Corporate Risk & Responsibility: Legal Responsibilities; Medical Evacuations; Corporate Policies & Stress - Seminar, April 28, 2000

Questions and Answers

DR CARR: I think we've tried to leave about 40 minutes. We want this to be a very interactive session and challenging both us but also maybe there are people in the audience that are equally expert and have equal experiences, and I'd like to share across the audience, not just bidirectionally this way.

I think what we've heard is that through effective planning, of course, and almost scenario planning through these kinds of case studies, one can really effectively position the corporation to reduce the risk and decrease through a loss prevention focus some preventable issues and crisis management.

I think one of the challenges that we face within SmithKline Beecham—and I'll throw kind of the first question out, I guess, at the panel—is: What is the role or responsibility of the corporation as to who should travel? In other words, are there requirements for periodic screenings and/or fitness-for-duty assessments that should be incorporated? And how rigorous should they be applied in terms of exclusion or inclusion in a traveling scenario? And if anyone on the panel or others in the audience want to take a stab at that.

DR. JARRIS: Well, that was an interesting observation, a question that I had actually earlier on when we heard about the oil workers in the North Sea and being able to disqualify people based on premorbid conditions or psychological conditions.

Again, from an American perspective, that's very problematic with the Americans with Disabilities Act. The U.S. military is able to do that without abandon, but in the corporate setting, I think that's a very real concern. I know a number of corporate medical directors here, but to really get to the point, I've been asked several times by corporate legal staff: Do you think we're better off running the risk of defending this against a federal attorney in an EEOC hearing, or are we better off fighting it out in litigation over an adverse outcome due to the fact that they were a diabetic working for us in whatever environment?

So it really comes down to a balancing act in the States where we are in double jeopardy almost.

MR. [NOT KNOWN]: A comment on the case review. One comment is that the Americans with Disabilities Act—and this isn't my experience, but it is of another corporate medical director—that if you send someone abroad who has bipolar disorder, you do so at your peril and let the lawyers come on, because it's much simpler to fight in court in the U.S. than to try to manage somebody who shuts your business down for a week because they're in a manic phase.

So that, I would say, other psychiatric disorders or psychological disorders, fine, but if you send somebody who has not been stable for at least five years with a bipolar disorder abroad, look out.

The second thing is we had a case in China where one of our executives who was going to run our Chinese business that we acquired was injured in a car accident, a road accident in China, and the cost to the corporation after the medical evacuation, six weeks in a coma in Hong Kong, and on and on and on and on, was something just short of $2 million. That included $100,000 being wired to Hong Kong at 3 o'clock Saturday morning from Dallas. You can imagine the logistics of that, along with everything else.

The patient was subsequently air evacuated—and International SOS helped us with that—back to Philadelphia, and it was a very tragic situation because his wife was killed in a car accident taking him home from rehab one day. So that's quite a story. I hope nobody has to live through that one again.

But the total cost of the case, the evacuation, transporting family—I spent six weeks in Hong Kong on that case—and so on was just short of $2 million. So $100,000 for air evac sounds like a lot, but you better think about everything else that goes with it.

MR. [NOT KNOWN]: I think your first comment on the bipolar, if you look at Case 3, actually, it's very apropos. That's one of the most challenging issues, I think, in the whole management of psychiatric illness in remote areas: one, the recognition of the individual that they even have the disease, and then how to approach the different methodologies for treatment in a remote area. So I would suggest you look at that case and some of the questions that have been reflected in that, and I think that would provide you some help, and maybe you can call Shoba and ask some specific details exactly on what it is that they did and some of the lessons learned from that case.

MS. NAYAR: Could I say just one thing, which is sort of backtracking a little bit? When I first started working in the early '80s, we did do physicals on everybody. Periodically, everyone had to come through the health unit and have a physical, and they got a little piece of paper that say, "You may now travel."

We discontinued that—I forget when it was, but it's been quite a while. I think the UN still does that.

?.]

MS. NAYAR: Right. We stopped doing it, and, therefore, the people who go on mission, we actually have no way of knowing what illness they have. The people that we assign overseas, we do clear them and their dependents. So we don't send people out with a known medical condition. But there's an element of unknown for the travelers, and, in fact, most of the emergencies that we have are travelers. I think part of it is we're all aging and we're becoming more decrepit as we go along, and there is also that element of the unknown.

DR. CARR: Thank you.

MR. [NOT KNOWN]: As a security person, it strikes me that there's a disconnect between security and health. As a former security officer for a Washington company, albeit a small company, we put together a crisis management plan knowing that 14 of our people of some 20 were going to travel on a continuous basis. Within weeks of our putting this together, my partner was on the Pan Am flight that was taken over by terrorists in Karachi.

One of the things which we had done in anticipation of just such a crisis was to map out exactly who was going to be responsible for what. And it turned out that the executive of the company tried to step in, when in point of fact we had a signed piece of paper saying that the security person was going to be in charge. And I showed that to him, saying, "You're out of it." And he was legally bound by the fact that he had signed off on that responsibility.

But what that meant was that we had a crisis management plan which included evacuation, although that wasn't put into place in this crisis. Some 29 people died, and my partner was not one of those. He got out okay because his passport was not on his person when they came looking for passports. But the point being that we knew who was going to do what by prearrangement and pre-decision, and that was a critical life-saving decision, because really it meant that we knew who was going to do what, we knew what we were going to do, we knew what documentation was on him, we knew what he was to be found with if any terrorists were to ask him all those questions. Those were going to be critical issues as much as his health was going to be, and the assistance company was going to be in some cases secondary.

So it seems that first when you deal with an organization like yours which may be too big to have such a pinpoint decision made, it seems to me if there's going to be a crisis, it might have—he might have been kidnapped. He might have been in Yemen and there could be somebody who's taking over and it's a political crisis, and to a certain degree, you need to decide who is the one who is going to make that decision before somebody goes out. I would suspect that the place to make that decision is when they come for their vaccinations. In my company now, which does vaccinations, we make that point to a corporate executive. We say here is the kind of crisis which you and your staff [? may be forced to make and these are the decisions that you are to make now and this is the reason to do this, and we'll refer you to a company or we'll do the plan ourselves if you want that kind of help. So at least they've said no in a systematic way when they get on the plane and when they send their employees.

But having a crisis management plan which is comprehensive to all aspects of the crisis for any corporation seems to me a no-brainer.

Just a comment: I guess not much of a question. It's just how you would instill that in your legal framework, how you would instill that in your framework, how you would relate to the corporation. But it does get to your point, which is somebody is told who's going to make the crisis decision and who's going to stay in charge and who's going to push everybody out of the way, and that's absolutely essential.

MR. [NOT KNOWN]: I'd like to maybe see a show of hands of how many companies have such a comprehensive linked crisis management with health and security.

Now, the other question, though: Is it just security of like the top 10, top 20, top 50, as opposed to crisis management for any employee?

MR. [NOT KNOWN]:?].

MR. [NOT KNOWN]: Mainly for the executives, senior executives. Hands? Or for all employees? Oh, very good. I would have thought different.

Anyone else have experience or—no. Okay. Yes?

MR. [NOT KNOWN]: Nathan Lamanack with International SOS. I just wanted to first commend Shoba on the excellent choice of cases that really illustrate a whole range of problems that have to be dealt with in this that I think often people are not aware of in terms of notification, communication, and decision making.

Just to answer the gentleman's question about the role of the assistance company, who's notified, at what point and so forth, there really is a wide range of options. The assistance companies will generally sell different types of policies, some of which as an individual traveler the decision making really is with the assistance company. That would be what we call an indemnified—it's very close to being an insurance policy, and in those cases, there are specified conditions under which an evacuation would be covered.

The assistance company would evaluate the situation. Ideally, the calls would come to the assistance company, and they would carry out whatever the indicated intervention would be.

There still may be—I think it's important to understand that even with those kinds of contracts, if the person is not covered, you may have a policy that will cover a certain named individual, that this person turns out not to be a named individual, or if you have not put him on your list so that our records don't reflect that, then we still have to have an authorized person to come back to and say this is our situation, do you want to proceed or not.

So, you know, the notification and authorization is still quite important, even with the service—what we call a service contract.

I think most of the clients that we deal with here have the access type of agreement, which the World Bank also has, and in this one the fee covered the access to the assistance company, which means that you can call us for anything, what do you think about medical care in this area,?] question to, of course, big ticket items such as an evacuation. And all of that service is provided up to the point that a cost has to be paid, and then that would—whatever it is, it is billed back to the corporate client.

My plea that I usually make, the word that I would like to get out, is that you not think of the assistance company as your evacuation company, because the assistance companies do a great deal more than that. And what we often find is that if people don't think of involving the assistance company until the point that we're ready to have the planes fly in, you've lost a lot of valuable time to be having the assistance company provide what they could be providing you.

So we like to really encourage as soon as there is a known problem, a potential problem, that that is really the time to get your assistance company involved and one way they can help, sometimes help prevent an expensive evacuation if they can be brought in earlier and come up with some other solutions to the problem.

DR. CARR: Thank you.

MR. [NOT KNOWN]: Our American employees at IBM have either Diner's Club cards or American Express cards, and both these companies say that they provide global assistance services not only for medical but also for legal. They have an 800 number and everything, and this arrangement was not made through us in Occupational Health Services. It was made through whoever in IBM happens to put out these cards. It turns out in France our French people who have Diner's Club cards also have this kind of service. So I have a couple of questions.

First of all, do any of you have experiences with the global assistance services that the credit card companies say they have? And are they any good? And, number two, around that, is there some kind of a protocol for assessing how good they might be? And, thirdly, are there any corporations in this room where you might have duplicative service between the credit card companies that somebody else handles in your corporation versus your occupational health service where you might have your own global assistance company in operation?

DR. CARR: Interesting. Anyone know of the actual services provided by either the AmEx or the Diner's Club?

MR. [NOT KNOWN]: Mondiale?].

DR. CARR: Mondiale?

MR. [NOT KNOWN]: [?] American Express.

DR. CARR: Is it provided like a retainer service of information and local medical support, physicians who speak—

MR. [NOT KNOWN]:?].

DR. CARR: I see.

MR. [NOT KNOWN]: [?] referral service [?] somebody else is going to pay for it later. It's just [inaudible]. If there is actual corporate relationship, then it [?] have a corporate policy [?]. Sometimes you have to watch out [?] legal services as well [inaudible] referral to a whole range of [inaudible] health policy, which is overpriced [?]. But you have to watch out [inaudible] not just referral services.

MR. [NOT KNOWN]: Well, there goes to my second question. You're raising all these fine points. Is there some kind of—you know, what do we look at so that we know that we're being covered in the way that we want to be covered by these companies at all? Is there some kind of a protocol or something written down that I can go to?

MR. [NOT KNOWN]: [?].

MR. [NOT KNOWN]: Yes, but I wouldn't know what to ask. That's the problem. I mean, I don't know all those points to ask. And you're saying—

MR. [NOT KNOWN]: [inaudible].

MR. [NOT KNOWN]: Well, that's what I'm looking for. Just in companies like AXA and Mondiale, are they good? I don't even know them.

DR. CARR: Just a point, because I know they're trying to capture this on the proceedings. If someone from the audience is answering, could we bring them up to the mike? Because I think that would help the proceedings record everyone. Your voice was loud enough, probably, but—

MR. [NOT KNOWN]: Just to follow up on that point, there's an entry level typically for the average gold card or platinum card-holder, not with the corporation. That's pretty much an entry-level service. Typically a corporation will have a customs service available for their employees. But be aware, if you're accessing it just as a card-holder, not through a corporation, that the service is bid out. So you may call one year and have a totally different provider the next. And some of the people who bid on those services are really just resellers buying it again from another assistance company, and you may end up speaking to someone that you don't have a lot of confidence in if you haven't done the research.

MS. [NOT KNOWN]: Another thought to this. I think it's very dependent on an organization to actually set their criteria of what they want, because at the end of the day, it's the organization's responsibility. And, therefore, if you could use the protocol for guidelines, who's doing what and what's their responsibility, then I think you begin to enter a legal tangle.

DR. CARR: Dr. Narula?

DR. NARULA: Just a few statements to make [inaudible] which came up. As Shoba was mentioning, we are still doing medical examinations in New York just for the people who travel. Usually we do them once in (?) years. [?] not only that, [?] a couple of days before traveling, [?] American Express will not give them their ticket unless they have the clearance to participate [?]. So they bring a little slip to us and we sign it. At least that way we can avoid something that's avoidable, especially when they're going from headquarters. But this is only for people who are going from New York. That's where we have this little control, but it does help a lot.

Otherwise, if we say he's not traveling, he's not traveling.

But then still we have so many medical evacuations because we have a huge population who work in the field duty station. UNICEF and UNDP [?] and over those two years they can have a medical problem which cannot be resolved in that country, so they have to be evacuated.

But we have guidelines. Guidelines, we used to call them personal directives, and now they are being called [?]. These guidelines are written by us in consultation with administration, and some input from the Staff Association [?]. So those guidelines tell us who are entitled to this travel, because we even evacuate our locally recruited staff members, including their recognized dependents, not only for emergencies but for the non-emergency conditions which cannot be [?]. So we have guidelines, certainly.

Now, who makes what decision? It's the doctor's decision whether this person should be evacuated or should not be evacuated, and where should he be evacuated and what kind of flight he should take, should it be commercial or should it be air ambulance. This whole thing is the doctor's decision made by a doctor in New York in consultation with a doctor in the field. I know we have a huge population in the field, but no support in the field right away. And also we have doctors with the World Bank also uses which are UN approved physicians, in the field, they're the ones who talk to us. We don't use any assistance companies for that, not at all.

We have these physicians. They are on our list. If they're approved by us, we use them, and [?] many physicians that we can consult. So there's no one in between. There's no company that we're using.

So based on those guidelines, everybody knows that [?] and for how long, and we have something else which is [?] travel. We have all these guidelines on that which helps many people.

But even in our guidelines it tells you very clearly where the medical escort will be allowed and where a family member will be allowed, and [inaudible] we might even allow this, a medical escort and a family member. But just to let you know, this is the most difficult medical evacuation that we ever have to deal with. We had a case [inaudible] and she only had to go to Canada. And I agreed. But [inaudible] female relatives should come [inaudible] brought her back home to Canada.

And whatever you do, I think the best one can do, one always try to do under the circumstances. We have an average of about eight to ten medical evacuations a day. But in the whole year, if you talk about air ambulances, not more than eight to ten air ambulances. And the air ambulance that we use is Swiss Air ambulance.

The Swiss Government has this- it is their contribution to peacekeeping. They have given us free use of air ambulance up to a certain number for a year, and especially when we have any problem in Balkans, they come and pick up people, and they've been very, very helpful even for coordinating.

We also have some arrangement with SOS, with UNICEF and UNDP. ?

MR. [NOT KNOWN]: I think what you were saying there is that all of the planning and guidelines and practices, you're really managing expectations, one, and you're being very consistent about the application and not creating precedents and inconsistencies which would lead to maybe legal and misperceptions later on.

DR. NARULA: Absolutely. But the legal part of it, I know when you are making these decisions, you are talking more about medical, and we don't think about legal at that time. And also there is no confidentiality in most of the medical evacuations. Almost the whole town will know what happened there and why this person is being evacuated. I'm being honest with you. We tell them on the telephone to keep it—but everybody knows it.

Coming to the legal part of it, if we have made a decision and if I have been wrong, they cannot sue me. But, of course, as you said, there is an internal procedures of the organization which can be followed. And despite having about 2,000 medical evacuations a year, I think so far you have only about four to five cases which end up in the Tribunal. And we have seen when they go to the Tribunal, most of our staff always wins.

Thank you.

MR. [NOT KNOWN]: Doctor, could I ask you one question before you go away? On this medical clearance for the people who are traveling from New York, have any of the staff objected to that?

DR. NARULA: Not at all. I think one—part of the administrative procedure, they don't object. They're not going to get their ticket. And that they have been told by the [?] not by us.

Thank you.

DR. CARR: Thank you.

MS. [NOT KNOWN]: In the U.K., I'll give an example, and this follows on what was just being said as well. We have a legal framework for the health and safety, management of health and safety [?], and also EU regulations. Under that, you have to stipulate organizational arrangements. Now, it's actually under that that you have all these operating procedures taking place as to how you organize things and how you actually operate it, all your procedures, guidelines, and using that framework it's very useful for also developing this for people working overseas.

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