Moore hiked Nepal's Annapurna Range with hundreds of mountaineering enthusiasts from all over the world (Photo: AP)
Young Israeli Mor Sapir will never forget October 2014. Sapir, a fierce young Israeli who served in the IDF as a combat engineering officer, was hiking the Annapurna range in Nepal at the time with hundreds of mountaineering enthusiasts from all over the world. Unfortunately, however, the hikers were trapped in a huge avalanche, and dozens of climbers perished, including four Israelis. Moore himself made his way from the disaster area with his bare hands, suffered severe frostbite, and doctors had to amputate all ten fingers of his hands.
He rehabilitated himself wonderfully, began to professionally engage in wall climbing, and even became a world champion in climbing. Before the accident, Mor purchased a long-term care insurance policy from Harel, and after rehabilitation he filed a claim with the company to realize the insurance, but the company rejected his claim and he had to file a claim in court.
The ruling in his case (Tel Aviv Shalom Herzliya, 43934-02-17 Sapir v. Harel), which reveals his struggle with the insurance company, is probably the most well-known ruling in the field of long-term care insurance. But before we get to it, let's say a few words about long-term care insurance.
Caution, increase in life expectancy In recent years, there has been a steady increase in life
expectancy. Our living conditions are better than ever, medicine is able to cure diseases that were considered incurable, and the pharmaceutical industry is developing vaccines for almost every disease. As a result, we are extending life more than ever before.
This news is great, but the flip side is that the older we get, the greater our risk of being in a nursing situation. The bottom line is that because of increased life expectancy, our risk of becoming a long-term care provider is greater than ever.
No one wants to become a burden on their family at an older age, hence the great importance that many see in arranging long-term care insurance at an early age.
When a person becomes a long-term care provider, he can apply to the National Insurance Institute for a long-term care benefit. The National Insurance Institute pays the benefit to those who are no longer of working age and are in a long-term care situation, while the benefit is contingent on income. For example, an individual whose income ranges from NIS 11,431 to NIS 17,145 is entitled to receive only half of the benefit.
When a person applies to the National Insurance Institute for a Long-Term Care Benefit, the institution checks his functional and mental state and sets a score for him, according to which the level of nursing care is determined for him. In other words, the number of nursing hours to which he is entitled (with part of the benefit being exchanged for money).
It should be noted that the Long-Term Care Benefit provides only a partial solution for those in a long-term care situation. There are those who are not entitled to it due to high income, and in any case most of those entitled to the benefit are not satisfied with it.
HMO policies are not enough
Most Israelis who want an additional layer of protection, beyond that of the National Insurance Institute, purchase a long-term care insurance policy from an insurance company. Group long-term care policies can be purchased through the health funds or through large workplaces or large committees. Another option is to purchase a personal long-term care policy directly from one of the insurance companies.
Group policies purchased through a workplace or workers' committee are usually preferable (in terms of premium amount, amount and insurance period, and other aspects), since they are the result of bargaining by a large and powerful economic entity that represents hundreds or thousands of customers vis-à-vis the insurance company.
The most common long-term care policy is the one purchased through the supplementary insurance of the health funds. It's a cheap policy, so almost everyone buys it. The relatively low cost is achieved through an insurance period usually limited to only five years, and through a fairly modest insurance amount - NIS 3,500 to NIS 5,500, depending on the date of purchase of the policy.
Since patients are often in a long-term care situation for more than five years, the coverage provided by this policy is often insufficient. For this reason, many purchase policies directly from insurance companies. These are usually expensive policies (compared to the group policy), but the monthly payment amount is larger and the payment period is longer.
In long-term care insurance there is no problem of double insurance, and therefore there is no prevention Purchase several policies and thus increase the amount of payment in the event that, God forbid, the insured becomes a long-term care provider.
The insurance company's attempt to shake off the climber
from implementing a long-term care insurance policy is possible in two cases: cognitive deterioration referred to in the policy as "mental exhaustion" (when a person loses orientation in place and time, his short-term memory is impaired and his judgmental ability is impaired) or functional deterioration.
A long-term care insurance policy defines six daily activities (getting up and lying down, dressing and undressing, bathing, eating and drinking, controlling lockdowns and mobility). An inability to perform three of these actions substantially enables the policy to be activated. Most of the legal discussions between insurance companies and policyholders concern these actions.
The exact same happened in the case of climber Mor Sapir, which we mentioned at the beginning. As mentioned, Mor had long-term care insurance in Harel and filed a claim to realize the insurance, but the insurance company claimed that he was not a nursing person.
According to her, Moore could, for example, have dressed on his own. Although he was unable to button or close a zipper due to the loss of his fingers, he could wear clothes without buttons or zippers, adapted to his abilities.
The company also claimed that Moore was able to bathe on his own. Although he couldn't open a bottle of liquid soap or shampoo, he could use body washers suitable for his condition.
The company further claimed that Moore could eat himself. While he can't cut the food to eat, he can eat ground food in a blender.
All these arguments were rejected by the court. He ruled that they violate the human dignity of the insured as a person, and that once a person cannot perform the basic daily activity like any other person, he must be provided with help to carry it out, and therefore in Moore's case there is an "insurance case."
How can an Alzheimer's patient even be aware of his condition?
In any case where a person purchases a long-term care insurance policy, the insurance company underwrites him, in the framework of which it asks him to disclose details regarding his medical condition.
Section 6 of the Insurance Contract Law requires every policyholder to provide a full and honest answer to the insurance company's questions, and states that deliberately concealing information is tantamount to giving an incomplete and honest answer.
In addition, section 7 of the law states that when a policyholder provides an answer that is not complete and honest, the insurance company is exempt from partial payment of the insurance premiums. In the event that the answer (or concealment) was fraudulent intent on the part of the insured (or the company would not have issued him a policy had it known the real situation), the company is fully exempt from payment.
Insurance companies consistently try to take advantage of these clauses to evade payment. This was the case, for example, of Victoria Behar, an elderly woman who purchased a long-term care insurance policy at the age of 84. The insurance company mailed Victoria a questionnaire about her medical condition.
Naturally, Victoria answered "no" to all the questions she was asked and returned the form to the company. Unfortunately, after a few years she became a nurse, probably as a result of Parkinson's disease and dementia, which were not diagnosed in a timely manner.
The insurance company checked Victoria's medical condition and found that she suffered from high blood pressure and heart disease, while in the medical questionnaire she indicated "no" when asked if she had these diseases. The insurance company rejected the claim on the grounds that Victoria had concealed details from her that, had she been aware of them, would not have agreed to issue her a policy.
Victoria filed a lawsuit with the court (TA 047015/01 (Shalom Tel Aviv) Behar v. Hadar), which ruled that there was no concealment of information on the part of the insured. The ruling stated, among other things, that at the age of 84, almost everyone suffers from various diseases, but he does not perceive himself as sick.
Moreover, at such an age, the insurance company must ask the insured for his medical records and check his condition for itself. If she does not do so and checks the medical condition of the insured only after the insurance incident, hoping to find a reason exempting her from payment, this is bad faith conduct.
Among other things, the verdict revealed that one of the questions Victoria was asked to answer was whether she suffers from Alzheimer's. The court noted that if a person suffers from Alzheimer's, there is a high chance that he is unaware of his condition and therefore no significance can be attributed to his answer.
Don't be tempted by promises from companies to exercise their rights
When a person finds himself in a long-term care situation and does not have the time or patience to deal with the bureaucracy of the insurance company or it rejects his claim, there is no reason to give up or despair. Instead, you can seek the advice and assistance of a professional.
There are many companies engaged in exercising rights that advertise themselves aggressively, but these companies cannot file a lawsuit in court, but only "bombard" the insurance company with medical documents, hoping that it will change its mind regarding the insured.
Experience shows that the most efficient and fastest means of realizing the policy, when the insurance company insists on rejecting the claim, is to take legal measures. For this reason, the correct way to deal with the insurance company is to contact a lawyer specializing in the field, so that he will handle the submission of forms to the insurance company and, if necessary, file a claim against it in court.
The insurance companies, it turns out, are not enthusiastic about managing long-term care insurance cases in court, and as a result, they can reach a compromise in these cases within a relatively short time.
Need assistance with the insurance company in activating long-term care insurance? Contact us hereor by phone at 053-9374940For an initial consultation with David Yadid - Law firm and notary, with decades of experience in the field of law firm and notary David Yadid did not represent in
Mor Sapir's case mentioned in the article.<B137>
To the firm's website To the firm's page on the legal website Article courtesy of Zap Legal
The information presented in the article does not constitute legal
advice or a substitute for it and does not constitute a recommendation to take proceedings or refrain from proceedings. Anyone who relies on the information appearing in the
article does so at his own risk
Advocate and Notary David Yadid and Adv. Doron Atsmon, in cooperation with Zap Legal
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