A person, defined as a nursing patient, is entitled by law to insurance benefits, provided he is unable to perform three of the following six actions: Get up and lie down, wash, eat and drink, control his needs, walk, dress and undress. Another subgroup is the mentally frail, such as those with Alzheimer’s or dementia, who are also considered to be nursing patients.
When a patient, insured by a private nursing policy in one of the insurance companies, demands the nursing benefits that he/she deserves, the company will be obliged to pay him/her monthly payments (as stated in the policy he/she signed at the time of joining), according to the length of time, during which he/she became a nursing patient and the place where he/she stays (his/her home or a special institution), for 36-60 months according to the terms of the policy.
Many people purchase nursing insurance exactly for such “rainy” days – in which they will no longer be able to function properly and will need existential help. In this situation, the insurance company must give them the money they deserve in order to pay for the nursing care expenses. This is not an amount that completely covers the entire scope of care for the patient, but is sufficiently high to allow the patient and his/her family significant relief.
The Tricks of Insurance Companies – Know This and Be Careful
According to data from the Ministry of Finance, insurance companies reject about one-third of the nursing claims submitted to them by the insured patients and in a systematic manner, so that nursing patients who are limited in their daily quality of life, and require constant assistance, are forced to conduct legal proceedings in order to realize their rights. Many nursing patients are forced to wage a stubborn struggle against the insurance company, in which they purchased a policy and paid money over many years in order to receive what they deserve.
This is a worrisome trend in view of the dire situation of the elderly in Israel, who, more than anyone else, are in need of caregivers, hospitalization in a nursing home or daily assistance due to their poor health and medical condition. If so, what is the best method of action against the insurance company? How can one ensure that the patient’s rights are indeed granted to him/her?
At the first stage, the “Redemption of the Insurance Policy Claim” must be submitted. This claim will be accompanied by all the relevant medical information. The claim is often rejected on the grounds that when the insurance was purchased, the company was not notified of the information regarding the patient’s current medical condition (non-disclosure claim) and that he/she did not report about suffering from any illness.
Many in the field of law resent this argument, since the company could have required the client’s medical record in advance and long before a claim was filed against them. It is therefore necessary to examine whether the policyholder was asked whether he suffers from an illness while filling the medical questionnaire and to prove that there is no connection between an illness that was not revealed, if any, and the fact that he is a nursing patient. In this situation, the insurance company will no longer be able to use the non-disclosure argument.
A small tip from the lawyer’s office: If you have not yet purchased a private nursing insurance policy and are considering this, it is recommended that you give the insurance company a medical document detailing your current state. Thus it will be possible to claim in the future that the company was indeed aware of your medical condition at the time of purchase.
The difficult fact of becoming nursing patients also leads to medical examinations on behalf of the National Insurance Institute, in order to determine the amount of the payment, to which the patient is entitled on behalf of the state. But if the patient is insured in a nursing insurance policy by a private company, the company will perform its own medical examination after a claim for redemption is filed. In many cases, the insurance company’s claim is rejected on the grounds that the patient does not meet 3 criteria.
However, when comparing the two examinations, on many occasions, there is a substantial difference, which may prove that the insurance company conducted a negligent examination. This is enough for filing a lawsuit and you should turn to court through a nursing claims lawyer for the insurance claim. Significant differences that get identified, will allow the judge to rule in your favor.
Your lawyer will be able to accompany you from the first moment and provide you with appropriate guidelines for dealing with any possible situation. For example, the lawyer will instruct you to check whether a full payment has been received from the date of becoming a nursing patient, according to law, or only from the date of filing the claim, which is against the law? He can also advise you to summon a geriatric specialist on your behalf to conduct a medical examination that contradicts the findings of the insurance company’s examination.
Despite the great attrition that the insurance companies seem to cause to their policyholders, it is important not to give up and continue to consistently demand what you deserve, until your rights are fully realized – even if the claim is rejected! Attorneys of our office will make sure to give your claims in full and in an orderly manner before the judge and will work for the realization of your rights based on the familiarity with the various claims raised by the insurance company and the ability to deal with any given rejection claim.
When does the claim get rejected?
70 year old Molly suffered from full blindness and severe edema in her legs. Her medical condition exhausted her physically and caused her to require full and constant assistance, including her deteriorated mental state, which caused her to be hospitalized in a psychiatric ward. The insurance company claimed that she cannot activate her policy because this nursing state is a result of mental impairment.
In another case, a nursing insurance policyholder had lung cancer. She had trouble breathing, suffered from weakness, and could not get out of bed anymore. She needed help in dressing, bathing, and was no longer in control of urination. The insurance company rejected her claim on the grounds that she had contracted breast cancer 30 years ago, while in the health questionnaire she filled out at the time of joining, she did not report it.
In a third case, a young man with severe arthritis was completely prevented from working with both hands: He could not dress or wash, including performing any other daily action. In addition, a serious digestive problem prevented him from controlling his needs. The insurance company claimed that the policyholder does not meet the definition of a nursing state according to law.
These three claims were indeed rejected by the insurance company and were brought before a judge who ultimately ruled in the policyholders’ favor. Each of these policyholders received payment of thousands of shekels each month from the insurance company, in accordance with the policy agreement.
It is important to know that according to the policies of the insurance companies, when a person’s nursing condition is caused as a result of a suicide attempt, mental disorders or traffic accidents, no benefit will be paid to him/her. However, with your lawyer’s help, you can check whether this rule is indeed in the policy according to law, whether a copy of it was sent to the policyholder before becoming a nursing patient and was the policyholder aware of this rule. The claim can also be rejected by virtue of the statute of limitations: If the claim is filed after three years from the date of becoming a nursing patient, it will not be possible to claim the benefit.
Remember that realizing your rights is not merely a recommendation! Despite the struggles waged by the private insurance companies against policyholders who purchase nursing policies in order to pay them as little as possible, you need a nursing claims lawyer who will accompany you throughout the whole process – from the moment you file your claim with the insurance company, to the full realization of your rights. Attorneys of our office will be happy to serve you with courtesy and professionalism and to be the professional factor that will work for you at all times.
*The above article is by no means a legal advice; any use of this information is solely under the reader’s responsibility.