Nursing Care Insurance Guide — The Complete Path to Filing a Claim Against an Insurance Company

Nursing Care Insurance Guide — Introduction

Nursing care insurance is an essential legal tool for individuals suffering from significant bodily injuries requiring prolonged daily care. Whether it is a traffic accident, workplace injury, or medical negligence, the right to nursing care benefits can be significant for your quality of life and your ability to cope with the damage. However, filing a claim against an insurance company is not a simple process — it requires a deep understanding of legal rights, procedural steps, and methods of calculating benefits.

This guide offers you a complete roadmap through the world of nursing care insurance in Israel. We will review the statutory definitions, the types of relevant insurance, the process required to file a claim, and the factors affecting the amount of compensation. At Mandelbaum, Gor, Witzman-Gor & Co., with more than 18 years of experience representing claimants exclusively in the field of tort and insurance law, we help victims obtain the compensation they deserve.

What is Nursing Care Insurance? Definition and Scope of Application

Nursing care insurance is a legal category covering payments for nursing care required as a result of bodily injury. According to the approach established in case law in Israel, nursing care is defined as assistance with basic daily activities — such as personal hygiene, dressing, personal grooming, mobility, and nutrition — performed by another person due to the injured party's inability to perform these activities independently.

Nursing care benefits are not necessarily tied to a specific nursing care insurance policy in the insurance contract. In many cases, they arise from a claim for comprehensive monetary compensation for bodily injury in a civil suit against the defendant (in the case of a traffic accident) or against the injured party's nursing care insurance company (if one exists). Additionally, national insurance may provide nursing care benefits in certain circumstances.

Types of Insurance Relevant to Nursing Care Claims

There are several avenues through which a claim for nursing care benefits can be filed:

• Direct Nursing Care Insurance: Some insurance companies offer standalone nursing care insurance policies. These policies set a daily or monthly benefit amount in case of a need for nursing care. The claim is filed directly with the insurance company according to the policy terms.
• Third Party Liability Insurance: When a third party is involved in an accident (for example, another driver in a traffic accident), the liability insurance of the responsible party may cover nursing care benefits as part of the total compensation.
• National Insurance: Under the National Insurance Law, a claim can be filed to receive nursing care benefits for workplace accidents or occupational diseases. The benefit is calculated according to criteria set out in the law.
• General Civil Claim: In traffic accidents or medical negligence cases, nursing care benefits can be part of a comprehensive claim for compensation for bodily injury against the responsible party.

Legal Rights in Nursing Care Claims

Under Israeli law, any person injured in their body and requiring permanent or temporary nursing care as a result of that injury is entitled to monetary compensation. This right is based on the principle of the civil remedy established in case law: the injured party is entitled to restoration to their condition prior to the accident, to the extent that this can be achieved through money.

In certain circumstances, the injured party is also entitled to compensation for future nursing care (anticipated nursing care), if there is medical evidence indicating that this need is expected to continue. Each case is examined individually according to the specific circumstances, type of injury, the injured party's current health status, and expert medical opinions.

The Process of Filing a Nursing Care Claim — Practical Steps

A claim against an insurance company does not begin in court. In most cases, there is an administrative process that precedes it, in which evidence must be collected, medical opinions obtained, and a settlement attempted with the insurance company. The following are the main steps:

Step 1: Collection of Medical Documents and Documentation of Damages

The first step is to collect complete medical documents related to the accident and subsequent treatment. This includes:

• Medical reports from the hospital or initial clinic
• Complete medical records (imaging studies, blood tests, other examinations)
• Reports from treating physicians (including specialists in cases of spinal cord, cognitive, or other injuries)
• Expert medical opinions on relevant topics
• Documentation of medical expenses already incurred

This collection is essential because the insurance company will seek to assess the extent of the damage and its impact on the injured person's ability to receive nursing care.

Step 2: Review of the Policy and Reading of Its Terms

Before filing a claim, the relevant policy must be carefully examined — whether it is direct nursing care insurance, liability insurance, or national insurance. You must check:

• Whether the circumstances of the accident are included in the coverage definitions of the policy
• What is the maximum coverage amount for the claim
• What expenses are covered (home nursing care, hospital nursing care, maintenance nursing care)
• What are the conditions for the claim to take effect (for example, waiting period, medical requirements)
• Whether there are uncovered expenses or limitations on the benefit amount

Insurance companies sometimes attempt to place expenses below a certain threshold, or to limit the claim based on a narrow interpretation of the terms. At this stage, it is advisable to consult with a specialist attorney.

Step 3: Filing the Claim with the Insurance Company

The claim is usually filed in writing, describing the accident, the injury, the need for nursing care, and the amount of compensation requested. The claim must be accompanied by:

• A copy of the policy or proof of insurance
• Complete medical documents
• Opinions from medical specialists regarding the type of nursing care required and its duration
• A detailed calculation of the requested nursing care benefit (based on daily nursing hours, hourly cost, and expected period)
• Evidence of expenses already incurred (invoices, receipts, contracts with caregivers)

At this stage, the insurance company will open a claim file and begin its internal investigation.

Step 4: Examination of the Claim by the Insurance Company

Upon receipt of the claim, the insurance company is obligated by law to examine it within a reasonable time period. At this stage, the insurance company may:

• Request additional documents or clarifications
• Conduct an independent medical examination (an examination conducted by a physician employed by the insurance company)
• Refer the case to a medical committee (in case of national insurance or significant disagreements)
• Offer a settlement for part of the claim amount
• Reject the claim in whole or in part

At this point, negotiations with the insurance company can begin. Often, insurance companies prefer settlement to entering litigation, and through skilled negotiation, a reasonable agreement can be reached.

Step 5: Medical Committee (if required)

If the insurance company and the national insurance company disagree about the extent of the damage or the need for nursing care, the case can be referred to a medical committee. The committee will review the medical documents, may conduct a follow-up medical examination, and its opinion will be binding on both parties (unless an appeal is filed).

Each case is unique in the committee process, but generally, the committee holds a significant position in determining eligibility.

Step 6: Negotiation and Settlement

After the insurance company has completed its investigation (or after the committee's decision), negotiations begin on the settlement amount. At this stage, an experienced attorney can protect your rights and pressure the insurance company to offer a fair amount. In many cases, a settlement is reached at this stage without the need for litigation.

Step 7: Judicial Claim (if no settlement is reached)

If no settlement is reached, a claim can be filed in court. In this claim, the matter will be heard by a judge, who will decide on entitlement and the amount of compensation. This process takes longer, but in some cases, it is necessary to obtain fair compensation.

Calculation of Nursing Care Benefits — Parameters and Cost Ranges

The calculation of nursing care benefits is not arbitrary but is based on defined legal and medical criteria. We will review the main parameters that affect the compensation amount:

Daily Nursing Hours

The first question is: how many hours per day is nursing care required? This depends on the severity of the injury and the functioning of the injured person. For example:

• An injured person who cannot move their body and requires assistance with every daily activity may require 8–12 hours of nursing care per day.
• An injured person who can move with assistance but requires help with nutrition, hygiene, and dressing may require 4–6 hours per day.
• An injured person who requires partial care or supervision only may require 1–3 hours per day.

The number of hours is determined based on expert medical opinions, clinical examination, and discussions with the insurance company or medical committee.

Hourly Cost of Nursing Care

The hourly cost varies depending on the type of nursing care and the setting in which it is provided:

• Home nursing care: Usually less expensive, as the caregiver comes to the injured person's home. Typical cost range: ₪60–₪120 per hour, depending on the caregiver's level of training and geographic location.
• Hospital nursing care: More expensive, as costs include a full medical team. Typical cost range: ₪150–₪300 per hour.
• Nursing care abroad: In cases where the injured person receives treatment abroad, costs may be significantly higher.

Insurance companies sometimes object to high costs and claim that calculations should be based on lower costs. At this point, proof of actual costs (contracts with caregivers, invoices) or expert medical opinions establishing the required level of training is necessary.

Duration of Nursing Care

The duration of nursing care may be:

• Temporary nursing care: In the case of an injury expected to heal or improve over time, nursing care will be temporary only. The duration of nursing care is determined based on medical opinion.
• Permanent nursing care: In the case of a permanent injury (for example, paralysis, blindness, or severe cognitive impairment), nursing care is expected to continue for life. In this calculation, actuarial tables are used to calculate the injured person's life expectancy.

Calculation Example

Let us imagine a concrete case (for example purposes only):

• An injured person aged 40 who was injured in a traffic accident and developed partial paralysis.
• A medical opinion determines a need for 6 hours of nursing care per day.
• The cost of home nursing care: ₪100 per hour.
• Life expectancy: 40 additional years (until age 80).
• Calculation: 6 hours × ₪100 × 365 days × 40 years = ₪8,760,000 (in nominal values, without discounting for time value or interest).

In practice, insurance companies use more complex formulas that include discounting for time value (discount rate) and account for expected future costs. Each case is reviewed individually.

Comparative Table: Types of Care, Costs and Insurance Coverage

Note: The table reflects typical ranges only. Actual costs vary according to geographic area, caregiver training level, insurance type and policy conditions. Each case is reviewed individually by the insurance company.

Common Challenges in Nursing Care Claims and Ways to Overcome Them

Challenge 1: Insurance Company Rejects the Claim that Nursing Care is Required

Insurance companies sometimes argue that the injured party does not require nursing care or that the need is minimal only. Their argument is based on:

• An independent medical examination (conducted by a doctor employed by the insurance company) concluding that the injured party can manage independently.
• An argument that the injured party is already receiving nursing care from national insurance, and therefore additional payment is not necessary.
• Analysis of medical documents reflecting improvement in the injured party's functioning.

Way to Overcome: An independent medical examination by an experienced attorney, a medical specialist with expertise in the area of injury (for example, a neurologist in case of brain injury), and also designation of trial nursing care (a period in which the injured party attempts to function independently to prove they need assistance).

Challenge 2: Insurance Company Claims that Nursing Care Costs are Too High

Insurance companies attempt to reduce nursing care costs, arguing that care can be obtained at lower cost. Their argument may be:

• The injured party can manage with nursing care at ₪60 per hour, not ₪120.
• Nursing care at the injured party's home is cheaper than care in a hospital.
• Nursing care from a close family member (who is not paid) should be cheaper than professional nursing care.

Way to Overcome: Proof of actual costs (contracts with professional caregivers, invoices, price quotes from organizations providing nursing care), medical opinion establishing the level of training required, and comparison to open market costs.

Challenge 3: The Medical Committee Sets Nursing Care Hours Lower Than Expected

The medical committee may decide that the number of nursing care hours is lower than claimed by the injured party and their opinion. This may be due to:

• Another medical opinion testifying to improvement in functioning.
• Different assessment of the type of nursing care required.
• Different discretion of committee members.

Way to Overcome: Filing an appeal against the committee's decision (if such legal option exists), or filing a court lawsuit in which additional evidence can be presented and the committee's medical opinions can be challenged.

Challenge 4: Full Nursing Care vs. Partial Nursing Care

Insurance companies sometimes argue that the injured party can manage with partial nursing care (for example, help with nutrition only) instead of full nursing care (assistance with all activities). This significantly affects the amount of compensation.

Way to Overcome: Close monitoring of the injured party's functioning in daily life, documentation of specific difficulties, and detailed medical opinion describing all activities in which the injured party requires assistance.

Legal consultation in nursing care claims — why is it essential?

A claim against an insurance company for nursing care is not a simple task. Insurance companies handle claims daily, and some attempt to reduce compensation in every possible way. Without professional legal consultation, it is easy to lose important rights or agree to an amount lower than deserved.

An attorney experienced in nursing care claims can:

• Review your policy and identify all possible coverage avenues
• Gather medical documents and create a strong claim file
• Negotiate with the insurance company on your behalf
• Present independent medical opinions to counter the insurance company's arguments
• File a legal claim if no settlement is reached
• Represent you before a medical committee or in court

At Mandelbaum, Gor, Witzman-Gor and Co., Attorneys at Law, we specialize in representing claimants exclusively in the field of tort law, including nursing care claims. With more than 18 years of experience, we know how to negotiate with insurance companies and obtain fair compensation for our clients. The first consultation meeting is free of charge, and we will be able to evaluate your case and suggest a course of action.