The world's largest cruise ship, "Oasis of the Seas," arrives in Southampton Water on October 15, 2014 in Southampton, England. (Matt Cardy/Getty Images/TNS) *FOR USE WITH THIS STORY ONLY*

The world's largest cruise ship, "Oasis of the Seas," arrives in Southampton Water on October 15, 2014 in Southampton, England. (Matt Cardy/Getty Images/TNS) *FOR USE WITH THIS STORY ONLY*

Royal Caribbean's gargantuan Oasis of the Seas boasts four outdoor pools and an 82-foot zip line and made quite a splash shortly after its 2014 refurbishment when it added the first Tiffany & Co. boutique at sea.

But in January 2019, the cruise ship, which bills itself one of the world's largest, produced less cheerful news: Hundreds of passengers fell ill from the highly contagious norovirus stomach flu.

The federal Centers for Disease Control and Prevention reported 561 passengers and 31 crew members were treated for the ultra-contagious gastrointestinal illness on a cruise out of Port Canaveral, Fla. That's more than the total number of passengers who fell ill from the norovirus on every cruise that set sail in 2018, the CDC said.

It could have been worse. As miserable as norovirus is, passengers sometimes face more serious crises at sea. In fact, most cruise ships have morgues on board as well as medical centers. Last year, 189 deaths were reported on cruises, according to CDC data provided to Kaiser Health News.

With a record 30 million people taking cruises this year, it is vital to understand the care available.

Before paying a deposit for any cruise, take time to read beyond the company's marketing material to study the quality of medical accommodations, said Ken Carver, chairman of International Cruise Victims, a nonprofit organization that supports passengers who suffer injuries or illnesses at sea. Most cruise lines are not sufficiently prepared to tend to serious illnesses or accidents, he said.

"Your health is at risk if you get ill on a cruise ship," Carver said.

Cruise line industry officials strongly disagree.

"The safety and comfort of our guests and our crew is of the utmost importance to the cruise industry - that includes medical facilities and personnel," said Megan King, a spokeswoman for the Cruise Lines International Association.

There are clear rules and regulations for medical care on cruises. At least one qualified medical professional must be available at all hours on every cruise.

What's more, all ships that carry at least 250 passengers, have overnight accommodations and embark or disembark in the United States must have an examination room, an intensive care room and equipment for processing lab work, monitoring vital signs and administering medications.

But medical care for passengers who suffer severe injuries or illnesses can be compromised by the limitations of being at sea without the benefit of costly medical equipment and specialized doctors, Carver said. The problems can be further magnified because:

Doctors on cruise ships aren't usually specialists. Cruise ships typically hire doctors to care for health problems like norovirus. "Many doctors on cruise ships are not even emergency room qualified," said Philip Gerson, a lawyer who for 49 years has been suing cruise ship lines for everything from personal injury to wrongful death. Most of the cases are slip-and-fall incidents that result in orthopedic injuries, he said.

Medical center hours are limited. For example, when Carnival cruise ships are at sea, clinic service hours are 9 a.m. to 12 p.m. and 3 to 6 p.m. On port days, the hours are 8 a.m. to 10 a.m. and 4-6 p.m., according to the cruise line's website.

Some onboard doctors are not fluent in English. Foreign doctors can be excellent and cruise lines require them to be certified under American standards. But few passengers realize that some onboard doctors may not speak English well, which can be important in critical situations, Gerson said.

Few passengers know how their health insurance works at sea. Before buying a cruise line ticket, it's critical to check with your health insurer to see whether and how you're covered for offshore medical issues, said Brett Rivkind, a Miami-based maritime lawyer who has handled thousands of cruise ship lawsuits over 35 years. The question to ask: If I get sick or injured on the cruise, how am I covered?

Most passengers don't buy travel insurance. Travel insurance might sound like a waste of money, which may explain why most passengers don't buy it, but insurance can save very sick passengers hundreds of thousands of dollars, Rivkind said. He had one client stuck with a $500,000 air ambulance bill. Carnival's Cruise Vacation Protection Plan reimburses up to $10,000 of certain medical-related costs and up to $30,000 for emergency medical evacuation, the company says on its site. Carnival's policies run from $49 per person for the least expensive cruises to up to $189 per person for costlier trips. But, Rivkind said, it's typically a better deal to buy insurance from an independent company than directly from a cruise company.

Injured passengers must act as their own investigators. If you slip, fall and break an arm or leg on a cruise ship, it's critical to quickly act in your own best interests, Gerson said. Take pictures of where you fell (or have someone else do so if you can't). Get video of the scene, if possible. And, if you get medical care onboard, make certain to request a copy of your medical records. All of this should be emailed to your lawyer, he said.

Some cruise lines try to gather information from passengers for legal reasons. If a cruise line has a passenger injury form that specifically asks what the passenger could have done to prevent the accident, "leave that part of the form blank," Gerson said. This is the cruise line's way of trying to shift the blame for the accident or injury.

Being sent off the ship for medical care isn't always a good thing. When a passenger has a serious medical problem, the ship often will drop the patient off at the next port for aid, Gerson said. If the next port is New Jersey, that might be fine, but if the next port is someplace foreign, maybe not, he said. You might consider refusing to get off the ship if you are wary of the medical care at a port, he said.

Seeing a doctor - particularly after hours - can be difficult. "Sometimes you have to have a very persistent family member," Rivkind said. "You have to be prepared to be very persistent to do what you need to do to get someone's attention."

After the Oasis of the Seas cruise in January, Royal Caribbean offered full refunds to the 5,400-plus passengers, even though fewer than 9% became ill. But refunds won't pay for unexpectedly huge medical bills at sea.

"The cruise lines are there to protect the cruise lines," Carver said. "If something bad happens at sea, you have to protect yourself."

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Visit Kaiser Health News at www.khn.org

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