Guide to Nursing Care Claims in National Insurance

What is a Nursing Care Claim in National Insurance?

A nursing care benefit in National Insurance is a monthly allowance paid by the National Insurance Institute to a person injured in a traffic or workplace accident who requires ongoing care due to bodily injury or health condition. It is one of the most important insured rights, designed to cover the costs of medical and personal daily care for the injured party.

Unlike one-time compensation for bodily damage, nursing care benefit is a periodic allowance that varies according to the level of disability and the degree of the injured party's dependence on care. A nursing care claim requires legal and statutory proof of a causal connection between the accident and the need for care, as well as a thorough medical assessment of the injured party's condition.

Who is Entitled to Nursing Care Benefit?

Entitlement to nursing care benefit in National Insurance exists when several essential conditions are met. First, it must be proven that the injured party sustained bodily injury as a result of a traffic or workplace accident recognized by the National Insurance. Second, the injured party must require ongoing care due to the injury – meaning they cannot perform basic daily activities without the assistance of another person. Third, a direct causal connection between the accident and the need for care must be established.

The National Insurance examines the injured party's disability level through a medical committee. If it is determined that the injured party suffers from a disability of 40% or more and requires ongoing care, they may be entitled to a benefit. It is important to note that entitlement is determined according to the approach prevailing in case law, and in any case, circumstances are examined on their merits.

Types of Care Recognized by National Insurance

• Care while awake: Assistance with daily activities such as dressing, eating, personal hygiene, and mobility in the home.
• Care during sleep: Assistance during nighttime periods, including operating medical devices, changing bedding, or simply being present in case of emergency.
• Medical care: Performance of medical procedures requiring certification or special knowledge, such as catheter replacement, wound care, or medication management.
• Supervision: Continuous supervision of the injured party to ensure their safety, especially when suffering from cognitive impairment or risk of self-harm.

Nursing Benefit Claim Procedure in National Insurance – Step by Step

The nursing benefit claim procedure is a complex legal and medical process that requires meticulous documentation, medical evidence, and precise legal argumentation. Below is a detailed description of the main stages:

Stage 1: Submitting an Initial Request to the National Insurance Institution

The injured party or their legal representative submits a formal request to the National Insurance Institution, detailing personal information, accident details, and a comprehensive description of the injury and its impact on the injured party's ability to perform daily activities. The request must be accompanied by initial medical documentation, including hospitalization reports, receipts from specialist physicians, and all relevant medical records.

Stage 2: Medical Examination by the National Insurance Institution

Following submission of the request, the National Insurance Institution schedules the injured party for a medical examination by a physician designated by the Institution. This examination aims to assess the degree of disability, the need for nursing care, and the types of nursing care required. The National Insurance physician analyzes the medical findings, examines the injured party personally, and prepares a medical report that serves as the basis for the initial decision.

Stage 3: Initial Decision by the National Insurance Institution

Based on the physician's report, the National Insurance Institution issues an initial decision. The decision may be positive (approval of entitlement to the benefit), negative (rejection of the claim), or partial (approval of daytime nursing care only, for example). The decision is based on determining the degree of disability, the need for nursing care, and the connection between the accident and the disability.

Stage 4: Filing an Appeal (if required)

If the injured party or their legal representative disagrees with the initial decision, an appeal may be filed within 30 days of receiving the decision. In the appeal, new legal and statutory arguments, additional medical evidence (such as a report from an independent specialist physician), or comments on errors in the initial examination process must be presented. This appeal is reviewed by an expanded medical committee of the National Insurance Institution.

Stage 5: Decision on the Appeal

The National Insurance Institution's appeals committee examines all submitted materials – the initial decision, the initial physician's report, the new appeal, and any additional medical evidence. Based on a renewed examination, the appeals committee issues a final decision. This decision may uphold the initial decision, modify it, or overturn it.

Stage 6: Request for Judicial Review (if required)

If the injured party disagrees with the appeals committee's decision, a request for judicial review may be filed in court. At this stage, the case undergoes full legal review, during which the National Insurance Institution's previous decisions are examined under the legal standard of judicial review. This is a critical stage that requires experienced legal representation and strong legal argumentation.

Calculating Nursing Allowance – How is the Monthly Benefit Determined?

Calculating nursing allowance in the National Insurance is not a simple process. It is based on several variables including the level of disability, type of nursing care required, hourly rate of the caregiver in the market, and the daily duration for which nursing care is needed.

Factors Affecting Benefit Calculation

• Disability Level: The National Insurance divides disability levels into different grades (40–49%, 50–74%, 75–100%). Each grade affects the amount of the benefit.
• Type of Nursing Care: Daytime care, nighttime care, medical nursing, or supervision – each has a different cost and payment amount.
• Duration of Care: The number of hours per day for which nursing care is needed (for example, 4 hours per day versus 8 hours per day) affects the total benefit.
• Hourly Rate: The National Insurance sets a minimum and maximum price for nursing care per hour. This price is updated annually according to the cost of living.
• Marital Status and Age of the Injured Party: In some cases, marital status and age may affect benefit determination.

Typical Calculation Example

A person injured in a work accident suffering from 60% disability requires 6 hours of daytime care per day. If the hourly rate for care is set at X shekels, the monthly benefit will be calculated approximately as follows: 6 hours × hourly rate × 30 days = monthly benefit. Additionally, if the injured party also requires nighttime care, an additional amount will be added to the benefit.

It is important to emphasize that this calculation is an approximation only, and the actual benefit amount is determined by the National Insurance according to its policy and updated regulations. In any case, it is important to verify that the calculation proposed by the National Insurance is correct and matches the injured party's data.

Benefit Update Over Time

The nursing allowance is not static. The National Insurance re-examines the need for nursing care at fixed intervals or when there is a significant change in the injured party's health condition. If the injured party's condition improves, the benefit may be reduced. Conversely, if their condition deteriorates, the benefit may be increased. Any such update requires a new medical examination and can be appealed.

Additional Rights Related to a Nursing Care Claim

In addition to the monthly nursing allowance, the injured party may be entitled to additional rights that are integrated into the nursing care claim process:

Lump-Sum Compensation for Personal Injury Damages

According to the Tort Law, a victim of a traffic accident or work accident may be entitled to lump-sum compensation for personal injury damages. This compensation is calculated based on the level of disability, age of the injured party, and loss of earning capacity. This compensation is paid in addition to the nursing allowance, not instead of it.

Medical Benefits and Treatment

The injured party is entitled to coverage for medical treatments related to their injury, including medications, tests, physiotherapy, and additional treatments. The National Insurance pays directly to service providers or reimburses the injured party for expenses they incurred from their own pocket.

Assistance with Home Adaptation

In some cases, the injured party is entitled to financial assistance to adapt their home to their needs (for example, installing an elevator, accessibility renovations, or installation of medical devices). This assistance is intended to facilitate the injured party and their caregiver.

Lump-Sum Bonus for Family Caregiver

If nursing care is provided by a family member (such as a spouse or parent), the injured party may be entitled to a lump-sum bonus or benefit supplement intended for the benefit of the caregiver.

Tax Benefits and Discounts

According to law, a victim of an accident is entitled to certain tax benefits, such as exemption from tax payment on part of the benefit, or discounts on medical treatment costs.

How Mendelboums, Gor, Witzman-Gor & Co. Can Help You

Filing a nursing care claim with the National Insurance Institute is a complex process requiring in-depth legal knowledge, understanding of National Insurance law, and experience in handling similar cases. Mendelboums, Gor, Witzman-Gor & Co. specializes in representing claimants in tort law, including claims related to National Insurance and nursing care benefits.

With over 18 years of experience representing victims of traffic and work accidents, our family law firm understands the difficulties faced by an injured party in a nursing care claim. We work systematically, lawfully, and with complete dedication to achieve the full rights you deserve.

Our services include:

• Free Initial Legal Consultation: At your first meeting, we will examine your case, explain your rights, and propose an appropriate legal strategy.
• Professional Preparation of the Claim: We prepare a strong and detailed claim, with all necessary documents and the strongest legal arguments.
• Case Management at Every Stage: From filing the initial claim, through appeals, to judicial review if required.
• Medical-Legal Consultation Services: We work with independent expert physicians to obtain strong medical reports supporting your claim.
• Representation at All Proceedings Stages: From communication with the National Insurance Institute, through appeals, to court proceedings if necessary.
• Continuous Follow-up and Reporting: We carefully monitor the process and keep you updated at every stage.

Our office is located in Ramat Gan and also in Petach Tikva, enabling us to serve clients throughout the Central region with maximum convenience. Initial consultation meetings are free of charge, and we offer personalized and dedicated service to every client.