Health Insurance Claim Guide — Protecting Your Rights

What is a Health Insurance Claim and Why It Matters

A health insurance claim is a legal action filed against a health insurance company when it refuses to cover medical treatment, medication, medical tests, or other health services. In Israel, private health insurance constitutes an essential part of the healthcare system, and policyholders expect the insurance company to fulfill its obligations as stipulated in the policy.

When an insurance company disputes coverage — whether claiming that the treatment is not covered by the policy, arguing that it is an experimental treatment that is not accepted, or making any other claim — the policyholder has a legal right to file a claim. Health insurance claims are part of Israel's tort law system and require a deep understanding of the policy, the law, and court rulings.

Mendelboum, Gor, Witzman-Gor & Co. specializes in representing claimants in tort claims, including health insurance claims combined with traffic accidents, work injuries, and public negligence. With over 18 years of experience in representing clients in this field, we understand the complex issues of insurance coverage and methods of combating denials.

When You Need a Health Insurance Claim

A health insurance claim is necessary in various situations:

• Refusal to cover treatment: The insurance company disputes coverage of medical treatment that you believe is covered by your policy.
• Refusal to cover medication: A medication that is essential or recommended by a physician is not covered, or the insurance company requires use of a cheaper alternative with adverse side effects.
• Refusal to cover diagnostic tests or imaging: A diagnostic test (CT, MRI, ultrasound, etc.) recommended by your physician is denied by the insurance company.
• Refusal to cover surgery or complex treatment: Surgery, chemotherapy, or other complex treatment is denied on the grounds that it is experimental or not accepted.
• Unreasonable attribution or assignment: The insurance company attempts to classify the treatment as a pre-existing condition that is not covered.
• Demand for full payment: Instead of partial or full coverage according to the policy, the insurance company demands a higher out-of-pocket payment than customary.

In each of these situations, you have a legal right to ask questions, demand explanations, and if necessary — file a legal claim.

Understanding Your Policy and Coverage Requirements

To file a successful health insurance claim, you must thoroughly understand the terms of your policy. A health insurance policy in Israel typically includes:

• Coverage Schedule: A list of treatments, tests, and medications covered by the insurance, with coverage percentages (100%, 80%, 50%, etc.).
• Annual Maximum Expenses: The maximum amount the insurance company will cover in a calendar year or policy year.
• Deductibles and Co-payments: The amount or percentage you must pay for each treatment.
• Pre-existing Conditions: Medical conditions that existed before purchasing the policy, which may not be covered or may be partially covered for a certain period.
• Excluded Expenses: A list of treatments not covered at all, such as cosmetic surgery, experimental treatments, or treatments that have not received regulatory approval.
• Prior Authorization Requirements: For certain treatments, you must obtain prior approval from the insurance company before proceeding with treatment.

When an insurance company disputes coverage, its claim is typically based on one of the above provisions. Our role as attorneys is to thoroughly examine the policy, compare your claim against the policy terms, and prove that the insurance company is incorrect.

Types of Coverage Denials and Legal Arguments

Health insurance companies use various arguments to justify denying coverage. The following are the most common types:

• Treatment Not Covered by Policy: The insurance company claims the treatment is not listed in the coverage schedule. In response, you must prove that the treatment is general enough to fall within a covered category, or that there is a reasonable interpretation of the policy supporting coverage.
• Experimental or Non-Standard Treatment: The insurance company claims the treatment is experimental or lacks medical consensus regarding its effectiveness. In response, you must present up-to-date medical evidence proving the treatment is accepted in the medical field or in Israel.
• Pre-existing Condition: The insurance company claims the medical condition existed before the policy began and is therefore not covered. In response, you must prove that the condition began or developed after the policy started, or that there is a coverage obligation despite the pre-existing condition.
• Special Policy Exclusion: The insurance company relies on a special exclusion written into the policy. In response, you can argue that the exclusion does not apply to your case, or that it should be interpreted more narrowly.
• Excess Costs: The insurance company covers only part of the cost, claiming the excess is beyond the medical standard or reasonable price. In response, you must prove the cost is reasonable and consistent with market prices or recommendations by the physician.

Each of these arguments requires a different legal strategy and different evidence. As attorneys specializing in tort law and insurance, we are equipped to handle each one.

Comparison of Scenarios and Cost Ranges

Health insurance claims vary in complexity and cost depending on the type of treatment, type of denial, and the amount in dispute. Below is a table presenting typical scenarios:

Important Note: The costs in the table reflect typical ranges only. Each case is different, and the actual cost depends on the specific circumstances, type of treatment, medical condition, and the degree of denial by the insurance company. Additionally, if the claim reaches court, legal costs (attorney fees, witness examination costs, etc.) may be added. However, in many cases, the court will order the insurance company to reimburse the claim costs if it decides in your favor.

Insured Rights in Health Insurance Claims

In Israel, an insured person has essential legal rights in the context of health insurance claims. These are rights that protect you from misrepresentation, defamation, or unfair treatment by the insurance company:

• Right to receive a written explanation: When an insurance company disputes coverage, it must explain in writing the reason for the denial. You are entitled to a clear explanation, not a general rejection.
• Right to request a review: If you disagree with the denial, you can request the insurance company to review the case again, or file an appeal with an internal appeals committee.
• Right to consult with a doctor: You can obtain a second medical opinion, and this opinion should be considered in the case review.
• Right to file a legal claim: If the insurance company does not restore coverage after repeated requests, you have the right to file a claim in court.
• Right to compensation for legal costs: If the court decides in your favor, the insurance company may be required to pay your claim costs, including attorney fees.
• Right to compensation for non-pecuniary damages: In some cases, if the insurance company acted in bad faith or with negligence, you may receive compensation for suffering, defamation, or emotional damages.

These rights are fundamental, but they can sometimes be expanded according to court decisions and the specific circumstances of the case.

How Mandelboums, Gor, Witzman-Gor & Co. Can Help

Our firm specializes in representing claimants in tort law, including health insurance claims combined with traffic accidents, work accidents, and public negligence. With more than 18 years of experience in this field, we know how to:

• Analyze your policy in depth and identify weaknesses in the insurance company's claim.
• Gather strong medical evidence and medical opinions that support your claim.
• File persuasive written requests that often lead to settlements without the need for legal proceedings.
• Conduct efficient negotiations with the insurance company and other interested parties.
• File a claim in court, if necessary, and represent you at all stages of the proceedings.
• Ensure that you receive the full compensation you are entitled to, including legal costs.

We work on a basis of personal and dedicated relationship. Each case is examined on its own merits, and each client receives full attention from an experienced attorney. Furthermore, your first meeting with us is at no cost, so you can understand your case and your options before committing to legal proceedings.