Private Health Insurance: What Is Covered and What Is Not

What Does Private Health Insurance Cover?

Private health insurance covers medical services not included in the national health basket, or enables receiving services at a higher standard. Common coverages include: private surgeries, private specialists, non-basket medications, biological treatments, and transplants. This insurance complements the health fund basket and allows bypassing long waiting lists.

The Insurance Contract Law, 5741-1981, and the Supervision of Insurance Services Law, 5741-1981, regulate the obligations of insurance companies toward policyholders. The insurance company is required to honor the policy terms and may not refuse coverage without a lawful and justified legal ground.

What Is Usually Not Covered?

Private health insurance generally does not cover: experimental treatments that have not been approved, alternative treatments, cosmetic procedures, and treatments not pre-approved by the insurer. Similarly, conditions excluded in the application form may not be covered. It is important to read the policy before any treatment.

Pre-Existing Condition: What Does the Law State?

The insurance company may exclude a condition that existed at the time of joining, but must specify it explicitly. Non-disclosure by the insurance company regarding exclusion of a pre-existing condition may result in invalidation of the exclusion. Section 6 of the Insurance Contract Law sets out the duty of disclosure in detail.

List of Pre-Approved Providers

Many policies require treatment at pre-approved providers. However, in emergencies, the insured may approach any provider. After the treatment, a reimbursement claim may be filed. It is important to preserve all receipts and medical records.

How to Utilize the Insurance

Before expensive treatment, request prior approval from the insurance company. If refused, obtain the refusal in writing and consult a lawyer. After treatment, submit all documents in advance. Delay in submission may prejudice entitlements.

Common Rejections and How to Respond

The most common rejections in private health insurance include: the claim that treatment is experimental, the claim that there is a basket substitute, a pre-existing condition claim, and non-compliance with procedural conditions. Each of these rejections can be appealed.

Under Section 28 of the Insurance Contract Law, an insurance company that delayed payment without sufficient reason is required to pay arrears interest. Professional legal representation can change the outcome of a rejection in the majority of cases.

Typical Coverage Amounts

Private surgeries in private health insurance policies typically cover up to 150,000-500,000 shekels per event. Non-basket medications may cover up to 50,000-100,000 shekels per year. Transplants from abroad may be covered in higher amounts, depending on the policy.

It is important to know that there are policies with a double coverage ceiling and policies without a ceiling. This distinction is critical when dealing with expensive chronic illnesses.

Group Health Insurance via the Employer

Group private health insurance through the workplace is usually cheaper but tied to the employment relationship. Upon leaving employment, the insured is entitled to continue the policy in private payment for a limited period. It is important not to miss the opportunity to convert the policy.

Differences Between Private Health Insurance and Full Health Fund

“Full” insurance of the health fund is full insurance for the health fund basket. Full private health insurance is a separate product that covers providers not in the health fund network. The important distinction: a claim for full health fund insurance is filed with the health fund, a claim for private health insurance is filed with the insurance company.

Frequently Asked Questions

What to do when the insurance company refuses to approve urgent treatment?

In an emergency, receive treatment first and file a reimbursement claim afterwards. The insurance company may not refuse to cover urgent treatment that was medically necessary, even if it was not possible to obtain prior approval. Preserve all medical records and proof of urgency.

Is it possible to sue both the health fund and the private insurance?

Not simultaneously for the same expense. The indemnity principle in insurance provides that one may not profit from insurance. However, one may claim from the private insurance what the health fund did not cover. Coordination between the two sources is a matter that requires professional advice.

Is it possible to upgrade a health insurance policy and add coverage?

Yes, it is usually possible to add coverage, but coverage added after an existing illness may be subject to exclusion. For example, if you were diagnosed with a condition before the policy extension, that condition may be excluded from the new coverage. It is important to ask the insurance company explicitly.

What to do if the insurance company delays payment without reason?

First, send a formal demand letter with a final deadline. If it does not respond, you may approach the Capital Market, Insurance and Savings Authority. You may also consult a lawyer and file a lawsuit for the delay in payment, including arrears interest according to the Insurance Contract Law. For claims up to 75,000 shekels, a small claims court claim may be filed.

Is it worthwhile to approach the insurance commissioner before a lawyer?

It depends on the case. Approaching the insurance commissioner is free and swift, and is suitable for small disputes. For large amounts or when dealing with a material rejection, legal representation yields better results. Both avenues may be pursued simultaneously.

What is the time limit for filing a claim after treatment?

According to most policies, a claim must be filed within 90-180 days of treatment. Failure to meet the deadline may prejudice entitlements. However, under the Insurance Contract Law, the insurance company may not automatically reject a claim for a minor delay without proof of damage. In any case, file as soon as possible.

For assistance with a rejected health insurance claim, contact the insurance claims attorney at the Lev-Taieb firm: 072-2428822.