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Sticker shock in sick bay

The Gardners just wanted to enjoy their first-ever cruise, a trans-Atlantic voyage aboard Royal Caribbean's Legend of the Seas. But when a stomach bug landed them in the ship's infirmary, they were headed for a shock: a medical bill for $1,600.
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Inga Gardner and her husband just wanted to enjoy their first-ever cruise, an October trans-Atlantic voyage aboard Royal Caribbean’s Legend of the Seas. But the fun stopped the moment they caught a gastrointestinal illness. After a long night of vomiting and other discomforts, the Gardners sought treatment at the ship’s infirmary, where the ship’s doctor ran blood tests and gave them each two shots: one to calm the symptoms and another to help them sleep. They were also given intravenous fluids for hydration and were kept in the infirmary for an hour of observation.

Inga says she and her husband pressed the doctor for a diagnosis but said he was “vague” in his assessment. The blood tests ruled out any infection, and the Gardners later learned that their tablemates at dinner had experienced similar symptoms the same evening, but no definitive diagnosis was reached.

A few days after their visit to the infirmary, the Gardners got another unpleasant surprise: a bill for medical services totaling $1,600. The amount was immediately charged to the Gardners’ account, and a hold was placed on their credit card.

Inga was enraged. “For an hour’s worth of treatment, it was quite a shock,” she says. But that wasn’t the worst of it. “We agreed to all this treatment and then discovered that the cruise line didn’t accept insurance — even traveler’s insurance, and even the insurance purchased through the cruise line,” Inga says.

Interestingly, if the Gardners had been diagnosed with norovirus, the family of Norwalk-like viruses that cruise lines dread, their treatment would have been free. But there was no outbreak of norovirus aboard the Legend of the Seas, and the Gardners were left holding a whopper of a bill.

Insurance doesn’t travel well
What many people don’t realize is that all cruise ships of foreign registry are considered to be entities operating outside the United States. And, as the Gardners discovered, domestic medical insurance coverage doesn’t travel the same way aboard ship as it does within the United States. Sometimes, coverage doesn’t extend to foreign travel at all; other times it just works differently. For example, co-payments may be higher than usual or your reimbursement may be limited.

Even with complete medical coverage, you can’t just hand the cruise line your insurance card. You will usually have to pay your treatment costs up front and file for reimbursement after you return home. That’s what the Gardners did. Their insurer accepted the claim but explained it could take up to 90 days to receive reimbursement. The Gardners were relieved to be covered at all.

Could the Gardners have avoided the out-of-pocket expense? Maybe. If they had purchased third-party travel insurance, they could have received upfront financial assistance and they might have gotten their money back more quickly.

“Depending upon the situation, if a medical facility requires an upfront payment, we can coordinate that on behalf of the client,” says Dan McGinnity, spokesman for Travel Guard, one of the largest travel insurance providers.

Third-party insurers usually provide primary coverage, i.e., the insurance company pays the traveler directly for any medical claim. Most cruise lines also sell insurance policies, but these usually provide secondary coverage, which means that you must file your claims through your regular medical insurance carrier, then seek reimbursement from the cruise line’s insurance company.

Watch for gaps
Medicare beneficiaries should always purchase travel insurance when they cruise, because they do not have Medicare coverage outside the country. Another very big gap is medical evacuation and transportation services, which are seldom covered by medical insurance policies. According to Medjet Assist, an Alabama-based evacuation operation, domestic air medical evacuation services average $10,000 to $20,000, while international transports can exceed $75,000. If you travel more than once a year, consider buying an annual policy; both MedjetAssist and Travel Guard offer this kind of policy, which can be purchased for as little as $185 a year.

Cruising is exciting, but it can turn into more of an adventure than you planned if you discover that you aren’t covered for the unexpected. So check your insurance policies and don’t forget to pack the hand sanitizer.

Anita Dunham-Potter is a Pittsburgh-based travel journalist specializing in cruise travel. Anita's columns have appeared in major newspapers and many Internet outlets, and she is a contributor to Fodor's "Complete Guide to Caribbean Cruises 2006." or visit her Web site .