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Private Health Policies

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Major changes were implemented by the government health reform in February 2016.

The main change determined that coverage in all policies issued from February 2016 onwards would be upgraded automatically every two years without a declaration of health being required. 

Operations 

Operations in Israel

Policies issued prior to February 2016 allowed you to use surgeons on the insurance company's list or a surgeon of your choice.
If the surgeon is on your insurance company's list of surgeons, the payment would be made directly by the insurance company to the surgeon and the private hospital.
If the surgeon is not on the list of your insurance company, payment would be made by the insurance company directly to the private hospital, and you would pay the surgeon and be reimbursed up to the level of coverage paid by insurance company to surgeons on their list performing similar medical procedures.

In policies issued after February 2016, the choice of surgeon is only from the designated list of surgeons working with your insurance company. This is in accordance to the change in the law no longer giving coverage for any surgeon of your choice.
This change leaves NO grey area – If the surgeon used is NOT on the list of surgeons, NO payment will be reimbursed. All authorizations have to be issued prior to the procedure.

Preventative surgery in policies issued after February 2016 is covered. In policies issued prior to February 2016 preventative surgery is NOT covered. Examples of preventative surgery - Bariatric band for weight loss, mastectomy for BRACA 1 carriers etc.

Medical devices implanted during surgery
In policies issued prior to changes in the reform at the end of January 2016 the maximum coverage per medical implanted devices used in surgery is approximately NIS 20,000.
In policies issued from February 2016 the maximum coverage per operation is approximately NIS 80,000.
For example: stents for heart surgery, orthopedic devices used in hip and knee replacements etc.

Operations worldwide
There have been no major changes under this section of the policy.
In the event of an operation abroad, hospitalization and surgeon's fees are covered in full. If hospitalization for surgery is more than 10 days, accommodation and travel expenses for the patient as well as an accompanying member of family would be covered for up to 30 days.

Alternative technologies and medical procedure replacing operations
In recent years, new technologies, alternative surgery procedures and medical implanted devices have become more accessible to people with comprehensive private health policies. These expensive, less invasive procedures, reduce considerably hospitalization and recovery time. Two examples are the Da Vinci and the Mako robotic assisted surgery procedures, which use a minimal invasive surgical approach.
The Da Vinci system is used mainly for removing prostrate tumors, cardiac valve repairs and in recent years, other complicated surgical procedures.
Mako is used mainly for knee and hip replacement carried out robotically.

Medication not in the government package
Policies pre February 2016 and after February 2016 have coverage for points "A' to "D" below.
The main difference is that future technological and pharmacological discoveries and/or increase in level of coverage in policies issued after February 2016 which are automatically upgraded without the need of a health declaration.

Coverage only in policies issued after February 2016.
1. Coverage for personal adapted medication, point "E" below
2. Medication based on personal genetic screening

What do private medication policies actually cover? 

Medication not in the government package needed for a medical reason:
  • Medication which has been approved for use in Israel, the US, EU and 6 additional western countries
  • Medication which has been approved for use in the USA, EU and 6 other western countries, but NOT for the specific use that you are applying for. Eg. Avistan is a medication in the government package accepted for ovarian cancer. This same medication has also been proven successful for reducing the size of brain tumors, is NOT in the government package of medications for brain tumors. Your private medical policy would cover the medication in the event of a brain tumor.
  • Off-label medication for any disease. This is medication not yet approved for the required use, however, has been recognized as effective in treating the insured's condition.eg. Medication in trial period, not yet approved by FDA.
  • Orphan medication – medication used for very rare illnesses.
  • Personal adapted medication – medication found to be effective for the patient, based on genetic testing. This would be accepted if the medication has not yet been approved for use, but a senior medical professional has determined that treatment would be effective, based on two recognized scientific publications that the medication is suitable for the patient's condition.

Genetic screening to find most suitable medication for treatment
In policies issued from February 2016, this coverage falls under the medication section of the policy. It allows for genetic testing to identify the best form of treatment for a cancer patient. This saves valuable time, and prevents the use of medications that are not effective.
The level of coverage for genetic tests is approximately NIS 30,000.

Ambulatory coverage (diagnostic tests and consultations)
Generally speaking, tests and consultations in policies issued prior to Feb 2016 covered a specific list of diagnostic tests. After Feb 2016, it becomes an "open" list covering ANY diagnostic tests costing more than NIS 250.

Most of these changes, together with additional changes expected to be implemented in December 2022 will change the face of private medical insurance for years to come. Keeping in line with the technological developments, automatic upgrades is and will be a big advantage in the new policies.

I recommend consulting with a professional in the field to check that your policy is in line with the most updated level of coverage, giving you peace of mind in the years to come.

Wishing you a Shana Tova and good health in the coming year.

Mark Joffe is an Independent Insurance Agent 

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Thursday, 06 October 2022

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