The largest figures in travel insurance claims are rarely hospital bills. They are the cost of moving a patient from where they are to somewhere they can be treated or brought home.
The aircraft is dedicated, not shared
An air ambulance flies for one patient, so the entire cost of positioning, operating and returning the aircraft falls on a single case.
The aircraft must also reach the patient first, which frequently means an empty flight of similar length before the transfer even begins.
Two long flights for one journey, with no other revenue, is the structural reason the totals reach the levels they do.
Medical crew and equipment travel with the patient
A transfer requires clinical staff appropriate to the condition, along with monitoring and support equipment configured for flight.
Those staff are unavailable for other work during the transfer and the return, so their time is charged against the single case as well.
Where a patient needs intensive support, the crew and equipment requirement increases sharply, and so does the aircraft type needed to carry it.
Commercial flights are used where possible
Many repatriations occur on scheduled aircraft, with seats removed to accommodate a stretcher or with a medical escort accompanying a seated patient.
This is considerably cheaper but requires the patient to be stable enough for a commercial cabin and for the airline to accept the case.
Insurers and assistance companies assess this carefully, which is why repatriation is sometimes delayed until the patient can travel by the less expensive route.
Coordination across jurisdictions takes time
A transfer involves treating and receiving hospitals, aviation authorities, immigration in multiple countries and often ground ambulances at both ends.
Any one of these can delay the movement, and the arrangements must hold together simultaneously for the transfer to proceed.
Assistance companies exist to manage this, and their involvement is why policies require contact before arranging anything independently.
Remote locations change the figure entirely
Evacuation from a mountain, a vessel or a location without a suitable runway may require helicopters or specialist teams before air transfer can begin.
These operations are priced differently again and can be excluded or limited under standard policies, particularly where the activity itself is listed as hazardous.
Anyone travelling to such places should read the activity definitions in the policy carefully, since coverage limits vary widely between providers and change over time.