He fell ill on a cruise. Before he boarded the rescue boat, they handed him the bill.

Vincent Wasney and his fiancée, Sarah Eberlein, had never visited the ocean. They had never been on a plane. But when they bought their first home in Saginaw, Michigan, in 2018, their real estate agent gave them tickets to a Royal Caribbean cruise.

After two years of delays due to the coronavirus pandemic, they left in December 2022.

The couple chose a cruise to the Bahamas in part because it included a trip to CocoCay, a private island accessible to Royal Caribbean passengers that featured a water park, hot air balloon rides and a swimming with pigs excursion.

It was that day at CocoCay that Wasney, 31, started feeling ill, he said.

The next morning, as the couple made plans in their cabin for the last full day of the trip, Wasney made a noise of pain. Eberlein saw him convulsing in bed, with blood coming out of his mouth from biting his tongue. She opened the door to seek help and found another guest, who awakened his wife, an emergency room doctor.

Wasney was able to climb into a wheelchair brought by the ship’s medical crew to take him to the medical center, where he was given anticonvulsants and fluids and monitored before being discharged.

Wasney has had seizures in the past, starting about 10 years ago, but it had been a while since the last one. Scans at the time showed no tumors and doctors concluded he was likely epileptic, he said. He took medication initially, but after two years without another seizure, he said, his doctors took him off it to prevent liver damage.

Wasney had a second seizure on the ship a few hours later, back in his cabin. This time he stopped breathing and Eberlein remembered his lips being so purple they almost looked black. Once again, she ran for help, but in her haste, she locked herself outside. When the ship’s medical team entered the cabin, Wasney was breathing again but had ruptured blood vessels along his chest and neck that he later said resembled tiger stripes.

Wasney was in the ship’s medical center when he had a third seizure – a major seizure that typically causes loss of consciousness and violent muscle contractions. By this time, the ship was close enough to the harbor that Wasney could be evacuated by rescue boat. He was placed on a stretcher to be lowered by ropes into the side of the ship, with Eberlein descending a rope ladder to join him.

But before they disembarked, the bill arrived.

The patient: Vincent Wasney, 31, who was uninsured at the time.

Medical services: General and enhanced observation, blood test, anticonvulsant medication and fee for services performed outside the medical center.

Service Provider: Independence of the Seas Medical Center, the medical facility aboard the cruise ship operated by Royal Caribbean International.

Total account: $2,500.22.

What gives: As part of Royal Caribbean’s guest terms, cruise passengers “agree to pay in full” all expenses incurred on board until the end of the cruise, including those related to medical care. Additionally, Royal Caribbean does not accept “earthly” health insurance plans.

Wasney said he was surprised to learn that, along with other charges like wireless internet, Royal Caribbean required him to pay his medical bills before leaving the ship — even though he was being urgently evacuated.

“Are we being held hostage right now?” Eberlein remembered asking. “Because obviously if he had three seizures in 10 hours, that’s a problem.”

Wasney said he has little memory of being on the ship after his first seizure — seizures often leave victims dizzy and disoriented for a few hours afterward.

But he certainly remembers being shown a bill, the bulk of which was $2,500.22 in medical expenses, while he waited for the rescue boat.

Still dazed, Wasney remembers saying he didn’t have the money for it and a cruise ship employee responding, “How much can you afford?”

They depleted their bank accounts, including money saved for the next house payment, and maxed out Wasney’s credit card, but were still about $1,000 short, he said.

Ultimately, they were allowed to leave the ship. He later learned his card was overdrawn to cover the shortfall, he said. Once on dry land in Florida, Wasney was taken by ambulance to the emergency room at Broward Health Medical Center in Fort Lauderdale, where he incurred thousands of dollars more in medical expenses.

He’s still not sure what caused the seizures.

On the ship, he was told it could have been extreme dehydration – and he said he remembers feeling very thirsty on CocoCay. He also reflected on whether trying escargot for the first time the night before might have played a role. Eberlein’s mother is convinced the episode was related to swimming with pigs, he said. And not to be discounted, Eberlein accidentally broke a pocket mirror three days before the trip.

Wasney, who works at a stone store, didn’t have insurance when they left. He said that a month before they embarked on the trip, he finally felt like he could afford the health plan offered by his employer and signed up, but the plan didn’t start until January 2023, after he returned.

They also did not have travel insurance. As inexperienced travelers, Wasney said, they thought it was because of lost luggage and canceled trips rather than unexpected medical expenses. And because the cruise was a gift, they were never asked to purchase coverage, which is often the case when tickets are purchased.

The resolution: Wasney said the couple returned to Saginaw with virtually no money in their bank account, several thousand dollars in medical debt and no idea how they would cover their mortgage payments. Because he was uninsured at the time of the cruise, Wasney did not attempt to receive reimbursement for the cruise bill from his new health plan when his coverage began weeks later.

The couple set up payment plans to cover the medical bills for Wasney’s care after leaving the ship: one with two doctors he saw at Broward Health, who billed separately from the hospital, and one with the ambulance company. He also made payments from an account with Broward Health itself. These plans do not charge interest.

But Broward Health said Wasney missed two payments to the hospital and the bill ended up being sent to collections.

In a statement, Broward Health spokeswoman Nina Levine said Wasney’s bill was reduced by 73% because he was uninsured.

“We do everything in our power to provide the best care with the least financial impact, but we also cannot emphasize enough the importance of taking advantage of private health insurance plans and the Affordable Care Act, as well as travel insurance , to reduce the risks associated with unplanned medical issues,” she said.

The couple was able to pay for the house with $2,690 they raised through a GoFundMe Campaign that Wasney set up. Wasney said much of that help came from family as well as friends he met playing disc golf, a sport he picked up during the pandemic.

“A lot of people came to help us,” Wasney said, still moved by the generosity. “But there’s still the hospital bill.”

The conclusion: Billing practices differ by cruise line, but Joe Scott, chairman of the cruise ship medicine section of the American College of Emergency Physicians, said medical expenses are typically added to a cruise passenger’s onboard bill, which must be paid before leaving the ship. Individuals can then submit receipts to their insurers for possible reimbursement.

He recommended that those planning to take a cruise purchase travel insurance that specifically covers their trips. “This will make it easier for them to get reimbursed if they incur charges and potentially cover a costly medical evacuation if necessary,” Scott said.

Real Caribe suggests that Passengers receiving care on board submit paid bills to their health insurer for possible reimbursement. Many health plans does not cover medical services received on cruise ships, however. Medicare sometimes covers medically necessary health care services on cruise ships, but not if the ship is more than six hours away from a U.S. port.

Travel insurance can be designed to address many accidents outside the citysuch as lost luggage or even transportation and accommodation for a loved one to visit if the traveler is hospitalized.

Travel medical insurance, as well as plans that offer “emergency evacuation and repatriation,” are two types that can specifically help with medical emergencies. These plans can be purchased individually. Credit cards may also offer travel medical insurance among their benefits.

But travel insurance plans have limitations. For example, they may not cover care associated with pre-existing conditions or what plans consider “risky” activities such as rock climbing. Some plans also require travelers to first register their primary health insurance before requesting travel insurance reimbursement.

As with other insurance, read the fine print and understand how reimbursement works.

Wasney said that’s what they plan to do before the next Royal Caribbean cruise. They’d like to return to the Bahamas on basically the same trip, he said — there’s a lot about CocoCay they didn’t get to explore.

Bill of the Month is a crowdsourced investigation by KFF Health News It is NPR who dissects and explains medical bills.