Appealing to the Health Plan Exceptions Committee (Right)

From All Rights (Kol-Zchut) (www.kolzchut.org.il)

הקדמה:

Health fund policyholders requiring funding for treatment not included in the healthcare basket are entitled to appeal to the health fund's exceptions committee to request approval for the treatment
The committee is required to consider every claim brought before it and provide a detailed, reasoned decision to the applicant
The committee is required to reveal all documents related to the decision before the applicant
Those appealing to an exceptions committee are entitled to do so with the assistance of an attorney or an authorized representative for purposes of the appeal

The health funds are not obligated to fund treatment not included in the healthcare basket. Applicants requiring treatment not included in the basket, have the option of appealing to their health plan's exceptions committee.

  • The exceptions committee is part of the health fund and is composed of a number of health fund employees, some of which may be Doctors. The purpose of the committee is to consider requests for assistance beyond that which is required by law, and it has the authority to consider and decide regarding the provision of services that are not included in the healthcare basket for health fund policyholders.
  • The committee must make decisions according to the law, without discriminating against applicants in any way. Accordingly, the committee must perform a thorough, defensible and systematic examination of all requests before making a decision. The committee gathers and summarizes all relevant information, examines the significance of the information which is gathered, checks alternative solutions and provides the applicant with a reasoned decision. All of the committee's documents are supposed to be available for the applicant to view.
  • The health funds do not require applications to the appeals committee in the following cases:
    • The exceptions committee has previously discussed a similar case and decided not to approve the treatment. (In this instance the health fund is allowed to disapprove all similar cases without taking the individual cases to the appeal committee.)
    • If a forum of the health fund that is not the exceptions committee has ruled on the incorporation of a certain technology into the routine operations of the health fund, without relating to this specific instance, yet the issue of the policyholder makes no difference from the types of instances discussed by the forum. (In this case they will act according to the conclusion of the forum.) However, the health fund is forbidden to prevent the presentation of an instance before the exceptions committee merely because there is a possibility of a future forum decision, when no date has been set for the discussion, or the wait will be long enough that it will mean an unreasonable delay in beginning the treatment.

Who is Eligible?

How to Claim It?

  • Applicants must submit a written request to the exceptions committee in which the reasons they are requesting the treatment not included in the healthcare basket are detailed.
  • All relevant documentation must be attached to the written request such as:
    • Doctor recommendations regarding the requirement of a specific medication/surgery/other medical intervention or treatment
    • Receipts
    • Medical documentation
    • Professional medical opinions
    • Prior correspondence with the health plan and/or Ministry of Health officials, and documentation including other relevant information (for example, documentation indicating that the medication is provided to other health plan policyholders).
  • Written requests may be submitted to the offices of the policy holder's health fund branch. For more information (In Hebrew):

Please Note

  • Applicants are entitled to have an attorney or an authorized representative to represent them before the committee.
  • Exceptions committee decisions may be appealed by filing a claim in regional labor court.
  • In some cases, free legal aid is available.
  • Policyholders are able to appeal to the exceptions committee with requests for nonlife saving treatments.

Court Rulings

Aid Organizations

  • For a comprehensive categorized listing of healthcare organizations offering assistance and support, click here.

Government Agencies

Laws and Regulations

Sources