NURSING INSURANCE GUIDELINES

Nursing Insurance – Explanations and Highlights Under the Guidance of Attorney Sharon Peres Ben-Haim

Nursing insurance is an insurance options offered nowadays by both the kuppot cholim (group insurance) as well as directly by insurance companies (private insurance).

Lately, KESHER has received quite a number of queries from parents who wished to find out about their child's right to nursing insurance, as well as questions regarding utilizing and accessing this insurance once they find out the insured child requires LTC (long term care).

These questions have been run by Attorney Sharon Peres Ben-Haim who specializes, among other thing, in issues regarding rights and benefits of those insured in various insurance programs.

Her highlights:

1.The definition of "LTC" is based on the guidelines of the Supervisor of Insurance and according to it. In order for the patient to be considered "LTC" he must be in a condition in which he cannot independently perform a significant part of at least three out of the six basic daily activities (getting up/lying down, getting dressed/undressed, bathing, eating, bathroom and mobility) or that he requires supervision due to cognitive impairment (i.e. Alzheimer's).

Private insurance policies can be purchased according to which the patient will be considered "LTC" if he has no sphincter control and in addition, cannot independently perform a significant part of only one additional daily activity.

It is important to stress that there exist within the policies detailed definitions of the above daily activities and attention must be paid to small nuances, such as – if the child can move himself about in a wheelchair, but can move the chair around on his own… the insurance company will claim that he moves independently. If he cannot cook, warm up and cut his own food, but can physically eat independently – the insurance company will claim that he does not fall under the category of "unable to perform eating activity."

2.There are differences between the nursing insurances offered by the various kuppot cholim, including all that is related to thein which a child can be added to the insurance, to the necessity of filling in a health statement as a condition to joining the insurance, and to the conditions of the policy and its exclusions, including the time for nursing insurance payment, the monthly benefit paid and more.

In all Kuppot cholim, the nursing insurance up until age 18 is free of charge.

It is important to emphasize that while insurance to a child is given free of charge, joining is not automatic and must be specifically requested from the Kuppat Cholim.

3.If the family has decided to file a claim with the nursing insurance, it is best to first consult with a lawyer specializing in the field, since unfamiliarity with the policy nuances may lead to a dismissal of the claim.

In any case of dismissal of the claim, it is warmly recommended NOT to continue corresponding with the insurance company, because such correspondence can worsen the condition of the insured in the company (according to the guidelines of the Supevisor of Insurance, the insurance company is limited to the arguments it had raised in the rejection letter. By continuing to correspond with the insurance company, you will be allowing it the opportunity to raise further defenses).

In case of a rejection of the claim, it is best to consult with a lawyer regarding the success prospects of the claim against the company if filed in court.