Medical Evacuation Coverage for Indian Corporates' Expat and Inbound Employees: 2026 Programme Design

Indian corporates employed approximately 480,000 expatriate Indians on overseas assignments as of FY2025-26 per Federation of Indian Chambers of Commerce and Industry (FICCI) International Mobility Survey estimates. This population is distributed across the Gulf (1,80,000 in Saudi Arabia, UAE, Qatar, Kuwait, Oman, Bahrain), Africa (90,000 across multiple countries), Southeast Asia (75,000 in Singapore, Malaysia, Indonesia, Vietnam, Thailand), Europe (55,000), North America (45,000), and other locations (35,000). The reverse flow of inbound foreign nationals working for Indian corporates within India runs at approximately 65,000 individuals principally from Japan, Korea, Germany, USA, UK, China, and Southeast Asian countries.

The expatriate population covers a range of assignment types:

1. Short-term assignments (3 to 12 months) for project-specific deployments.
2. Standard assignments (1 to 3 years) for managerial and technical roles.
3. Long-term assignments (3 to 5 years or longer) for senior leadership.
4. Permanent transfers where the employee relocates indefinitely.
5. Frequent business travellers who do not formally relocate but spend significant time abroad.

Each assignment type creates distinct insurance needs, but medical evacuation cover has become a standard component across all categories. The 2024-2025 experience drove this universalisation:

• The 2024 H5N1 highly pathogenic avian influenza outbreaks in parts of Africa and Southeast Asia raised concerns about regional health system capacity for severe respiratory cases.
• The 2024 dengue surge in Bangladesh and parts of Southeast Asia exposed assignment workers to severe vector-borne disease.
• The 2025 evacuation of approximately 1,200 Indian nationals from Sudan during the renewed conflict highlighted security-driven evacuation needs and the inadequacy of pure-medical evacuation cover for combined security-medical situations.
• The 2025 mass casualty event at a NEOM project site involving Indian workers underscored the need for systematic evacuation cover including body repatriation.
• The October 2025 acute health system stress in parts of South Asia during a respiratory illness cluster temporarily limited local hospital capacity for severe cases, requiring evacuation to other regional centres.

These events shaped the 2026 programme design discipline. Indian corporates now treat medical evacuation cover as a standard component of any overseas assignment package, with cover specifications increasingly aligned to assignment country, role criticality, and the assignment-specific risk profile.

The Indian corporate's group medical and group personal accident programme provides the foundation for expatriate medical cover, with specific riders and extensions creating the international medical and evacuation component.

Group Medical Cover (GMC) placed by the Indian corporate with an Indian insurer (typically Star Health, Niva Bupa, Manipal Cigna, Care Health Insurance in the standalone health space, or ICICI Lombard Health, Bajaj Allianz Health, HDFC ERGO Health, Aditya Birla Health in the general insurance space) covers the India-resident employee population. For expatriate employees, the standard GMC requires specific extensions:

1. Worldwide treatment extension covering medical treatment outside India.
2. International network access through the insurer's global partnerships.
3. Pre-existing condition handling with continuity from the India-resident period.
4. Maternity benefit coverage with appropriate waiting periods.
5. Mental health benefit coverage under the IRDAI Mental Health Cover Guidelines 2018 extension.
6. Cumulative bonus and no-claim bonus portability.

The GMC with worldwide extension typically provides reasonable cover for outpatient and elective treatment but is sub-optimal for serious acute medical events requiring evacuation. The standard GMC sum insured per employee of INR 5 to 20 lakh with family floater extension is materially insufficient for international medical emergencies, where a single ICU stay in a major US, EU, or Singapore hospital can exceed USD 100,000 within days.

Group Personal Accident (GPA) cover provides lump-sum benefits for accidental death, permanent total disability, permanent partial disability, and temporary total disability. For expatriate employees, GPA cover typically includes:

1. Worldwide coverage with no territorial restriction.
2. Air travel and transit coverage across all modes.
3. Repatriation benefits including body repatriation in the event of death.
4. Compassionate visit benefits for family travel to the affected employee.
5. Emergency evacuation benefit sub-limit (typically INR 5 to 25 lakh).

The GPA evacuation sub-limit is typically inadequate for actual evacuation costs, which can range from USD 25,000 to 250,000 depending on the route, the medical condition, and the aircraft type required.

International medical cover placed as a separate policy provides the higher-limit primary cover for expatriate medical needs. The 2026 Indian market has matured to offer:

1. International medical policies issued by Indian insurers with worldwide treatment and evacuation cover, typically with sums insured of USD 250,000 to 5 million and evacuation cover up to USD 1 million.
2. International medical policies issued by IFSC insurers in USD denomination with seamless cross-border coverage.
3. Specialty international medical insurers placed through Indian brokers including products from Cigna Global, Allianz Care, Bupa Global, GeoBlue, AXA - Global Healthcare, AETNA International, William Russell, Now Health International.

The coordination structure for a mid-to-senior expatriate employee typically combines:

• Indian GMC with worldwide extension providing the first layer of cover and continuity with India-resident benefits.
• Indian GPA with worldwide coverage providing accident-related lump sums.
• International medical policy providing the primary high-limit cover for serious illness and elective treatment.
• Dedicated evacuation cover through an evacuation service provider with global response capability.
• Indian travel insurance for short-term trips and family visits.

This layered structure is sized to the specific assignment, with senior leadership and country-manager-level assignments typically receiving the full layered programme and junior assignment workers receiving a more limited GMC-extension-plus-evacuation structure.

The medical evacuation service market for Indian corporates operates on three tiers, each providing distinct services and operating models.

Tier 1: Global integrated providers offer end-to-end medical evacuation services including risk assessment, pre-deployment health screening, in-country medical assistance, and air ambulance evacuation. The major Tier 1 providers serving Indian corporates include:

1. International SOS: the largest global medical and security assistance provider, with regional centres in Singapore (Asia Pacific hub), Dubai (Middle East), Johannesburg (Africa), London (Europe), and Philadelphia (Americas). International SOS provides 24/7 medical assistance, medical evacuation coordination, and integrated security services. The annual subscription cost for an Indian corporate with 200 to 500 expatriate employees typically ranges from USD 180,000 to 480,000 for full membership including unlimited consultations and evacuation coordination (actual evacuation costs are typically separately insured).
2. Medjet (formerly Medjet Assist): US-headquartered concierge medical evacuation provider with global air ambulance capability. Medjet's flagship Medjet Member service provides air medical transport to the member's home country hospital of choice for any covered medical emergency. Annual membership ranges from USD 295 to 2,400 per member depending on the plan level.
3. Aspen Medical: Australian-headquartered integrated healthcare and medical services provider with significant Middle East and Africa operations.
4. AXA Partners (formerly AXA Assistance): integrated assistance services including medical evacuation.
5. Aetna International / CVS Health: integrated international medical and evacuation.

Tier 2: Regional and specialist providers focus on specific geographies or specialised evacuation capabilities. Active providers serving Indian corporates include:

1. Air Ambulance India (operated by various carriers including Aviators India, Lifeline Air Ambulance India, and Sky Air Ambulance): India-based air ambulance providers with operating bases in Mumbai, Delhi, Bangalore, and Hyderabad. They serve evacuations to India from the Gulf, Southeast Asia, and Africa, and inbound evacuations to specialist Indian hospitals from foreign locations.
2. Medecall (operated by Medecall Services India): India-based emergency medical coordination service providing 24/7 medical advice, hospital referral, and evacuation coordination to and from India.
3. EuropAssistance: European-anchored assistance provider with Indian partnerships.
4. GlobalMed: assistance services with specific India presence.
5. Specialist air ambulance operators including Royal Flying Doctor Service (Australia) for Asia-Pacific evacuations, Phoenix Air for trans-continental evacuations, and various regional providers in Africa and Middle East.

Tier 3: Insurance-bundled providers are evacuation services provided as part of an insurance policy without separate subscription. Most international medical insurance policies include evacuation cover with a designated provider or network. The quality of these bundled services varies significantly, and Indian corporates should examine the specific provider arrangements in any international medical policy.

For Indian corporates, the typical 2026 structure combines:

1. Tier 1 subscription with International SOS or equivalent for medical advice, in-country assistance, and evacuation coordination across the global footprint.
2. Tier 2 partnerships with Air Ambulance India and Medecall for India-bound evacuations and Indian-domiciled coordination.
3. Insurance cover through international medical policies providing the financial reimbursement for evacuation costs.

The annual cost for this combined structure for an Indian corporate with 500 expatriate employees and 50,000 frequent business traveller employee-days typically runs at USD 750,000 to 2.1 million including subscription, insurance, and contingency evacuation budget.

Pre-existing condition handling is a recurring complexity in expatriate medical cover. An employee with a pre-existing condition (diabetes, hypertension, cardiac history, asthma, autoimmune conditions, mental health history) requires continuous medical management across the assignment and the policy structure must accommodate this.

The IRDAI Pre-Existing Condition (PED) framework applicable to Indian-issued health insurance includes:

1. Definition: pre-existing condition is defined under the IRDAI Standardisation of Health Insurance Definitions 2020 as any condition, ailment, injury, or disease that is or was diagnosed by a physician within 36 months prior to the policy issuance date.
2. Waiting period: standard waiting period for pre-existing conditions ranges from 24 to 48 months under most Indian health insurance products, after which the condition is fully covered.
3. Disclosure obligation: the proposer must disclose all known pre-existing conditions at policy proposal stage; non-disclosure can void cover.
4. Portability: under the IRDAI Portability Regulations 2011 and subsequent enhancements, a customer transferring from one health insurer to another can carry forward the waiting period credit for pre-existing conditions.

The 2025 IRDAI Continuity Framework for group medical insurance (under the IRDAI Master Circular on Health Insurance Business 2024) established that:

• Group medical insurance with continuous renewal must provide pre-existing condition coverage after the initial waiting period, without re-imposing the waiting period at renewal.
• An employee transferring from one Indian employer's group medical to another employer's group medical, where both are with IRDAI-licensed insurers, retains the pre-existing condition waiting period credit accumulated.
• An employee on overseas assignment whose group medical coverage continues during the assignment retains the pre-existing condition status without disruption.

For the cross-border context, the practical issues include:

1. Indian-issued GMC with worldwide extension: pre-existing conditions covered after the waiting period regardless of whether treatment occurs in India or abroad.
2. International medical insurance issued during assignment: the new international policy typically applies its own pre-existing condition waiting period, which may re-set the clock.
3. Coordination between policies: the Indian GMC and the international medical policy may apply different pre-existing condition definitions and waiting periods, creating gaps or duplications.

The 2026 best practice for Indian corporates managing expatriate pre-existing conditions includes:

1. Pre-deployment medical assessment documenting any pre-existing conditions with full medical history.
2. Continuous GMC coverage through the assignment with worldwide extension, preserving the Indian-domiciled pre-existing condition status.
3. Coordinated international medical cover that accepts the Indian GMC's pre-existing condition acceptance, often through a group international medical placement where the insurer underwrites on a group basis without re-examining individual pre-existing conditions.
4. Insurer letters of acceptance documenting the pre-existing condition cover for each expatriate at the start of the international medical policy.
5. Coordination at policy transition: when the employee returns to India and transitions from international medical back to standard GMC, the continuity is explicitly documented to preserve the pre-existing condition status.

Mental health coverage requires specific attention. The Mental Healthcare Act 2017 and the IRDAI Circular on Mental Health Cover 2018 require Indian health insurance to cover mental health conditions on parity with physical health. International medical insurance varies in mental health coverage, with some policies providing broad cover and others restricting to specific diagnoses or treatment types. The expatriate medical programme should specify mental health coverage explicitly at policy design.

The 2020-2022 COVID pandemic produced widespread policy wording changes that remain partially active in 2026 medical insurance and evacuation policies. Indian corporates should examine the specific wording in their expatriate medical and evacuation programmes for these legacy clauses.

COVID-related coverage status in 2026:

1. Active COVID coverage: most international medical insurance policies issued in 2024-2025 cover COVID-19 treatment and complications on the same basis as other respiratory illnesses, with no specific exclusions.
2. Vaccination coverage: routine COVID vaccinations are typically covered as preventive care; expatriate-specific vaccination requirements for entry into certain countries are covered as travel-related preventive care.
3. Quarantine and isolation: policies cover medically required quarantine or isolation as part of treatment cost; government-ordered quarantine that is not medically required is typically not covered.
4. Travel restriction: policies do not typically cover the additional cost of travel disruption caused by COVID-related restrictions; travel insurance with specific pandemic cover may be required for this.

Other pandemic-related wording considerations in 2026:

1. H5N1 and other novel pathogens: the 2024 H5N1 surge in Africa and Southeast Asia raised concerns. International medical policies typically cover novel pathogens unless specifically excluded; the 2024-2025 underwriting cycle removed most blanket novel-pathogen exclusions that had been imposed during early COVID.
2. Vector-borne disease cover: dengue, malaria, Japanese encephalitis, chikungunya, and other vector-borne diseases are covered as standard medical illness; pre-deployment prophylaxis is sometimes covered.
3. Pandemic-triggered evacuation: most evacuation cover responds to individual medical needs; mass evacuation triggered by pandemic threat (without individual illness) is typically not covered, although some Tier 1 providers like International SOS include pandemic outbreak response coordination as part of subscription.
4. Telemedicine cover: post-COVID, telemedicine and remote consultation services have become standard inclusions in international medical policies.

Wording pitfalls to check in 2026 international medical and evacuation policies for expatriate Indian employees:

1. Specific pandemic exclusion clauses that may have been added during COVID and not removed at subsequent renewal. Some carriers added "pandemic" or "WHO-declared public health emergency" exclusions that, if still active, could exclude future pandemic-triggered medical costs.
2. Communicable disease exclusions that may exclude treatment for certain infectious diseases.
3. Specific country exclusions added during COVID for high-risk countries that may not have been removed.
4. Pre-travel screening requirements that may impose obligations on the corporate or the employee for pre-departure testing or screening.
5. Repatriation conditions during ongoing pandemic situations that may restrict the route or method of repatriation.

The 2026 best practice is to request a policy wording review at renewal specifically addressing COVID-legacy and pandemic-related clauses, with explicit confirmation in the policy schedule or endorsement that no pandemic-specific exclusions apply for the current period.

The operational reality of medical evacuation differs materially across the regions where Indian expatriates work. Programme design must account for the regional differences in air ambulance availability, medical facility access, route restrictions, and political clearance requirements.

Africa evacuation logistics:

Medical evacuation from Africa to India or to specialist Indian-network hospitals in South Africa, Kenya, or the Gulf is operationally complex. Key considerations:

1. Air ambulance availability: dedicated medical air ambulances based in Africa are limited. Aviassist in South Africa, Wilson Air in Kenya, and MedFlight Africa provide regional services. For Indian-bound evacuations, Air Ambulance India carriers typically deploy from Mumbai or Delhi with 12 to 24 hour mobilisation.
2. Route distances and refuelling: African evacuations from West Africa or Central Africa to India typically require refuelling in Sub-Saharan or Middle Eastern locations, adding to evacuation timelines.
3. Political clearance: overflight and landing clearances in African countries can require 24 to 72 hours, even for medical emergencies. International SOS and Medjet have established political clearance relationships that accelerate this process.
4. Receiving hospital quality: the receiving hospital network in Africa for advanced trauma and cardiac cases is limited to specific facilities (Netcare and Mediclinic in South Africa, Aga Khan Hospital in Nairobi, certain Cairo facilities for North African evacuations). For complex cases, evacuation to the Gulf or to India is typically necessary.
5. Specific country considerations: evacuation from active conflict zones (Sudan, parts of DRC, parts of Sahel region) requires combined security-medical capability and may not be feasible during peak conflict.

For Indian corporates with African operations, the recommended evacuation programme structure includes:

• Tier 1 subscription (International SOS, Aspen Medical, or equivalent) for in-country medical advice and evacuation coordination.
• Pre-positioned air ambulance access through regional providers.
• Receiving hospital pre-agreements with Aga Khan Nairobi, Netcare facilities in Johannesburg or Cape Town, and specialist Indian hospitals (Apollo, Fortis, Medanta) for India-bound cases.
• Insurance cover with evacuation sub-limit of USD 250,000 to 1 million per event.

Gulf evacuation logistics:

Medical evacuation in the Gulf is operationally simpler given the high-quality regional medical infrastructure and the established air ambulance market. Key considerations:

1. Local medical capacity: Saudi Arabia (King Faisal Specialist Hospital, King Fahad Medical City, Dr Sulaiman Al Habib Group facilities), UAE (Cleveland Clinic Abu Dhabi, Sheikh Khalifa Medical City, Mediclinic Middle East, NMC Specialty Hospitals, Saudi German Hospital), Qatar (Hamad Medical Corporation, Sidra Medicine), and Kuwait/Bahrain/Oman provide advanced acute care capability for most conditions.
2. Air ambulance services: regional providers including Medic'Air International (Dubai), AeroFlite (Dubai), Royal Jet Medical (Abu Dhabi) provide rapid air ambulance with 4 to 8 hour mobilisation.
3. India-bound evacuations: from the Gulf, evacuation to Mumbai, Delhi, Bangalore, or Chennai takes 4 to 6 hours flight time with clear overflight permissions.
4. Receiving hospital quality: Indian metro hospitals can accept and treat any case that originates in the Gulf; the choice between local Gulf treatment and India evacuation often depends on family preference, cost, and the employee's longer-term care plan.

For Gulf-based Indian expatriates, the typical evacuation cover provides:

• Local hospital network access through international medical policy with Gulf network.
• India evacuation option on employee or employer election.
• Compassionate visit benefit for family travel.
• Evacuation sub-limit of USD 100,000 to 500,000 per event.

Southeast Asia evacuation logistics:

Medical evacuation in Southeast Asia is generally well-supported by the regional medical infrastructure but varies by specific country. Key considerations:

1. Singapore as regional hub: Singapore General Hospital, Mount Elizabeth Hospital, Gleneagles, Raffles Hospital, and the Parkway Pantai network provide advanced care for the region. Most serious cases in Southeast Asia are evacuated to Singapore as the regional hub.
2. Bangkok as alternative hub: Bumrungrad International Hospital, Bangkok Hospital, and other Bangkok facilities provide advanced care with strong India-network access.
3. Country-specific considerations: medical capacity varies significantly. Indonesia (outside Jakarta) and the Philippines (outside Manila) have more limited capacity for complex cases. Vietnam (Ho Chi Minh City and Hanoi) has improved significantly but specialist care often requires evacuation. Malaysia (Kuala Lumpur) has strong medical infrastructure.
4. India evacuation routes: Singapore-Mumbai, Singapore-Delhi, Bangkok-Delhi, and Kuala Lumpur-Mumbai are short-route evacuations with 4 to 5 hour flight times.

For Southeast Asia-based Indian expatriates, the programme typically routes through Singapore or Bangkok as the regional medical hub, with India as the alternative for cases where family-supported recovery is preferred.

The IRDAI Overseas Medical Insurance Guidelines 2020 and subsequent amendments through 2025 govern Indian-issued overseas medical insurance products and the claims experience that Indian corporates can expect.

The key regulatory provisions include:

1. Minimum coverage requirements: standardised minimum benefits including emergency medical treatment, hospitalisation, evacuation, repatriation, and accidental death benefits.
2. Standardised exclusions list: limiting the exclusions an insurer may apply to a defined list including pre-existing conditions (subject to waiting period), specific high-risk activities, war and nuclear risks, and certain elective procedures.
3. Claim handling timelines: claims must be acknowledged within 7 days, decision-on-cover within 30 days, and settlement within 7 days of decision under the IRDAI Claim Settlement Regulations.
4. Cashless network access: insurers must provide cashless access to a defined network of overseas hospitals through their international network partnerships.
5. Customer information requirements: standardised customer information sheet and policy summary in defined format.
6. Grievance redressal: Indian Insurance Ombudsman jurisdiction for policy disputes.

The claims experience for Indian expatriate medical cover in 2026 shows characteristic patterns:

1. Cashless utilisation: cashless claim rates have improved substantially with major Indian insurers now offering cashless access in over 4,000 international hospitals globally through their network partnerships (often with international assistance providers acting as the network manager).
2. Claim settlement time: average claim settlement time for non-cashless international medical claims runs at 18 to 28 days for major Indian insurers, with reimbursement claims requiring documentation review and authentication.
3. Currency-of-payment: most Indian insurers pay claims in INR converted from the foreign currency at the RBI reference rate. For high-value foreign-currency claims, the exchange-rate exposure between treatment date and payment date can affect the customer's net recovery.
4. Dispute patterns: the principal sources of claim disputes are pre-existing condition disclosure, specific procedure coverage interpretation, and the boundary between covered and excluded conditions.
5. Evacuation claim handling: evacuation claims are typically handled through the assistance provider with direct billing rather than reimbursement. The customer's exposure is principally to the difference between covered evacuation cost and any non-covered components (such as upgraded class travel or family accompanying costs beyond covered limits).

The USD-INR exchange rate exposure is a meaningful consideration. Between 2020 and 2026, the USD-INR rate has moved from approximately INR 75 to INR 88, representing a 17% INR depreciation. For Indian-issued medical insurance with INR-denominated sums insured, this creates a real reduction in the USD-equivalent cover over time. Indian corporates with multi-year expatriate assignments should:

1. Review the USD-equivalent of the sum insured at each renewal.
2. Consider USD-denominated international medical cover through IFSC insurers or international specialist insurers.
3. Build in periodic sum-insured indexation to track exchange rate movements.
4. Maintain top-up emergency cover for cases where the primary INR cover is insufficient.

The total cost of a structured expatriate medical and evacuation programme for an Indian corporate scales with the expatriate population size, the assignment country mix, the seniority profile, and the family extension structure. The 2026 cost benchmarks and renewal discipline have settled into recognisable patterns.

Cost benchmarks for FY2025-26:

For an Indian corporate with 200 expatriate employees distributed across the Gulf (60%), Africa (15%), Southeast Asia (15%), Europe (5%), and Americas (5%), with family extension covering spouse and 2 dependent children for 70% of employees:

1. Indian GMC with worldwide extension: approximately INR 4.5 to 6.5 crore annual premium for combined India-resident workforce plus expatriate workforce.
2. Group Personal Accident with worldwide cover: approximately INR 1.2 to 2.0 crore annual premium.
3. International medical insurance for expatriate population: approximately USD 380,000 to 720,000 annual premium (INR 3.3 to 6.3 crore).
4. Tier 1 assistance subscription (International SOS or equivalent): approximately USD 150,000 to 280,000 annual subscription.
5. Indian travel insurance and short-term traveller cover: approximately INR 80 lakh to 1.5 crore annual premium.
6. Total programme cost: approximately INR 12 to 18 crore annual for a 200-expatriate population.

The per-expatriate-employee programme cost ranges from INR 6 to 9 lakh per employee per year depending on the assignment mix and seniority profile.

Sum-insured calibration principles for 2026:

1. Senior leadership and country-manager-level expatriates: international medical sum insured of USD 2 to 5 million per employee with full family extension, evacuation cover up to USD 1 million.
2. Senior expatriate professionals and managers: international medical sum insured of USD 500,000 to 2 million, evacuation cover up to USD 500,000.
3. Mid-level expatriate technical and operational staff: international medical sum insured of USD 250,000 to 1 million, evacuation cover up to USD 250,000.
4. Junior assignment workers and contractors: international medical sum insured of USD 100,000 to 500,000, evacuation cover up to USD 100,000.
5. Frequent business travellers: travel insurance with USD 100,000 to 500,000 medical cover, evacuation cover up to USD 250,000.

Renewal discipline should include:

1. Pre-renewal claims review covering the prior year's medical and evacuation utilisation by region, condition type, and severity.
2. Expatriate population update with deployment changes, new countries, and seniority changes.
3. Network and provider review confirming the current hospital networks and assistance provider arrangements remain fit for purpose.
4. Sum-insured indexation tracking medical inflation in the assignment countries (often 6 to 12% per annum in OECD and Gulf markets, materially higher than Indian medical inflation).
5. Currency exposure review for INR-denominated covers in USD-economy assignments.
6. Pandemic and outbreak monitoring covering current global health risks and policy wording implications.
7. Coordination between Indian GMC, GPA, international medical, evacuation, and assistance covers with documented protocols for joint claim handling.

The inbound expatriate cover for foreign nationals working for Indian corporates within India is a separate but related programme. The 2026 inbound population of approximately 65,000 foreign nationals typically receives:

1. Indian-issued GMC for India-resident treatment.
2. International medical cover maintained through the home-country employer or home-country individual cover.
3. Indian travel insurance for family visits.
4. Repatriation cover for end-of-assignment return and emergency repatriation.
5. Coordination with home-country social security including bilateral social security agreements where applicable (the India-Germany Social Security Agreement, the India-Japan Social Security Agreement, and similar bilateral agreements).

The inbound programme typically costs 30 to 60% less per employee than the outbound programme because Indian medical inflation and Indian medical costs are lower than equivalent OECD market costs.