long-term care insurance – what is it and how can you file a clame?

More than half of the citizens of the State of Israel, women, men, the elderly and infants, are insured by an A long-term care insurance. Therefore, as most of the readers of this article are insured by A long-term care insurance policy let’s understand what it is all about.

A long-term care insurance policy is a policy which should guarantee that when we are in a nursing condition and need increased help from others in the basic operations, the insurance company will pay us a monthly stipend – a sum of money which will help us and in the best way possible to survive the difficult life anticipated for a nursing person
In the previous paragraph several terms were written that require clarification: what is the definition of an nursing condition? What are basic functions? What is the extent of the monthly stipend? For how long will the stipend be paid? We will attempt to provide answers for those questions hereinafter.

Most of those insured with a nursing policy drew up the insurance policy through the HMO with which they are insured. However the HMOs of course do not carry insurance but rather serve only as a pipeline that transfers hundreds of thousands of its members to one insurance company or another, who will be required to work with the insurance company when an insurance incident occurs. It shall be emphasized that the HMOs have no insurance liability vis-à-vis the insured and all his requests, as aforementioned, must be referred to the insurance company which drew up the insurance policy in his favor.

The insurance cover within the framework of these policies is uniform: both as regards the duration of the insurance term (60 months) and as regards the monthly stipend paid pursuant to the policy (dependent on age and situation).

There are, of course, private or collective insurance policies, in which the term of the compensation can also change (including policies that award life term compensation) and also the extent of the compensation.

What is a long-term care insurance case?

 The definition of nursing insurance incident (a situation that awards a monthly stipend) is identical in all the types of policies: either the long-term care insured is not capable of carrying out alone (at a level of 50% of the function) 3 of 6 of the basic functions defined as the ADL functions (eating, washing, dressing, getting up, mobility and continence) or he is defined as mentally frail.

FOR HOW LONG WILL THE STIPEND BE PAID?

 As aforementioned, the majority of the policies define the maximum period of time for receipt of the monthly stipend. The majority of the stipends note a time framework of 60 months (five years) whereby this is a “bank” of months. That is to say, the insured has eligibility throughout his lifetime to receive a stipend of 60 months, whereby the framework of the time does not have to be consecutive, however each month for which the insured has received compensation is offset from the overall total of months.

There are also (relatively inexpensive) policies in which there is a “waiting period” of 60 months, the objective of which is to constitute another and complementary layer over the basic policies, which are in the main part, as aforementioned uniform and marketed through the HMOs.

WHAT IS THE OBSOLESCENCE PERIOD OF THE NURSING INSURANCE?

 The obsolescence period for the nursing insurance is 3 years (alike every insurance claim), however “the insurance incident” (that is to say the point of time from which one starts to count the obsolescence period) is each and every month, that is to say at any given moment one can claim 3 years retroactively and then there will be eligibility for retroactive compensation.

SO WHAT DO WE DO?

 When an insured person is in a nursing condition, he needs to fill out a claim form to the insurance company, attach to it all the relevant medical documents and wait for a representative from the insurance company to come to his home to examine him. The insurance company will send a physician or other medical practitioner with the relevant proficiency, who will examine the insured’s condition. The examination will focus on the definitions of the policy as to the insured condition. The insured will be examined as to his ability to carry out the basic functions defined as ADL functions (eating, washing, dressing, getting up, mobility and continence) and his cognitive condition will be examined pursuant to tests and the definition as to being “mentally frail”.

Thereafter, the insurance company shall advise of its position and inasmuch as the insured shall be recognized by the insurer he shall be eligible for a monthly stipend.

Unfortunately, in many cases the insurance companies abuse their power and attempt by various means to evade their duty to the insured, however we will discuss this in the next article.

The information in this article is general information only and does not constitute a legal opinion or a substitute for legal advice.

(This image is for demonstration purposes. Photography: unsplash)