The largest sum insured in most travel policies covers medical treatment and repatriation. That section drives the premium more than any other, because its worst case is extremely expensive.
The cost is in the aircraft and the crew
Moving a patient who cannot travel on a scheduled service requires a dedicated aircraft configured as a flying intensive care unit.
That means flight crew, medical crew, equipment and often positioning flights before and after the transfer, all of which are chartered at short notice.
The total for a long-distance repatriation is large enough that a single case can exceed the premiums collected from a substantial number of policies.
Scheduled repatriation still consumes capacity
A patient stable enough for a commercial flight may still need a stretcher, which typically requires several rows of seats to be removed from service.
An escorting nurse or doctor travels alongside, with their own outbound and return costs, and airlines apply their own approval process.
Even this cheaper route is therefore far more expensive than a normal ticket, and it is the option insurers use wherever it is clinically appropriate.
Destination changes the exposure sharply
Treatment costs vary enormously between health systems, and policies price regions differently for that reason alone.
Distance compounds it, since repatriation cost scales with flying hours and with how many crew changes a route requires.
Remote destinations add a further layer, because reaching a facility capable of stabilising a patient may itself require a separate transfer.
Reciprocal arrangements reduce but do not remove it
Some countries have agreements giving each other's residents access to state healthcare on the same terms as locals, which covers treatment.
Those arrangements do not generally fund repatriation, and repatriation is the expensive part, so they complement insurance rather than replacing it.
Eligibility and scope differ by country and change over time, so the current terms for a specific destination need checking rather than assuming.
Why the assistance line matters
Insurers operate assistance services that assess cases clinically, arrange treatment and decide when and how a patient is moved.
That service controls cost by managing the case, which is why policies require contact before major treatment or transport is arranged.
Arrangements made independently may fall outside cover, and the practical value of the policy lies as much in the coordination as in the payment.