Submitting a Complaint to the National Health Insurance Law Ombudsman (Right)

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

הקדמה:

All national health insurance policyholders whose rights have been violated according to the National Health Insurance Law, may submit a complaint to the National Health Insurance Law ombudsman (also known as the public complaints commission)
The National Health Insurance Law Ombudsman addresses submissions concerning treatment through The Healthcare Basket, and does not handle submissions concerning the quality of medical care provided, medical malpractice, information under the Freedom of Information Act, etc.
In cases where the ombudsman has approved the provision of medical treatment, the policyholder's health plan must fund it
One can contact other agencies dealing with inquiries from the public health system, but in some cases these inquiries may interfere with the work of the National Health Insurance Law Ombudsman
For more information, see the Ministry of Health's English website

Forms:


  • Patients claiming that their medical rights have been violated according to the National Health Insurance Law by the health plan or a facility acting on its behalf (medical facility, hospital, etc.), may submit a complaint to the National Health Insurance Law ombudsman.
  • The National Health Insurance Law ombudsman is responsible for clarifying if a violation of the National Health Insurance Law occurred in such cases, and reaching a decision.
  • In cases where the ombudsman has approved the provision of medical treatment, the policyholder's health plan must fund it or provide reimbursement if the patient paid for the treatment since the decision was made.
  • The health plans are not required to provide reimbursements for medical treatments paid for by the policyholder before an ombudsman decision was made, even if the treatment was approved.
  • If the ombudsman decides that the law was violated, the health plan is required to act according to the ombudsman's decision.
  • In cases where a service was paid for before the ombudsman's decision, and in cases where the health plan does not honor the ombudsman's decision, the claimant may bring the case before a regional labor court.
  • Health plans are permitted to appeal an ombudsman decision before a regional labor court.

Who is Eligible?

  • All national health insurance policyholders.

Services for which a Complaint May be Submitted to the National Health Insurance Law Ombudsman

  • All healthcare services provided by the health plan to its members, including the following, among others:
    • Eligibility for medications, testing, medical treatment in the various fields (such as rehabilitation, child development, fertility, etc.)
    • The manner of service provision, wait time, etc.
    • Additional Health Services (Supplementary Insurance) provided by the health plans

Matters which the National Health Insurance Law Ombudsman does not address

  • The National Health Insurance Law Ombudsman does not address the following matters: Complaints about the quality of health care, medical staff rapport, Medical Malpractice, and requests for information under the Freedom of Information Act.
  • In these cases, please contact the appropriate professionals to discuss these issues and complaints as elaborated upon here.

How to submit a claim to the National Insurance Law Ombudsman

The letter of complaint and the documents for attachment

  • A written complaint may be sent detailing the problem or complaint, and it must include the patient's name, national identification (teudat zehut) number and contact information, as well as the name of the health plan.
  • The following documents must be attached to written complaints:
    1. Copies of medical documentation supporting the claim. One must ensure that documentation is current.
    2. A copy of the health plan decision if it was provided in writing.
    3. If the complaint is related to payment for a service, receipts must be included.
    4. If the complaint is related to emergency room services, a copy of the emergency room release paperwork must be included
    5. If the application is made through an attorney or another authorized representative, it must be accompanied by a power of attorney form and a waiver of medical confidentiality (without attachment the application will not be processed).

Submitting a complaint letter

  • One can file a complaint through the online form.
  • It is also possible to send the complaint to the ombudsman via email:kvilot@moh.health.gov.il
  • One can also submit their complaint via mail or fax (although it will likely take longer than a submission via email or online.) The complaint must be sent to the following address:
  • The written complaint must be sent to:
Complaints Commissioner, Ministry of Health
39 Yirmiyahu St.
Jerusalem, 9446724
Fax: 02-5655981

Verification Process

  • In cases where the ombudsman decided that the complaint concerning the health services is warranted, and the health plan did not act in accordance with the ombudsman's decision within 21 days of the decision, the insured may contact the General Director of the Ministry of Health to enforce the decision.
  • If the patient purchases healthcare services after and in accordance with the ombudsman decision, the director will order the health plan to issue a financial reimbursement to the patient for the purchase.

Appealing the decision of the ombudsman

  • Health plans and the insured are permitted to appeal an ombudsman decision before a regional labor court.
  • If a complaint submitted to the ombudsman was found to be unjustified, this does not impact that patient's right to submit a claim to the regional labor court.

Appealing to other bodies before or simultaneously

  • In certain cases, one can appeal to other bodies before referral to the ombudsman.
  • Preliminary referral to other bodies may facilitate in clarifying the complaint to the ombudsman, but in some cases, it may impact negatively upon the insured or even prevent the ombudsman from handling the complaint.

Complaints of non-approval of treatment or service which according to the insured is included within the healthcare basket

  • Complaints of non-approval of treatment or service which according to the insured is included within the healthcare basket can refer to Submitting a Complaint to the Health Fund.
  • In such a case, preliminary referral to the Health Fund could help solve the immediate problem and obviate the need for addressing the ombudsman.
  • If the Health Fund does not approve the provision of treatment, one can file a complaint to the ombudsman.

Inquiries about medications or treatments not included in the health basket

  • Inquiries about medications or treatments not included in the health basket can must be submitted to the Health Care Exception Committee. The ombudsman has no authority to order the health fund to grant treatment which is not included within the health basket.
  • However, when there is a dispute whether the treatment is included in the health basket or not, the ombudsman is responsible for determining if the treatment is included and subsequently can insist that the health plan provide the treatment. This is in contrast to the Health Plan Exception Committee, who is not empowered to determine this, but rather can exercise it's opinion in determining if in the specific case treatment should be provided despite not being included in the healthcare basket.
  • In cases where there is a dispute whether or not medication or treatment are included in the healthcare basket, one should initially contact the ombudsman. If it is decided that the treatment is not included in the basket, one can then turn to the Health Plan Exceptions Committee with a request to provide the medication or treatment not included in the healthcare basket.
  • The ombudsman encourages the submission of complaint in cases that treatment or medication is not included in the healthcare basket, as this helps in enabling the submission of a recommendation to the Health Plan to expand the service or treatment to be included in the healthcare basket.

Appealing to the Labor Court

  • The Labor Court is the only court competent to judge a case between the insured and the medical institution, medical service providers, or the Ministry of Health regarding the right to receive medical care or financing it.
  • One can contact the court directly without previously contacting the ombudsman.
  • Once one has appealed to the Labor Court, the Ombudsman no longer has the authority to deal with the appeal.

Inquiries on issues the ombudsman is not empowered to handle

Important Information

  • One can seek assistance of an attorney or proxy at the time of application. In this case, one is obligated to attach to his/her submission a power of attorney form and a waiver of medical confidentiality.
  • In certain circumstances, one can receive free legal assistance.
  • The authority to enforce decisions is given to the ombudsman when the insured purchased the service or medical treatment after submitting the complaint. If the service or treatment is acquired before the filing of the complaint, the health fund can approve retroactive reimbursement, but does not guarantee such.
  • The ombudsman encourages the submission of complaints even if that the treatment is not included in the basket and there is a chance that the request will be rejected. Submission of the complaint may increase the chance that the health fund committee, who determines which service or treatment is retained in the health basket, will include treatments or medicines that have accumulated numerous complaints the following year.

Aid Organizations

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

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