First aid in flight: a growing number of medevac helicopters are used for medical evacuation, but the air ambulances also carry a host of liabilities.

A three-car pileup on a major interstate with numerous injuries is a tragic scene, but medevac helicopters are a saving grace in helping get injured individuals the help they need quickly.

The medical rescuers in the sky are a growing part of today's health-care system, and many hospitals operate or contract for the aircraft to transport patients. But the helicopters have numerous exposures and can be a liability waiting to happen for insurers.

About 650 medevac helicopters or air ambulances are currently in service, according to a recent Consumer Affairs article. But with the many aircraft in flight comes a corresponding increase in accidents. Since 2002, the National Transportation Safety Board reported 64 medevac accidents that resulted in 62 deaths, up from 15 accidents and 17 deaths over a similar period a decade earlier. About 75% of the accidents reviewed by the board occurred while no patients were on board.

Some of the more recent tragic events included a 2002 helicopter crash that occurred shortly after takeoff from the roof of a Cleveland hospital to pick up a patient from another facility, killing the pilot and a nurse and seriously injuring a medic. Two years earlier, a pilot of a Duke University Medical Center helicopter died after the helicopter crashed shortly after he initiated a maintenance check while en route to pick up a patient.

Helicopter operators are running for cover. Among the largest coverage demands are medical malpractice, aircraft hull and liability, and helipad premises, said Greg Sterling, senior vice president of Aon Aviation's Global Practice.

Generally, coverage for medevac helicopters isn't much different from the rest of the aviation and helicopter industry, said Larry Mattiello, president of AirSure Ltd. and a member of the board of directors of the nonprofit, professional trade association Helicopter Association International. However, where things "are different and get intricate" is around underwriting the aircraft because of the various business models involved with what he calls "HEMS"--helicopter emergency medical service. In a community-based model, hospitals contract with commercial helicopter operators to provide helicopters and crew. In a hospital-based model, hospitals may own a helicopter or contract with commercial operators for an aircraft, but the medical facility employs the medical crew and operates the service in-house. Typically, a flight crew consists of a pilot, flight nurse and a paramedic.

Mattieilo said the standard limits on coverage vary depending on operations but can range from $10 million to as much as $100 million. The average, he said, ranges between $20 million and $30 million.

Some of the exposures related to medevac helicopters include passenger bodily injury, ground bodily injury and ground property damage, said Sterling. "The utility of EMS helicopters is generated by the fact that they can land outside a controlled airport environment, such as on the side of a highway or in a field. This utility, however, also increases their exposure to rotor strikes on power lines and trees."

A number of claims have been filed over the years, including weather-related losses, hard landings, foreign object damage and rotor strikes resulting from helicopters operating in unimproved conditions. "Rates for EMS helicopters tend to be higher than rates for corporate or simple charter helicopters because of their unique missions," said Sterling.

Exposures can also increase, he said, when helicopters operate primarily over urban areas. "In this environment, exposure to ground bodily injury and property damage increases."

Mattiello said in the past year, there's been a dramatic improvement in HEMS operations. "HAI, the Federal Aviation Administration, the International Helicopter Safety Team, insurers and others have put together HEMS programs and we're providing risk management and safety insight." He said the industry needs to continue working with local law enforcement agencies to educate them about safe operation practices for landing zones, particularly off-road landings.

Sterling anticipates expanded capacity in the line of business in 2007 because of several new players entering the market. "EMS helicopters as a whole still produce higher losses relative to the industry at large, so we would premiums on this line of business to be under pressure to move higher," he said.