoulder the expense and the care.

Of course, this sort of management is all free to them. Once this was realised Ms Page was informed as much and offered the option to go to St Luke's Hospital which to her would be free of charge according to there reciprocal agreement.

As it turned out she did not enjoy the seven-hour delay with a temperature of 103. But so is the experience of thousands of Maltese every day. When she went up to the ward she did not find a decent bed behind a curtain. But such applies to thousands of Maltese and many other tourists every day.

Ms Page's insurance is aware of this situation but still pressures its clients into accepting it while they continue to have a free ride.

The department of health is aware of this situation but when International Medical Rescue came to Malta in May, they were encouraged to go on with their practice. Ms Page never came to pay any fee at all despite being asked for a "humanitarian" professional fee. It is expected that neither she nor her insurance will take up the offer.

However, the picture is not all gloomy. I know of various satisfied patients who give Malta a good name. I have a long list of responses. I am informed of one, a Ms Agnes Mellor at Capua Palace Hotel, who even wrote to The Times about her pleasant experience while being treated in Malta. To date, I have not seen her letter published.

Maybe your readers should be heartened up with what she said.

The real problem

by Louis Deguara, Minister of Health

As part of the health agreement between Malta and the UK, all British tourists requiring emergency treatment, including hospitalisation in Malta, are entitled to receive them free of charge. This arrangement applies to tourists staying in Malta for less than 30 days. When the stay is longer British tourists pay prefential rates of only 15 per cent of normal charges levied.

This in return for sending a number of Maltese patients to the UK for treatment not available locally. So as you can see once a tourist presents himself at hospital he is given appropriate care.

It is not the remit of the Health Division to investigate claims against individual doctors or private hospitals/clinics or insurances for misconduct of any kind, overcharging or breach of ethics. This is the sole responsability of the Medical Council which is autonomous.

As regards the information from Dr Portelli, I received it by hand three weeks ago and the letter was also fowarded to the minister of finance who was abroad at the time. We shall be meeting shortly to discuss the matter together with the minister of tourism.

I would like to see a breakdown of the figures quoted by Dr Portelli as I have been informed that they are grossly inflated and nowhere do they reflect the true position on the local side.

Having said this, I still feel very bad about what is going on.

I think that the real problem is not a medical issue but a commercial and financial one between foreign private insurances (who fail to inform British tourist of their rights) and local private physicians (who again prefer referring privately insured tourists to private hospitals, failing to inform them of their rights, for more than obvious reasons).

'Excessive charges' for medical services

by Graham J. Reed, medical claims investigator for and on behalf of International Medical Rescue Limited

Initially, I should explain that International Medical Rescue Ltd (IMR) is a company appointed by various insurance underwriters (including White Horse Insurance Ireland Limited) to provide assistance to British/Irish visitors to Malta where medical and other emergencies may unfortunately arise in the context of holiday and travel insurance cover.

You should note that such policies are not private health insurance policies. Under the terms and conditions of travel/holidays insurance the cover for medical costs is limited to reasonable and applicable emergency medical treatment. Elective medical management is not covered and also certain pre-existing medical conditions are either excluded from cover or are subject to other conditions, e.g. an increased policy excess.

I would confirm that IMR was involved in the handling of Ms Page's case under the terms and conditions of the WHII policy. Before dealing with the specific matter of Ms Page's case you should be aware of the existing situation which led to the unfortunate experience for Ms Page.

The broad background to this matter initially arose last year when IMR became aware of what we consider were excessive charges for various medical services provided to our insured clients in Malta.

These persons are essentially UK passport holders on holiday in Malta and who would not necessarily be aware that a bilateral reciprocal health care agreement exists between the governments of Malta and the UK.

However, we would expect that every medical practitioner in Malta who treats British visitors is aware of the provisions of the reciprocal agreement and to respect that provision.

Regrettably, a few doctors in Malta have seen fit to ignore such a provision and in doing so, have not only denigrated the high level of medical care available in the state system but have diverted patients into the private sector, thereby incurring unacceptable and unnecessary costs. IMR is also a member of the British Medical emergency Services Forum (BMESF) and they are already addressing this issue on behalf of the wider UK insurance market.

Consequently, a delegation from IMR visited Malta in April and had a meeting, among others, with the Director of Institutional Health, Dr John Cachia, (the BMESF is aware of this initiative). We raised several issues.

Over a year ago, it became apparent that some British visitors who sought medical attention and were staying in hotels in the Bugibba, Qawra and St Paul's Bay area were attended initially by a Dr Adrian Vella, who was usually summoned by the hotel receptionist.

He would in many instances advise that the patient would require hospital admission but instead of arranging such admission to St Luke's Hospital would do so at the privately run St Philip's Hospital.

It could be said that there is nothing sinister in that, if for a valid medical reason this could be justified. Indeed, UK/Irish insurers would probably have been sympathetic to any claim that would have arisen if the costs involved had been reasonable and customary for the standard of care provided.

However, it became apparent that the costs of treatment on being admitted to St Philip's Hospital were excessive.

This is not only in the opinion of IMR but also that of other doctors in Malta. We have based this opinion using the price guidelines provided by Dr Cachia for treatment in the state system and also on information obtained from other providers in the private sector.

In addition, this hospital unreasonably demanded that each patient provide signed credit card imprint implying that when the insurer settled the bill, the slip would be destroyed. In all the time that IMR has been operating in the area of emergency assistance, we have never come across this practice, except in a very few instances in the United States. Never though, even in the US, where a dispute had arisen over whether the charges on a hospital bill were reasonable and customary, had any other hospital then sought redress by targeting the patient and charging their credit card account for the disputed portion of the bill without warning.

However, St Philip's Hospital decided to use this method by using the signed authority without the courtesy of formally confirming to the card holder at the time that a debit was about to be made.

While St Philip's Hospital is not doing anything strictly illegal per se, we do believe that their action amounts to nothing short of sharp practice. This is especially so when on admission the patient may not be aware that their insurance company will not guarantee the costs even though the hospital had been informed of this situation.

Indeed, on April 30, 2002, because we had been threatened with litigation over non-payment of St Philip's Hospital bills, which on behalf of our principals we considered to be excessive, this company sent a faxed letter to Dr Frank Portelli, the medical director of St Philip's Hospital, advising that on behalf of our principals, IMR would not issue any new guarantees of costs.

We also requested that the hospital informs all new patients who presented for treatment that no guarantees would be issued.

The hospital and doctors concerned have palpably ignored our request and refused to cooperate as has been demonstrated by what happened to Ms Page.

We have also unearthed evidence that Dr Louis Buhagiar has raised bills for his consultation fees under the auspices of The Medical Centre in Zurrieq that are excessive.

Following our meeting with Dr Cachia in April, we were advised to pursue any grievances with the appropriate regulatory authorities in Malta, namely the Medical Council and the Office of Fair Trading. On behalf of our principals, we have done just this and last month we wrote to these authorities providing what we believe is evidence to support our submissions that the conduct of some doctors was unprofessional and that costs charged were excessive by both local and international standards. We await the outcome of any investigations these authorities are conducting.

Turning now to the case of Ms Page, you will note the similarities of what happened to her when Dr Adrian Vella initially attended her in her apartment and subsequently when she arrived at St Philip's Hospital.

Ms Page was taken ill on August 4 but it was not until the morning of August 5 that IMR were notified by St Philip's Hospital of her admission.

After speaking with Mr Page at that time, he told IMR that St Philip's Hospital would not accept any guarantee of costs. He was immediately put in the picture with regard to the fact that IMR would not issue a guarantee anyway.

He advised that in any event, Ms Page was being transferred to St Luke's Hospital. Mr Page also went on to say that St Philip's Hospital were demanding payment of Lm500 for Ms Page's stay at the hospital. On August 8, IMR received a call from the British High Commission in Malta informing us that Mr Page had complained to them that IMR on behalf of the insurers would not pay the costs, which were now quoted as Lm800.

We advised the BHC that they should tell Mr Page, acting on instructions from his insurers, that he will have to pay the hospital bill and submit a claim to his insurance claims handlers for consideration when they returned home to the UK.

Subsequently, Ms Page was discharged from St Luke's Hospital on August 8 and IMR then arranged a successful repatriation of Mr and Ms Page back home to Scotland.

It is clear from reading Ms Page's letter that given her medical history as a diabetic and the time of day she was seen, an ambulance should have been called, not a taxi. She should have been taken to St Luke's Hospital which has the appropriate A & E facilities to manage her case.

There was absolutely no medical justification for her to have been admitted to St Philip's Hospital. You will therefore appreciate that our resistance to admission to private hospitals is not just that of cost but also what is considered to be appropriate medical management. You will note that following her admission into St Luke's Hospital, no complaint has been registered by Ms Page concerning her treatment in the state hospital.

Quite frankly, it is about time that the wider public both in Malta and here in the UK are made aware of what is going on with regard to the activities of Dr Adrian Vella, Dr Louis Buhagiar, Dr Frank Portelli and St Philip's Hospital.

These medical personnel are exploiting British visitors and their insurance companies by diverting them into the private sector and thereby maximising their own revenues. This is based on the assumption that the insurance companies here in the UK and Ireland will not be able to challenge both their medical management and consequent unacceptable costs.

I have to tell you that this will not be allowed to happen and we would welcome publication of the correspondence in order to bring these matters to the attention of a wider public.

'My priority was the patient's wellbeing'

by Dr Adrian Vella, Medicare, Qawra

I was called out at 4 a.m. on Sunday, August 4, by Mr Page who told me that his wife was unconscious and that she was very ill.

I attended to her within five minutes and as she was a diabetic patient I had to take several blood glucose levels in order to help me in the emergency treatment of this patient. The patient stabilised and I decided to transfer her urgently to a private hospital as I knew she would be treated immediately.

I asker her for her insurance policy as it is a normal procedure to procure an insurance policy when travelling abroad in order to get the best possible medical attention.

As the patient was diabetic I asked her if she was covered for her condition and she told me that she had paid an extra premium in order for her to be covered.

I phoned for a taxi to transfer her to hospital and in fact she arrived there within 10 minutes. (An ambulance from St Luke's to Qawra and back takes an hour due to the distances involved.)

It is important to state here that I was called at 4 a.m. on a Sunday and I felt it was in the patient's interest to transfer her to a private hospital as the workload at St Luke's is excessive. In fact, she claimed she spent more than seven hours waiting in casualty and then she was transferred to a corridor.

For being on call 24 hours, attending an urgent Sunday call at 4 a.m., taking blood glucose levels, and staying with the patient until she was stable, a charge of Lm25 is reasonable.

Regarding her insurance policy, I think, in those circumstances, my priority was the patient's wellbeing not the small print of a 30-page insurance document.

I would presume that when a contract is signed between an insurance agent and a patient, the patient should have peace of mind that they should be given the best medical attention possible, regardless of the fine print!

It is a good business to take money off the patient and then send him to St Luke's which is free anyway to all British citizens!

St Luke's Hospital

'Priority 1' patient

by Dr Frank Bartolo, medical administrator

Ms Page was registered in the casualty department on August 5, at 7.16 p.m. She was triaged (examined) by the triage nurse at 7.38 p.m. and was assesed as a 'priority 1' patient.

A number of investigations were immediately carried after she was examined by one of the casualty medical officers on duty at the time.

Ms Page was transferred to Ward M7 and was examined by the ward doctor at 0.30 hrs, that is five hours after registering in casualty. She was never, repeat never, kept waiting for seven hours. During the five hours prior to her admission in M7, Ms Page was triaged, examined by a doctor, investigated and after a final medical assessment transferred to the appropriate ward.

A bed (Bed 21) was found for Ms Page and she was in the corridor for only a short period of time.

Ms Page was discharged from St Lukes Hospital (Ward M7) on August 8.

I am enclosing a declaration from our billing section which is self-explanatory. Ms Page was not billed for any services rendered to her by St Luke's Hospital, including the ambulance service.

Free treatment

by Shirley Sultana, principal, billing section

Ms Pamela Page, who was admitted in Ward M7 till August 8, was entitled to free treatment according to the reciprocal health agreement with Britain.

Indeed, she was not charged for anything from our office.

This includes both the medical treatment that she received while she was at St Luke's Hospital and the ambulance fees.

Further investigation was required in this case - White Horse

by Nigel Ennis

We were concerned to hear about this incident and the extra inconvenience experienced by Ms Page at this stressful time.

Our policy covers reasonable and applicable emergency medical treatment and while we always try to settle medical insurance claims as quickly as possible, in this case further investigation was required.

We are currently in liaison with the appropriate Maltese regulatory authorities and hope to bring this matter to a swift and satisfactory conclusion.

We wish Ms Page a full and speedy recovery and would urge her to contact us if any outstanding issues remain.