By Shmuel Weinstein
For one living in Israel and wanting top quality medical care, it is usually unnecessary to travel abroad to receive it, as Israel is a country where advanced medical care is available. In fact, Israel does a lively business catering to the medical needs of wealthy foreigners who choose to come here to receive high quality medical care.
This is not true though regarding organ transplants, as very few such operations are carried out in Israel due to lack of donors. The budget allocated by the government to send people abroad is not enough, and tragically approximately one hundred people per year in Israel die while waiting for approval to go abroad for a transplant.
This is an example of the downside of socialized medicine. There are needs beyond the budget’s ability to provide, at least at its current level. Politicians must choose how to best allocate the insufficient funds. Another example which is always the subject of budgetary debate is medications, and only those medications approved for specific conditions will be subsidized by the government. Other medications, though they may be lifesaving, are not approved because their cost/benefit ratio has been deemed too high for society as a whole, and their use is not funded by the government.
Such is the situation that the resident of Israel who relies solely on the Israeli public health care system finds himself in. The Israeli public health care system is based on the National Health Law, which defines a basket of medical services that the government undertakes to provide to all residents. The law is administered by the Israeli health funds (Kupat Cholim), who in turn offer their members a second tier of supplemental health coverage (Shaban) for a fee.
Although the Shaban plans provide some coverage, it is only a private health insurance plan that provides coverage for the problems just discussed (transplants and medications). Furthermore, only one who owns a full private health insurance plan (or someone with very deep pockets) will have access whenever the need arises to the advanced medical care that Israel has to offer and will have the ability to choose to go abroad (when he has concluded that it is medically advisable and without the need for an approval committee to review his case) for medical treatment.
Below are some of the major coverages that should exist in a full private medical insurance plan. All coverage has its limits and exclusions. Deductibles may apply. You should find this out from your insurance agent before you purchase a policy.
Private surgery in Israel
Coverage should include your ability to select the surgeon, the anesthesiologist, and the hospital for all medically prescribed operations. There should be full coverage with no deductible if the surgery is performed by a surgeon who is contracted with the insurance company. If the surgeon does not have a contract with the insurance company, the company should reimburse you the full amount that they pay to their contracted surgeons. The coverage should provide reimbursement for the initial consultation before the surgery. Check that prosthetics are covered and what limits apply.
Private surgery abroad
Coverage should include your ability to select the surgeon and the hospital of your choice for all medically prescribed operations. The coverage should include all the expenses related to the hospitalization and the surgery.
Transplants and other special treatments abroad.
The list of covered transplants should be as extensive as possible. All companies set a limit if you use a transplant center out of their network.
The ability to receive special treatments abroad should include non-surgical treatments and should be provided when there is a higher likelihood of success abroad or if the wait time in Israel seriously endangers the health or life of the insured.
Non invasive treatments
These are high tech alternative treatments to invasive surgery that produce similar results.
Medications which are not included in basket of health services.
The coverage should include the following medications:
- Medications approved for treating the insured’s condition but excluded from the government health basket.
- Medications that are included in the health basket but only for the treatment of a different condition.
- Off label medications – medications not approved to treat this condition, but have been proven effective in treating it.
- Orphan medications – medications developed to treat a rare disease.
The coverage should include reimbursement for visits to specialists, diagnostic tests, and a battery of other medical tests and services.
Budgetary considerations make it difficult to get approval for certain diagnostic and other medical tests from the health funds and even if approved, the wait time can be months. Having this coverage allows you to bypass health fund approval and brings you to the front of the line. This coverage requires an additional fee.
Medical management and medical advice in cases of major medical events.
Again, the above is a condensed list. There are a number of additional important coverages that may be included with the policy or available for purchase. Ask your insurance agent about which companies he represents and the different options that are available.
While each insurance company has its own product line, the following is true for all policies:
- Unless agreed otherwise in writing, the policy will not cover anything related to pre-existing medical conditions. Depending on the condition, the age of the applicant, and other factors, the company may be willing to cover a pre-existing condition for an additional premium.
- New applications have to be submitted when children are born and the insurance company will evaluate their application just as they evaluate the application of every new applicant. They have the right to refuse any applicant, and applicants with serious health problems may not be accepted for coverage.
- All policies have a waiting period of 90 days from the start date of the policy. The waiting period serves also as a trial period; any condition that develops in the first 90 days will be considered pre-existing and excluded from coverage. Caesarian operations have a 12 month waiting/trial period.
- All treatment must be coordinated in advance with the insurance company.
Regarding price, let your insurance agent know if you have the second tier of coverage from the Kupat Cholim (Shaban) as many companies offer a discount if you do. Also, don’t just look at what you will pay today. Look at what the rates will be as you and your family grow older.
While the cost of owning a full private health insurance plan is quite reasonable, the Israeli insurance companies also offer a type of “catastrophic” health insurance plan for those whose budgets do not afford them the ability to purchase a full plan. A “catastrophic” plan should at a minimum cover private surgery abroad, transplants and other special treatments abroad, medications which are not included in basket of health services, and medical management in the case of major medical events.
If you’ve concluded that having private health insurance is a good idea, I encourage you to contact a qualified and experienced insurance agent right away while everyone is healthy and insurable.
The information appearing in this article is of a general nature only. The only legally binding language is that found in the insurance policy conditions.
Shmuel Weinstein is the General Manager of Best Insurance Agency (2013) Ltd.
He has been a licensed insurance Agent in Israel since 1989
He can be reached at 02-6519343 or through his website: israelinsuranceagent.com