Proven preventive treatment against disease?
Not sure if your cover has it/ShutterStock
The position of the insurance companies, Fenix and Harel, not to apply the health insurance policies to preventive surgeries, was recently discussed in the Supreme Court as part of an appeal filed in a class action and was rejected.
The interpretation cast by the court for the definition of "surgery" will now include prophylactic surgeries, something that until today the insurance companies rejected outright in the claims of the insured.
This determination has far-reaching consequences for the existing insured and new insureds who will now have to follow the renewed definitions and premiums of the insurance companies that are expected to change following this ruling.
In case REA 3515/22, The Israeli Phoenix Insurance Company Ltd. and Harel Insurance Company Ltd. against Gali Alon Bover, a case was discussed in which a healthy woman who discovered that she was a carrier of a cancerous gene requested to undergo surgery in order to avoid the development of cancer early and her claim to the insurance company was rejected.
Both insurance companies argued that they should not be held liable under the circumstances of the case since policies of this type are not intended to insure theoretical disease states and one can be satisfied with treatment alternatives other than surgery. On the other hand, the insured claimed that the assessment of disease risks on which the policy is based must include preliminary treatment, Because if a disease breaks out, the cost of treating it will be immeasurably expensive. In the case in question, the insured is included in a risk group of between 50-80 percent of having breast cancer and ovarian cancer at a risk of 40 percent.
How will the court decision affect your coverage?
Under the circumstances, prophylactic surgery for excision may significantly reduce the probability of morbidity by between 90-95 percent for ovarian cancer and 50 percent for breast cancer.
The insurance companies believed that one should wait for the outbreak of the disease in order to obligate them, while the insured believed that this refusal meant a breach of contract and a cynical exploitation of the vague definition that the average insured was not aware of at the time of signing the policy.
The court accepted the position of the insured and in light of the changes that the insurance companies introduced into the new policies specific definitions for preventive analysis, this position was strengthened.
The inspector of insurance, he also expressed his opinion before the court and claimed that the term "surgery" in the discussed policies is a broad clause that includes preventive surgeries, and as evidence can be found on the way of the negative the explicit exclusion of aesthetic surgeries from the policy.
In light of this interpretation, it seems that there is room for re-examination and periodic updating by the insurance companies of the policy wordings that appear in the standard coverages, thus preventing misunderstanding or conflicting interpretation on the part of the insured.
On the other hand, the insured must be vigilant and check the coverage in the new insurance policies they join.
And of course, it is recommended to get professional advice in order to avoid misunderstandings.
Adv.
More on the same topic:
Private health insurance
breast cancer
Ovarian cancer