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Long-Term Care Insurance: The Complete Guide to Rights and Process
Long-term care insurance is designed to protect you when you can no longer manage your daily life independently. Yet the gap between what is written in the policy and what the insurer actually pays is often enormous. Long-term care attorney at Lev-Taieb will protect your rights.
What Is Long-Term Care Insurance?
Long-term care insurance is a form of benefit insurance — it pays a fixed monthly sum as long as the policyholder is in a care-dependent condition, regardless of actual expenses. This distinguishes it from reimbursement insurance (which refunds actual costs).
In Israel, long-term care insurance comes in two main forms:
- HMO long-term care insurance — included in the supplemental health package (Shabar) of the four HMOs, governed by the National Health Insurance Law
- Private long-term care insurance — purchased independently from insurance companies such as Menora, Harel, Clal, Phoenix, and others
The Care-Dependent Condition: Legal Definition
The central concept in all long-term care insurance is “care-dependent condition.” Though both systems use this term, the legal definitions differ significantly — and this difference often determines whether you receive benefits.
HMO Definition
Inability to independently perform at least 3 of the following 6 daily activities: getting up and going to bed, dressing/undressing, eating and drinking, moving around the home, maintaining personal hygiene, controlling sphincters.
Private Insurance Definition
Varies by policy. Some policies require inability to perform only 2 activities; some include cognitive impairment (dementia, Alzheimer’s) as an independent qualifying criterion. Always read the policy’s summary page carefully.
Filing a Long-Term Care Claim: Step by Step
Step 1: Submit the Claim in Writing
Submit the claim in writing — never verbally. The submission date determines when the waiting period begins. Include: medical records, treating physician’s letter, specialist reports.
Step 2: The ADL Assessment
The insurer sends an assessor for a home visit to verify the care-dependent condition. This assessment is critical — see our guide on how to prepare for the ADL assessment.
Step 3: Decision Within 30 Days
The insurer must respond within 30 days. If additional documents are requested, the clock pauses and restarts from submission of the documents.
Step 4: Waiting Period
Most policies require a waiting period of 60–90 days from claim submission before payments begin. Some policies have a shorter waiting period or none at all.
Step 5: Monthly Benefit Payment
HMO benefits are typically paid in service hours (6–12 hours per week of home care). Some HMOs allow a cash alternative. Private insurance usually pays a fixed monthly cash sum.
The Most Common Reasons for Denial — and How to Fight Them
“Does Not Meet the Definition of Care-Dependent Condition”
The most common reason. The insurer’s assessor determines that the person performs all 6 ADL activities or at least 4 of them. Response: obtain an independent geriatrician’s opinion and submit a written appeal with detailed medical documentation.
“Pre-Existing Condition”
The insurer claims the condition existed before the policy was purchased. Response: medical documentation showing the condition arose or significantly worsened after the policy start date.
“Claim Filed Late”
Most policies set deadlines for filing. If you missed a deadline, consult an attorney — Israeli court rulings have in some cases allowed late claims when delay was reasonable.
“Change in Definition” — Policy Amendment
If the insurer changed the policy terms during the coverage period, such a change may be invalid. An attorney can assess whether the amendment is legally binding.
The Right to Appeal
If your claim is denied, you have the right to appeal within 90 days. The appeal process:
- Request the full assessor’s report in writing
- Obtain an independent geriatrician’s opinion
- Submit a written appeal with the supporting medical opinion
- If still rejected — request an external medical committee
- If still rejected — file a complaint with the Capital Market, Insurance and Savings Authority
- Legal action — civil lawsuit or small claims court
Old Policies: Why They May Be More Valuable
Policies purchased before 2000, especially before 1995, often have broader definitions that are more favourable to the insured. The benefit amounts were set at the time of purchase but are indexed.
If you have an old policy — keep it carefully. It cannot be “upgraded” without losing its original terms. There are cases where families did not find the old policy and did not know it existed. You can check through bitoach.gov.il, the government insurance database.
Frequently Asked Questions
I have both HMO and private long-term care insurance. Can I claim from both?
Yes. Long-term care insurance is benefit insurance, so you can receive benefits from both simultaneously. If the private policy includes coordination with national insurance, this will be reflected. Read both policies carefully.
My parent has dementia. Is she eligible?
Depends on the policy. Private policies often include dementia as an independent qualifying criterion. For HMO insurance, dementia alone (without ADL limitations) may not qualify — but patients with dementia often also have ADL limitations. A geriatrician’s assessment is recommended.
The insurance company stopped paying after 3 years. Is this legal?
Depends on the policy. Some policies are “limited benefit” — they pay for a fixed period. Others are “lifetime benefit.” Check what is written in your policy. If you believe the insurer stopped payments unjustifiably, consult an attorney.
How much compensation can we get in a lawsuit against the insurer?
It depends on the benefit amount, the number of months denied, and whether there are grounds for damages beyond the unpaid benefits. An attorney will calculate the full claim value.
For a free consultation, contact the long-term care attorney at Lev-Taieb. Phone: 072-2428822.
