Health fund cannot refuse your request for services, says Knesset

Many health fund members have been turned down for such services without being given any explanation and details about how to complain to appeals committees.

The four public health funds will be forced to provide detailed reasons in writing for refusing to provide members with a treatment or medication and clear information on how to appeal their refusals, according to a bill approved by the Knesset Health Committee on Tuesday.
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Many health fund members have been turned down for such services without being given any explanation and details about how to complain to appeals committees.

The change was initiated by committee chairman Yonatan Mishraki (Shas). The obligation to provide detailed reasons already exists in the procedures of the health insurance funds and in the circulars of the Health Ministry’s director-general, he said, but since this obligation is not enforced, it must be anchored in legislation.

Reason for refusal

“Many times, the health fund’s response to an insured person’s request for health services is updated in its systems without providing the insured with a detailed explanation of the reason for the refusal,” Mishraki said. “Sometimes, the response is sent by the HMO’s confirmation center based on partial information available to it, when the insured or their doctors do not know what is the reason for the refusal of the request.

“In the absence of a detailed explanation for the refusal, it isn’t possible to hold a dialogue with the administrative body in charge of making the decision at the cash register or to know what additional relevant information must be transferred for the purpose of checking eligibility.”

“The change will allow the insured to clearly understand the decision and its reasoning, to return to the care provider and examine whether the criteria for receiving the service are met in the patient’s medical condition, whether there are other treatments suitable for him in the basket, or if any information is missing from the request and only for this reason was a refusal notice from the fund,” he said.

In addition, a reasoned answer in writing will make it easier for the insured to obtain it before the internal mechanisms of the fund or to file a complaint with the ombudsman, Mishraki said.

Dr. Kalanit Kay is the commissioner of public inquiries at Clalit Health Services, which as the largest health fund insures about half of the population. In most cases, she said, the refusal is caused by insufficient documents, a lack of information, the need for an expert’s opinion, or the failure to include the requested medicine in the health basket.

“In any case of refusal, the insured is offered an alternative to the service or medicine he is requesting or can contact the district clinic,” Kay said, adding that the amendment would force the health funds to develop additional computerized systems and could lead to information leakage.

Shir Cohen, vice president of Maccabi Healthcare Services, the second-largest insurer, said the change would lead to a need for computerized development for a reasoned response in writing, including a budget and the recruitment of skilled personnel.

Meuhedet Health Maintenance Organization said it would need a computerized development of about a year before it could implement the change.

Gennady Zaslavsky, director of information systems development at Leumit Health Care Services, said every answer would take up the doctors’ precious time when forced to write it down.

Lior Barak, the Health Ministry’s deputy director for supervising the health funds, said the cost of developing a computerized system was negligible, and in any case of refusal, it was mandatory to offer an alternative.

Shmulik Ben-Yaakov, chairman of the Association for Patient Rights, said the change would fill an urgent need, and a reasoned explanation in writing will save the need for a visit to the emergency room and a waste of time for the patient and the doctor.

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