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International Risk UnderwritingForeign Travel and Residence Risks, Facts and Trends
Melissa Gallegos, FALU, FLMI, ACS, ARADirector, Team Manager
Brittany Donohue, FALU, ACS, ALMIUnderwriting Consultant
September 11, 2019
2
“The world is a book and those who do not travel read only one page.”
St. Augustine
3
Historical Growth of World Travel
Source: UNWTO
1950: 25 million 2005: 808 million 2016: 1.2 billion
Annual growth: 4% Forecast for 2030: 1.8 billion
4
Foreign risks are sensationalized in the news & entertainment media
Most short-term foreign travel is low risk
Foreign residence is far more significant than short-term foreign travel
Major mortality and morbidity differences exist among countries
Look beyond popular opinion and preconceptions
Foreign Residence and Travel Observations
5
How dangerous or safe is foreign travel?
What are the most significant mortality risks?
What are the major differences among nations?
Why does it matter what country you live in?
6Source: CIA World Fact book 2019 est.45 – USA: 80.10 years
Life Expectancy at Birth
High Years Low Years
Monaco 89.40 Afghanistan 52.10
Japan 85.50 Zambia 53.00
Singapore 85.50 Lesotho 53.00
Macau 84.60 Somalia 53.20
San Marino 83.40 Central African R. 53.30
Iceland 83.10 Mozambique 54.10
Hong Kong 83.10 Uganda 56.30
Andorra 82.90 Niger 56.30
Switzerland 82.70 Eswatini 57.20
Guernsey 82.70 Chad 57.50
Israel 82.70 Congo 58.10
Malta 82.70 Sierra Leone 59.00
South Korea 82.50 Nigeria 59.30
Italy 82.40 Cameroon 59.40
Australia 82.40 Cote D’Ivoire 60.10
7
From Wikipedia, the free encyclopedia
Life_Expectancy_2013_Estimates_CIA_World_Factbook
Geography of Life Expectancy
Life Expectancy at Birth (Years)
8
HIV/AIDS Adult Prevalence Rate
Source: CIA World Fact book 2017 est.
Country Percent Country Percent
Eswatini 27.40 Brazil 0.60
Lesotho 23.80 Spain 0.40
Botswana 22.80 United Kingdom 0.33
South Africa 18.80 Mexico 0.30
Zimbabwe 13.30 Germany 0.20
Namibia 12.10 Australia 0.10
Zambia 11.50 Iran 0.10
Malawi 9.60 Philippines 0.10
Equatorial Guinea 6.50 Somalia 0.10
United States – 0.30 %
9UNAIDS
10
Tuberculosis (TB) Prevalence
Source: The World Bank 2017
(Selected Countries - cases per 100,000 population)
Countries TB Prevalence Countries TB Prevalence
Lesotho 665 Guyana 86
South Africa 567 China 63
Philippines 554 Mexico 22
Mozambique 551 Japan 15
Gabon 529 United Kingdom 9
Pakistan 267 Australia 7
India 204 Italy 7
Thailand 156 Canada 6
Vietnam 129 United States 3
11
12
Hepatitis B Prevalence (percent of population)
Source: https://www.rightdiagnosis.com/h/hepatitis_b/stats-country.htm 8/13/2015 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4641116/
CountryHepatitis B
PrevalenceCountry
Hepatitis B
Prevalence
Zimbabwe 25.0 Saudi Arabia 1.5-2.6
Mali 15.5 Jordan 1.4
Nigeria 13.6 Iraq 0.6
Cameroon 10.1 USA 0.5
China 7.2
Zambia 6.5
South Korea 4.0
Bulgaria 3.8
India 3.7
Singapore 3.6
13
Hepatitis B Prevalence
Source: WHO, work conducted by the London School of Hygiene & Tropical Medicine (LSHTM). See Annex 2.
14
Hepatitis C Prevalence (selected countries percent of population)
Source: 1999 WHO
CountryHepatitis C
PrevalenceCountry
Hepatitis C
Prevalence
Egypt 18.1 India 1.8
Rwanda 17 United States 1.8
Bolivia 11.2 South Korea 1.7
Mongolia 10.7 Mexico 0.7
Vietnam 6.1 Australia 0.3
Thailand 5.6 Canada 0.1
China 3.0 United Kingdom 0.02
Japan 2.3 Sweden 0.003
15
Maternal Mortality Rate (number of maternal deaths per 100,000 live births)
Source: CIA World Fact book 2016
Infant Mortality Rate (deaths before age one per 1,000 live births)
USA 5.80 (57th)
Country Deaths Country Deaths
Finland 3.0 Sierra Leone 1360
Greece 3.0 Central African R. 882
Iceland 3.0 Chad 856
Poland 3.0 Nigeria 814
Austria 4.0 South Sudan 789
Belarus 4.0 Somalia 732
Czechia 4.0 Liberia 725
Australia 6.0 Canada 7.0 USA 14.0
Country Deaths Country Deaths
Monaco 1.80 Afghanistan 112.80
Japan 2.00 Mali 100.00
Iceland 2.10 Somalia 96.60
Singapore 2.40 Central African R. 72.7
Source: CIA World Fact book 2015 est.
16
Infectious and Parasitic Disease Mortality
Country Death rate per 100,000
population
Total Fatalities in 2008
Australia 10.0 2,100
United Kingdom 13.4 8,200
Germany 15.9 13,100
United States 22.8 71,200
Canada 37.0 12,300
India 181.9 2,149,100
Haiti 299.7 29,600
Nigeria 568.7 860,000
Dem Rep Congo 687.4 441,700
Malawi 744.4 106,800
Source: WHO 2008
17
Global Smoking Prevalence
18
Global Obesity Prevalence
In the U.S., obesity levels continue to rise, with 42% of Americans predicted to be obese
by 2030
Source: CDC
19
WHO World Health Systems’ Ranking
Rank Country Rank Country
1 France 17 Netherlands
2 Italy 18 United Kingdom
6 Singapore 19 Ireland
7 Spain 20 Switzerland
9 Austria 25 Germany
10 Japan 27 United Arab Emirates
11 Norway 30 Canada
12 Portugal 32 Australia
14 Greece 36 Costa Rica
17 Netherlands 37 USA
High correlation between this rank and life expectancy rank.
USA: Physician density/1,000 pop. = (2.4), rank 49 Hospital beds/10,000 pop. = (30), rank 64
20
The availability of physician care is an indicator of the quality of a country’s healthcare system. The number of physicians per 1,000 population was provided by the World Economic Forum (WEF) as part of the Travel and Tourism competitive index. The most recent year of data available is as of 2017.
Physician Density
Physicians/1,000 population:
Top 5 countries
Physicians/1,000 population: Bottom 5
countries
1 Qatar 7.7 131 Tanzania 0.03
2 Spain 4.90 132 Burundi 0.03
3 Greece 4.40 133 Ethiopia 0.03
4 Russia 4.30 134 Sierra Leone 0.02
5 Norway 4.30 135 Malawi 0.01
21
Physician Density
The United States has a physician density of 2.45 per 1,000 population and ranks 49 of the 135
countries provided by the WEF data in our study.
22
Annual Global Deaths
Causes of Death Per Year
HIV/AIDS 1,100,000
Tuberculosis 1,800,000
Malaria 429,000
Motor vehicle accidents 1,250,000
Job related accident/illness 2,300,000
Armed conflicts 180,000
Terrorism* 28,238
Sources: WHO 2013-15, ILO 2014, IISS Armed Conflict Survey of 2015
*Includes perpetrators
23
24
Deaths of U.S. Citizens Abroad by Non-natural Causes
Reported to U.S. State Department abroad Jan. 1, 2014, to Dec. 31,2014
810 total deaths reported (approx. 67,000,000 U.S. citizens traveled/resided abroad in 2014)
Main Non-natural Causes Number of Deaths Abroad Percent of Total
Motor vehicle accidents 225 27.8
Homicides 174 21.5
Suicide 140 17.3
Drowning 106 13.1
Other accidents 94 11.6
Drug related 27 3.3
Air accidents 19 2.3
Terrorism 19 2.3
Maritime accidents 6 0.8
25
Causes of Non-natural Deaths Abroad of U.S. Citizens in 2014
Motor vehicle accidents28%
Homicides22%
Suicide17%
Drowning13%
Other accidents12%
Drug related3%
Air accidents2%
Terrorism2%
Maritime accidents1%
Total 810 deaths
26
Deaths of U.S. Citizens Abroad by Non-natural Causes
Source: US Department of Commerce, National Travel and Tourism Office, July 2015
Most Common Causes of Death(October 2002-June 2015)
Cause of Death
Reported # of American
Deaths Abroad
Traffic Accidents 3,104
Homicide 2,000
Suicide 1,461
Drowning 1,320
Other Accidents 1,294
Countries with the Most American Deaths 2014-2015
Country
American Deaths
July 2014-June
2015
American
Visitors in 2014
Mexico 228 25,900,000
Thailand 35 339,000
Costa Rica 31 862,000
Philippines 29 708,000
Dominican
Republic
28 2,700,000
27
U.S. Citizen Non-natural Deaths Abroad
Non-natural
Causes of DeathDeaths in Mexico Deaths in Canada
July 2007 – June 2011 Jan. – Dec. 2016 July 2007 – June 2011 Jan. – Dec. 2016
Vehicle Accidents 352 78 18 3
Homicides 313 73 1 1
Drownings 117 38 11 3
Other Accidents 80 31 5 1
Suicides 75 35 11 1
Other 30 3 3 0
Drug-related 10 5 2 1
Total 977 263 51 10
Mexico vs. Canada
Source: U.S. State Department
28
U.S. Citizen Non-natural Deaths Abroad
Country # of Homicides
July 2007-
June 2011
Jan.-Dec.
2016
Mexico 313 73
Honduras 40 6
Philippines 39 8
Dominican
Rep
27 4
Guatemala 24 3
Haiti 20 6
Colombia 19 2
Costa Rica 16 3
El Salvador 16 2
Iraq 15 0
Jamaica 12 8
Source: U.S. State Department
Vehicle AccidentsJuly 2007-
June 2011
Jan.-Dec.
2016
Mexico 352 78
India 32 5
Dominican Rep 32 6
Thailand 31 11
SuicidesJuly 2007-
June 2011
Jan.-Dec.
2016
Mexico 75 35
Thailand 34 11
Germany 34 7
South Korea 30 6
DrowningsJuly 2007-
June 2011
Jan.-Dec.
2016
Mexico 117 38
Costa Rica 34 13
Bahamas 27 9
Dominican Rep 18 5
29
Natural Causes
62%
Accidents
25%
Murder
7.8%
Suicide
5.2%
Major Causes of Traveler Deaths Abroad
Source: MacPherson, J. Travel Med, 2000
30
Major Causes of Traveler Deaths Abroad
1 Hargarten SW, Baker TD, Guptill K. June 1991. Medical
College of Wisconsin, Milwaukee 2 MacPherson, J. Travel Med, 2000
U.S. Citizens1
Cardiovascular and cerebrovascular (mainly myocardial infarction
and stroke/CVA) 49%
Injuries/trauma (mainly traffic accidents) 25%
Canadian Citizens2
Natural deaths 62%
Accidental 24.99%
Murder 7.80%
Suicide 5.20%
31
International Homicide Rates (per 100,000 population)
Country Murder Rates Country Murder Rates
Honduras 74.6 Andorra 0.0
El Salvador 64.2 Greece 0.1
Venezuela 62.0 Cyprus 0.1
Jamaica 36.1 Luxembourg 0.2
Belize 34.4 Japan 0.3
South Africa 33.0 Singapore 0.3
Guatemala 31.2 Switzerland 0.5
Colombia 27.9 Austria 0.5
Trinidad & Tobago 25.9 Indonesia 0.5
Brazil 24.6 Norway 0.6
Puerto Rico 18.5 Slovenia 0.7
Dominican Rep. 17.4 Poland 0.7
Mexico 15.7 Spain 0.7
Source: The World Bank 2014
31
USA: 3.9
32
Homicide Rates (per 100,000 population)
Two neighboring cities in 2016
Ciudad Juarez, Mexico: 43.63 El Paso, Texas: 2.77
33
Country Guns per 100
people
Total firearm-related deaths per 100,000
population
Japan 0.6 0.06
Australia 15.0 1.04
Canada 30.8 2.44
Netherlands 3.9 0.46
Belgium 17.2 2.43
Sweden 31.6 1.47
Finland 45.3 3.64
Italy 11.9 1.28
Switzerland 45.7 3.84
United Kingdom 6.2 0.25
United States 88.8 10.20
Sources: The American Journal of Medicine, “Gun Ownership
and Firearm-related Deaths,” October 2013.
U.S. National Vital Statistics: 33,594 total firearm deaths in
USA in 2014.
34
Occupational Accident Fatality Rate (per 100,000 workers)
Country Rate Country Rate
United Kingdom 0.8 Vietnam 27.0
Netherlands 1.5 Bangladesh 26.4
France 3.0 Egypt 24.0
Australia 3.2 Philippines 20.0
Japan 3.2 South Africa 19.2
Germany 3.6 Malaysia 18.3
United States 5.2 Mexico 15.9
Canada 6.4 U.A.E. 15.9
Italy 6.9 India 11.5
Poland 10.0 China 10.5
Source: Global Estimates of Accidents. Tampere University of Technology (Finland) 2005
2015: USA 3.4
4,836 total fatalities:
93% male, 7% female
Hours worked: male
57%, female 43% Source: U.S. Bureau of Labor Statistics 2015
35
Worldwide, there are 2.3 million annual job-related deaths.
Work accidents are more prevalent in developing countries with dangerous construction, farming, mining, factory jobs and low safety standards
Developing countries’ occupational ill health risks are 10-20 times greaterthan those of developed countries
There were an estimated 58,200 workplace fatalities in China in 2013
Occupational Mortality
Source: International Labour Organization, 2014
and The Rand Corporation, 2016
36
GDP per capita on a purchasing power parity basis was found in the CIA’s World Factbook and is an indicator of a country’s wealth, as well as the standard of living of its citizens.
Economic Factors – GDP per Capita
GDP – Top 5 countries GDP – Bottom 5 countries
Qatar $129,700 Somalia $400
Monaco $115,700 Central African Rep $700
Luxembourg $102,000 Burundi $800
Macau $96,100 Congo, D.R. $800
Singapore $87,100 Liberia $900
37
Economic Factors – GDP per Capita
The per capita GDP in the U.S.A. is $57,300, which is a
rank of 20 of the 203 countries.
38
The data for the Gini index as of 2013 is included in the CIA’s World Factbook. “The Gini index measures the degree of inequality in the distribution of family income in a country.” The index ranges from 0 to 100, with 0 indicating perfect income equality among households in a country and 100 is perfect inequality. Therefore, the higher the Gini index, the more income disparity there is within a country.
Gini Index – Income Distribution Inequality
Gini Index – top 5 countries Gini Index– bottom 5 countries
1 Slovenia 23.7 141 C. African Rep. 61.3
2 Ukraine 24.6 142 South Africa 62.9
3 Denmark 24.8 143 Sierra Leone 63.0
4 Sweden 24.9 144 Botswana 62.5
5 Czech Republic 24.9 145 Lesotho 63.2
The Gini index is 45 for U.S.A which ranks 102 out of the 145 countries with data, meaning there is a greater
difference in income distribution in the U.S. than in the majority of countries in this study
US CEO compensation ratio (S&P 500 companies) compared to rank & file worker:
1950s 20:1 1980 42:1 2013 204:1
39
In US from 1979-2007 Top fifth in household income increased share of income by 10% (most going to top 1%), while 80% of households saw their share of income decline 2-3%. US income inequality has been steadily growing. Sources: Congressional Budget Office & Bloomberg
Generally, the Gini index is lowest in the Scandinavian countries in Europe and highest in South America and Africa.
Gini Index – Income Distribution Inequality
40
Age of Death (Poor vs. Wealthy Countries)
Source: WHO, 2014
High-Income Countries
(Deaths among people age)
70% >70 yrs
29% 15-69
1% 0-14
Low-Income Countries
(Deaths among people
age)
20% >70 yrs
40% 15-69
40% 0-14
41
Other Foreign Risk Factors
Mongolia has fewer than 2 people per square kilometer.
Population density of Lagos, Nigeria, is 10,000-50,000 per square
kilometer.
Population density
Access to medical care
Environment, climate, drought, famine
Legal issues
Natural disaster frequency and severity
Military conflict
Political situation – instability (Bolivia: 193 coups since 1825); foreign relations
Corruption (CPI: least – New Zealand and Denmark; most – Afghanistan and Somalia)
Document and claims fraud
Transparency International Corruption Perception Index 2016
42
Access to medications (prescription, nonprescription and non-FDA approved)
Availability of reliable medical records
Quality of medical care, access to new treatments, safety of blood supply
Socioeconomic conditions, hygiene, sanitation
Anti-selection potential
Other Foreign Risk Factors (cont’d.)
43
Compounding Foreign Travel Risk
Serious pre-existing
medical conditions
Older age
Hazardous avocations and
lifestyle concerns
Long-distance travel (“economy
class syndrome”): approx. 3x
increased risk of venous
thrombosis on flights >4 hrs.
44
Tourist Injuries in European Union (EU)
Approximately 300,000,000 tourists visit EU countries annually
Approximately 3,800 tourists die of injuries annually while visiting the EU
30% of all tourist fatalities are due to injuries
Tourist vs. resident overall injury mortality is 1.70/1,000 vs. 0.37/1,000, representing a 4.6 times greater injury mortality rate for tourists
Injury fatalities peaked in 25- to 44-year-olds and were predominantly among males
Main causes: traffic accidents (2,900), drowning (340) and mountain activities (280)
Source: Bauer R, Kormer C, Sector M; Int J of Injury Control and Safety Promotion, March 2005.
45
Thirty years ago, Beijing had few cars. By 2007 it had 3 million cars. 2011, 5 million. Recently has begun banning on high pollution days.
Rapidly growing economies in the Middle East and Southeast Asia have a growing middle class with resulting increase in airborne particulates due to increased public transportation and personal vehicle use, with many thousands of deaths attributed to air pollution.
In 2009 China passed the USA to become the world’s largest new car market and remains #1 as of 2016.
Estimated: >700 fatalities and 45,000 injuries on China’s roads daily, >260,000 fatalities/yr.
Foreign Travel and Residence Risk: Changing World Traffic
Beijing, 1979 Beijing today
Source: WHO
45
46
Road Traffic Mortality (annual number of deaths per 100,000 population)
Country
Road Traffic
Mortality Country
Road Traffic
Mortality
Thailand 36.2 India 16.6
Iran 32.1 Mexico 12.3
Rwanda 32.1 United States 10.6
Dominican Rep 29.3 Canada 6.8
Kenya 29.1 Belgium 6.7
Saudi Arabia 27.4 Italy 6.1
South Africa 25.1 Australia 5.4
Belize 24.4 Japan 4.7
Brazil 23.4 Germany 4.3
Morocco 20.8 Netherlands 3.4
Russia 18.9 United Kingdom 2.9
China 18.8 Sweden 2.8
Source: WHO, Global Status on Road Safety 2015
47
Alcohol related road traffic crashes,Per 100,000 of population
Source: WHO 2012
US 74.0 as of 2008
48
Road Traffic Mortality Trends (Developing Countries)
Rush hour can be chaotic in Delhi, India.
Currently there are 1,250,000
fatalities/yr., 50,000,000 injuries/yr.;
90% of the world’s road fatalities occur
in low/middle income countries though
they only have about half the world’s
vehicles
Half of those dying on the world’s
roads are “vulnerable users”
pedestrians, cyclists and motorcycles
WHO: “Without action, road traffic
crashes are predicted to rise to become
the 7th leading cause of death by 2030”
49Source: WHO 2004
50
Traffic Mortality Statistics and Trends in DevelopedCountries
Country 1979 Fatalities 2002 Fatalities Percent Change
United States 51,093 42,815 -16.20%
Great Britain 6,352 3,431 -46.00%
Canada 5,863 2,936 -49.90%
Australia 3,508 1,715 -51.10%
U.S. ranking has fallen from 1st to 18th over the last 30 years
51
With similar percentage improvement as Canada and the U.K., the U.S. could save 7,000 to 10,000 lives per year.
Some reasons U.S. is lagging
• Less seat belt use (84% in U.S. vs. 95% in Canada) and less motorcycle helmet use
• Not all U.S. states have primary seat belt laws
• Crumbling infrastructure, poorly maintained roads and bridges: 26% of U.S. roads and bridges are structurally deficient or obsolete
• Inconsistent enactment and enforcement of laws regarding driving under the influence of alcohol/drugs or distracted driving
Road Traffic Mortality Trends (Developed Countries)
52
• More SUVs, pick-up trucks, minivans (rollover danger, and these large vehicles pose considerably more risk to occupants of cars than other cars do)
• Less public transportation available
• Ill-considered new laws repealing mandatory helmet use by motorcyclists are guaranteeing many more deaths and injuries
o Only 19 U.S. states and the District of Columbia still require universal motorcycle helmets for all riders
o 47 states required helmets in 1975 when Federal Highway Finance was tied to helmet laws
• In the U.S. a total of 4,693 motorcyclists died in crashes in 2015. Motorcyclist deaths had been declining since the early 1980s but began to increase in 1998 and continued to increase through 2008. Motorcycle deaths accounted for 13 percent of all motor vehicle crash deaths in 2015 and were more than double the number of motorcyclist deaths in 1997.
Road Traffic Mortality Trends (Developed Countries)
53Source: The Association of Americans Resident Overseas, 2011
8.7 million Americans (excluding military) live in 160-plus
countries as of 2016 per US State department.
2011 Government Estimate of Overseas Americans by
region around the world
The estimated figures, by region, were:
Africa: 171,000
East Asia and Pacific: 864,000
Europe: 1,612,000
Near East: 870,000
South Central Asia: 212,000
Western Hemisphere: 2,591,000
For a total of 6,320,000
54
World’s Top Travel Destinations 2015
Total US Resident trips abroad by year:
• 1990 – 44.6M
• 2000 – 61.3M
• 2009 – 61.4M
• 2015 – 74.0M
Country Million Country Million
France* 83.7 Turkey 39.8
United States 74.8 Germany 33.0
Spain 65.0 United Kingdom 32.6
China 55.6 Russia 29.8
Italy 48.6 Mexico 29.1
* France 2012 results. Source: UNWTO
55
U.S. Resident Travel Abroad (Outbound): 2006-2015
56
United States Resident Travel Abroad: 2015
International Trade Association – Office of Travel and Tourism Industries
Historical Visitation (Outbound) 2014 vs 2015 – One or More Nights
Region/Country 2014 (000) 2015 (000) % Change
(2015/2014)
TOTAL OUTBOUND 68,185 73,997 9%
Mexico 25,882 28,733 11%
Canada 11,523 12,475 8%
Overseas* 30,780 32,789 7%
Europe 10,804 11,378 5%
Caribbean 7,387 7,837 6%
Asia 5,694 6,066 7%
Central America 2,370 2,590 9%
South America 2,278 2,361 4%
Middle East 1,724 1,902 10%
Africa 893 951 7%
Oceania 585 656 12%
*Overseas includes
all countries except
Canada and Mexico
57
Top Destinations of U.S. Residents Traveling Abroad (Outbound) 2014 vs 2015
International Trade Association – Office
of Travel and Tourism Industries
58
International Processing and Administering Concerns
Where will exams and lab tests be completed?
Foreign language problems
APS time delays, bureaucracy, unavailable, non-existent
The one-paragraph “perfect health” APS
59
Passport is proof of citizenship
Place of birth information (U.S. or another country)
Green card, immigrant visa
Non-immigrant visa
No visa or wrong visa
Citizenship and Visas
Why knowing applicant’s citizenship and visa status helps in foreign risk evaluation
60
U.S. Resident Documents
1997 – 2010
1977 - 1997Employment Authorization Card
2010 – Current
Historical Green Card
61
U.S. Visa and I-94 Form
62
U.S. Non-Immigrant Visas
Complete list at U.S. Citizenship and Immigration Services website: USCIS and Non-immigrant Visas
Visa Description
B-1 & B-2 Temporary visitor for business or pleasure
E-1 & E-2 Treaty trader or investor
F-1 Academic Student
H-1B Specialty Occupations
L-1 Intra-company Transferee
63
• Travel legislation in California, Colorado, Connecticut, Florida, Illinois, Maryland, Massachusetts, Missouri, New Jersey, New York, Oklahoma, Tennessee and Washington
• Directives issued in Georgia
64
Application: place of birth, type of visa, address/residence, foreign travel questions
Foreign Travel Questionnaire: citizenship; visa type; anticipated foreign travel; list of specific countries to be visited; and duration, dates and purpose of travel
Inspection reports, telephone interviews, separate letter describing travel
Official Documents: copy of passport, green card, US visa, EAD, other US government issued documents on residential status
APS medical records (inoculations for travel, illnesses acquired abroad, mention of frequent travel or foreign residence)
Underwriting Foreign RiskKey information sources
65
Locations, dates & duration of foreign travel or residence
Medical risk: medical history, applicant’s age, current health
Occupation & work duties abroad, office or field work
Planned activities abroad: any hazardous activities such as mountain/rock climbing, scuba diving, aviation, etc.
Red Flags: financial, lack of candor, conflicting information, substance abuse, unfavorable MVR, other risks
Underwriting Foreign Risk
Risk Assessment
66
Short duration of foreign travel/residence
Travel is not immediate and not already under way
Only major urban areas visited
Purpose of travel is business, vacation, family visit
Traveler is 18-70 years of age
Life insurance application is for permanent or level term plan
Proposed insured is in good health
Lodging is at a hotel or relative’s home
Country of destination is considered relatively safe
Favorable Underwriting Factors
67
Long duration of foreign travel/residence
Anticipated travel is less than 60 days away or already under way
Travel is to rural and remote locations
Purpose of foreign travel/residence is to work as a missionary, journalist (132 deaths in 2009), relief worker, government official, public figure, etc.
Traveler is under 18 or over 70 years old
Application is for annual renewable term or short-term plan
Unfavorable Underwriting Factors
68
Amount of coverage requested appears excessive
Engaged in hazardous activities abroad
Quality and type of lodgings are uncertain
Destination is one or more high-risk countries
Traveler has serious pre-existing medical condition
Minimum (one month) premium payment made or selected
Recent immigrant with no available medical records and little or no comprehension of English
Unfavorable Underwriting Factors (cont’d.)
69
People residing in the US for less than 12 months prior to applying for life insurance
People residing in the US without an established physician
Older age recent immigrant to US (especially 60 years+)
Extra caution if applicant speaks little or no English
Financial justification is lacking
Grandparents who watch grandchildren and apply for $1M+
People crossing US/Mexican border multiple times/week
Red Flags of International Risk
70
There are 25 indicator variables that are included in this analysis as contributors to a country’s overall risk and are used to rank the 205 countries studied.
In the example here, the U.S. would have a rank of 39
RGA 2018 Foreign Risk Study Research Bulletin
Country summary
71
Country Study Rank Country Study Rank
Monaco 1 Denmark 20
Sweden 2 Belgium 21
Switzerland 3 Hong Kong 22
San Marino 4 Canada 23
Austria 5 Korea, South 24
Norway 6 Greece 25
Iceland 7 United Kingdom 26
Netherlands 8 Malta 27
France 9 Ireland 28
Japan 10 New Zealand 29
Australia 11 Guadeloupe 30
Italy 12 Portugal 31
Luxembourg 13 Czechia 32
Spain 14 Cyprus 33
Germany 15 Poland 34
Andorra 16 Bermuda 35
Finland 17 Slovakia 36
Liechtenstein 18 Slovenia 37
Singapore 19 Taiwan 38
RGA Foreign Risk Study Worldwide Country Rankings
72
Message to readers of article:
“Before you plan on visiting any of these places, get a life insurance policy.”
Photo of soldier with fire & smoke in background with caption:
• “Travelers are under the ongoing threat of kidnapping and assassination in Afghanistan.”
US Business Magazine Headline:
“Most Dangerous Destinations 2006”
Source: Forbes, Sophia Banay, February 22, 2006
73
Countries differ in many significant ways
Long-term foreign residence does matter
Most short-term foreign travel is low risk
A person’s health, age and planned activities abroad are important to consider in regard to foreign travel & residence risk
Foreign risk assessment should be based on relevant data & informed judgment. Avoid sensationalism & overgeneralization
More reliable record keeping and study of foreign risk are needed
Some valuable reference sources for international information follow
Conclusions
74
International Information Sources
U.S. State Department Travel Warnings at http://travel.state.gov/travel_warnings.html
U.S. State Department statistics non-natural deaths of US citizens abroad at http://travel.state.gov/family/family_issues/death/death_600.html
British Foreign & Commonwealth Office (Travel Advice) at www.fco.gov.uk
BBC News, Country Profiles, News Services
CNN.com International
Foreign Affairs Canada at www.voyage.gc.ca/consular_home-en.asp
CDC Health Information for international travel at www.cdc.gov/travel
Australian Department of Foreign Affairs & Trade at smartraveller.gov.au or www.dfat.gov.au
USCIS (U.S. visa information)
WHO (World Health Organization)
United Nations Human Development Reports
CIA World Factbook
www.rgare.com/underwritingconnection
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Case 1 U.S. citizen, 35-year-old female who travels to Guatemala to volunteer as a nurse. Her stay is 1-3 weeks annually. She does not expect to visit non-urban areas.
Case 2 A 79-year-old male U.S. citizen applying for $750,000. Next month he is going on his honeymoon to Paris, France, for one week and then going on a safari trip in Kenya and Tanzania for two weeks.
Case 3 A 54-year-old male U.S. citizen seeking $1 million. He is an engineer with a multinational petroleum company. He is working and residing in Angola and travels back to the U.S. at least three times a year for visits.
Case 4 Male, age 56, Venezuelan citizen, seeking $2 million. He currently resides in Guyana, where the business he owns is located.
Case 5 Missionary living in Honduras, 41-year-old male. He makes two to three trips back to the States each year. He is a U.S. citizen and a resident of Honduras.
Case Studies
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Case 6 $2 million of permanent coverage requested a 48 year old physician, born in Mexico. who is a U.S. permanent resident living in El Paso, Texas. She travels daily to Ciudad Juarez, Mexico where her office is located.
Case 7 A 29 year old male citizen of Brazil who came to USA on a student visa when he was 16 and over-stayed his visa. Working as a building contractor in the USA and has no plans to ever return to Brazil.
Case 8 Citizen/resident of Peru seeking $2 million coverage. Male, age 44, non-smoker, has congenital non-obstructive hypertrophic cardiomyopathy. He has regular check-ups with his cardiologist in Peru.
Case 9 $400,000 application on a U.S.-born 3-month-old baby girl who will be going to China to live with her grandparents for one year. Mother has $600,000 of coverage, father has $500,000 of coverage.
Case Studies
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Case 10 A 66-year-old U.S. citizen seeking $2 million of coverage. Travels to Haiti with his church group every year to build water wells. He stays five to six days per trip.
Case 11 A 44-year-old female U.S. citizen seeks $250,000 term coverage. Retired and receiving disability due to a back injury. Income is from pension, Social Security disability and adoption stipend. Taking no medications. Plans two-week vacation to Liberia (Africa) in December.
Case 12 Female, age 51, U.S. citizen, has signed up for one of the first flights by Virgin Atlantic to go into outer space. The timing of this event is unknown and will occur in the future. Seeking $10 million of coverage.
Case Studies
78Thank you for your attention. Any questions?
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