Local vs international insurance, what to do about pre-existing conditions, how evacuation coverage works, and the seven questions to ask before signing any policy.
Health insurance is the most important financial decision most expats will make. A single serious medical event — a car accident, a cancer diagnosis, a complicated childbirth — can cost USD 50,000–500,000+ in many countries, an amount that would bankrupt most families without insurance. Yet expat health insurance is also one of the most complex insurance products, with significant variation in coverage, exclusions, and quality across providers. This guide covers everything you need to know to choose the right plan.
Every expat health insurance decision starts with two fundamental choices: local vs international insurance, and what level of coverage to buy. Get these two right and the rest of the decision is detail.
Local insurance is a policy from an insurer in your country of residence, designed for residents of that country. The advantages: lower cost (typically 30–60% cheaper than equivalent international cover); direct billing with local hospitals (no out-of-pocket then reimbursement); coverage that integrates with the local healthcare system. The disadvantages: does not cover you outside the country of residence (or covers only emergencies for a limited period); may not meet your home country's health insurance requirements for visits home; coverage ends if you leave the country.
International insurance is a policy from a global insurer (Cigna, Bupa, Allianz, AXA, William Russell, others) designed for globally-mobile customers. The advantages: covers you across multiple countries (often including your home country); portable if you move countries; comprehensive coverage that includes evacuation; often higher-quality coverage limits. The disadvantages: 2–4× the cost of equivalent local cover; reimbursement model (you pay then claim, except at network hospitals); may not be accepted by all local healthcare providers; pre-existing condition exclusions are more aggressive.
The right choice depends on your situation:
Reading an insurance policy is tedious but essential. Before signing any expat health insurance policy, get written answers to these seven questions:
Policies either have an overall annual limit (e.g., USD 1 million per year for all covered services) or per-condition limits (e.g., USD 100,000 per condition per year). Per-condition limits are more restrictive — a serious cancer diagnosis can hit the per-condition limit while overall treatment costs are still rising. Prefer policies with high overall annual limits (USD 1 million+) rather than per-condition limits.
Most policies exclude pre-existing conditions either permanently or for a waiting period (typically 12–24 months). Some policies cover pre-existing conditions after medical underwriting, possibly with a premium loading. Full disclosure of pre-existing conditions at application is essential — non-disclosure can void the policy. If you have significant pre-existing conditions, the policy choice may be constrained by which insurer will accept you.
Medical evacuation coverage pays for transport to a higher-level facility if local facilities cannot treat the condition. Key questions: what is the maximum evacuation benefit (should be USD 100,000–500,000+)? Where will you be evacuated to (the "nearest appropriate facility" — make sure this is defined clearly)? Does the evacuation coverage include repatriation to your home country if you prefer? Is evacuation subject to a separate deductible or limit?
For expats in countries with limited healthcare infrastructure (parts of Africa, South Asia, South-East Asia, Central Asia), evacuation coverage is the single most important policy feature. A medical evacuation from a remote location to a major medical centre can cost USD 50,000–250,000+. Without coverage, this is catastrophic.
The deductible is the amount you pay before insurance kicks in. Co-insurance is the percentage of covered costs you pay after the deductible (typically 10–20%). Higher deductibles reduce premium but increase your out-of-pocket risk. The right deductible depends on your risk tolerance — a USD 500 deductible is appropriate for most expats; a USD 5,000 deductible is appropriate for those who self-insure routine care and want insurance only for catastrophic events.
Basic policies cover inpatient treatment only. Comprehensive policies add outpatient (GP visits, specialist consultations, diagnostic tests), maternity (prenatal, delivery, postnatal), dental (routine and major), and mental health (therapy, psychiatry, inpatient treatment). Each addition increases premium by USD 300–1,500 per year. The right combination depends on your expected use — for families planning more children, maternity is essential; for young single expats, outpatient alone may suffice.
Policies either cover specific regions (e.g., "worldwide excluding USA") or specific countries. USA coverage is typically 40–80% more expensive because US healthcare costs are dramatically higher than elsewhere. If you do not need USA coverage, exclude it. Within covered countries, policies may have preferred provider networks — using in-network providers gives better coverage rates. Check that your preferred hospitals and doctors are in-network.
For non-emergency treatment, most international policies require pre-authorisation — you contact the insurer before treatment to confirm coverage. For emergency treatment, you seek care immediately and notify the insurer as soon as possible. Reimbursement timelines range from 5–30 days depending on the insurer and the complexity of the claim. Direct billing (where the insurer pays the hospital directly) is available at network hospitals but not elsewhere. Understand the claim process before you need to use it.
Cigna Global is one of the largest international health insurers, with comprehensive coverage and a wide network. Strengths: excellent USA coverage if selected; strong mental health coverage; flexible modular plans (you can select outpatient, maternity, dental, evacuation separately); good direct billing network. Weaknesses: premiums are at the higher end; underwriting can be strict on pre-existing conditions.
Bupa Global (part of the UK's Bupa group) offers premium international insurance with strong coverage and service. Strengths: excellent customer service; comprehensive coverage; strong network in Europe and the Middle East. Weaknesses: premiums are among the highest in the market; less flexible than Cigna's modular approach.
Allianz Care offers a range of international insurance plans from basic to comprehensive. Strengths: competitive pricing; good coverage in Asia-Pacific; clear plan tiers (Core, Pro, Pro Plus). Weaknesses: customer service can be slower than Cigna or Bupa; some exclusions are more aggressive.
AXA offers comprehensive international health insurance with strong global coverage. Strengths: excellent Europe and Middle East coverage; flexible plan design; strong evacuation coverage. Weaknesses: underwriting on pre-existing conditions can be strict.
William Russell is a smaller specialist international insurer with strong personal service. Strengths: competitive pricing; personal service; flexible coverage. Weaknesses: smaller provider network; less direct billing than the larger insurers.
International health insurance premiums vary dramatically based on age, location, coverage level, and deductible. Representative mid-2025 premiums for a comprehensive plan (inpatient + outpatient + evacuation, USD 500 deductible, worldwide excluding USA):
Adding USA coverage typically increases premiums by 40–80%. Adding maternity coverage typically adds USD 800–1,500 per year. Adding dental typically adds USD 300–600 per year.
Premiums increase with age — typically 5–8% per year for the same coverage, plus medical inflation of 5–10% per year. A premium that starts at USD 2,000/year at age 30 may reach USD 8,000+/year by age 60. Plan for this increase in long-term financial planning.
Pre-existing conditions are the most complex part of expat health insurance. The definition varies by insurer but typically includes any condition for which you have received medical advice, diagnosis, or treatment in the past 5 years (some insurers use 10 years or "ever").
Three possible outcomes for a pre-existing condition:
Full disclosure at application is essential. Non-disclosure can void the policy at claim time, even if the non-disclosed condition is unrelated to the claim. If you have a significant pre-existing condition, work with an insurance broker who knows which insurers are most lenient on that specific condition — acceptance criteria vary significantly.
Maternity coverage is typically an optional add-on with a 10–12 month waiting period before any pregnancy is covered. This means you must have maternity coverage in place before becoming pregnant — buying it after a positive pregnancy test will not cover the pregnancy.
The cost of maternity care without insurance varies dramatically by country: USD 5,000–15,000 for routine delivery in most countries; USD 15,000–40,000 in the USA; USD 3,000–8,000 in many Asian countries. Complicated pregnancies (premature birth, NICU stay, caesarean) can multiply these costs by 5–10×.
For expat families planning more children, maternity coverage is essential and should be in place 12+ months before conception. For families not planning more children, it can be excluded to save premium.
Medical evacuation and repatriation are often bundled with international health insurance but have distinct features worth understanding separately.
Medical evacuation covers transport to a higher-level medical facility when local facilities cannot treat the condition. The evacuation is typically to the "nearest appropriate facility" — which may not be in your home country. For example, an expat in rural Thailand might be evacuated to Bangkok or Singapore, not to the UK.
Repatriation covers transport back to your home country, typically after treatment has stabilised the patient. Some policies include repatriation; others offer it as an add-on. For expats who would prefer to recover at home, repatriation coverage is valuable.
Some expats supplement their insurance with a membership in a medical evacuation service (e.g., Air Ambulance, Medjet). These services provide evacuation to the hospital of your choice (not just the nearest appropriate facility) but do not cover the medical treatment itself — they are transport only. They are relatively inexpensive (USD 250–500 per year for individuals) and can provide peace of mind for expats in remote locations.
Understanding the claim process before you need to use it saves stress and money at the worst possible time. The typical process:
Expat health insurance is too important to skimp on and too complex to buy without research. The two fundamental choices — local vs international, and what coverage level — should be driven by your situation: how long you will stay, where you will travel, what pre-existing conditions you have, what family planning you anticipate. Get written answers to the seven questions before signing any policy. Use a broker who knows the market — they cost nothing to use (paid by insurer commissions) and can save thousands in premiums and hundreds of hours in claim disputes. And review your coverage annually — both your situation and the insurance market change, and the right policy last year may not be the right policy this year.
For most expats, the right combination is: comprehensive international insurance (inpatient + outpatient + evacuation) with a USD 500–1,500 deductible, plus maternity coverage if relevant, plus a separate medical evacuation membership if you are in a remote location. Expect to pay USD 2,000–8,000 per year for an individual and USD 5,000–15,000 for a family. The cost is meaningful but the alternative — self-insuring against the possibility of a USD 100,000+ medical event — is far more expensive for most expats.
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