An insurer eventually approved an insured woman's long-term care claim, but set the start of her entitlement at the date of a urology exam it had itself requested, about eight months after the claim was filed. The small claims court held that her care-dependent condition was proven from April 2025 and ordered the insurer to pay a further ILS 22,400 plus costs.
What happened
The insured woman was covered by a group long-term care (nursing) policy. Under the policy, an insured person living at home in a care-dependent condition receives a monthly benefit; in her case, because she joined after age 60, it was ILS 3,200 a month. A qualifying condition is defined, among other things, as being unable to perform on one's own a substantial part of three of six daily activities, one of which is continence control. The policy also sets a 60-day waiting period during which no benefits are paid.
At the end of March 2025 the insured woman was hospitalized and diagnosed with a serious illness, and a long-term care claim was filed. In July 2025 the insurer sent a nurse for a functional assessment, who found that she needed help with only some activities and was independent in continence control. At the end of that month the claim was rejected. The family disputed the findings, and her son filed an appeal in August 2025, after she had undergone major surgery and her condition had worsened. At the same time, the family submitted a decision of the National Insurance Institute recognizing her entitlement to a long-term care allowance from 1.5.2025.
Only in November 2025 did the insurer ask for a report from a urologist. The report was submitted on 2.12.2025, and in January 2026 the insurer approved the claim, but fixed the date of the insured event as the day of the urology exam. The insured woman sued for ILS 38,000, asking the court to rule that her entitlement began on 30.3.2025.
The parties' arguments
The insurer argued that the claim should be dismissed outright because she had not attached a medical expert opinion. In its view there was no objective evidence of a qualifying condition before December 2025, and National Insurance decisions are based on different criteria and do not bind it. Alternatively, it asked that the case be transferred to the Magistrates' Court, arguing that it involved a complex medical dispute.
The insured woman and her daughter testified that the insurer's assessor had not examined continence control at all, and had not even asked about it.
The decision
The court rejected the argument that a medical expert opinion was required. The question here was one of function, meaning what the person can do on her own, not one of medical diagnosis. The policy itself speaks of a functional assessment and does not require a doctor to determine the condition, and the insurer itself had sent a nurse rather than a doctor. The court relied on earlier case law holding that a person's functional condition can be proven through the testimony of family members and caregivers and through medical records, without an expert opinion. An expert opinion is needed where there is a dispute over the causal link between an illness and the condition, and that was not the dispute here.
The court also noted that the policy provides for an appeals committee that must convene within 45 days of an appeal being filed. The insured woman had filed an appeal, and it went entirely unanswered. If the insurer believed the matter was medical, it could have consulted a specialist as part of the appeal and resolved the dispute that way.
On the merits, the court found that the difficulty with continence control was documented in medical records from 29.4.2025, some of them predating the long-term care claim, as well as in the National Insurance assessment. The testimony of the insured woman and her daughter was found credible. The condition may have existed even earlier, but in the absence of records, the entitlement date was set at the day it was first written down: 29.4.2025.
The outcome
The insurer was ordered to pay the insured woman benefits for seven additional months, totaling ILS 22,400, linked to the consumer price index under the policy terms and with interest from the date the claim was filed, plus ILS 900 in costs. A request for compensation for emotional distress, raised only at the hearing and not included in the statement of claim, was rejected. A request for leave to appeal may be filed with the District Court within 30 days.
Key takeaways
- Had a long-term care claim approved? Check the date it applies from. The date the insurer sets is not necessarily the right one.
- Keep every medical record, visit summary and nursing assessment. An early written mention of a functional difficulty can decide when your benefits start.
- You do not always need a medical expert opinion to prove a care-dependent condition. Testimony from family members and medical records may be enough.
- During the insurer's functional assessment, make sure the assessor asks about and checks every activity, and note what was actually examined.
- If the policy has an appeals committee, file an appeal in writing. An insurer's failure to respond can count against it in court.
This article summarizes a published Israeli court decision in plain language and is not legal advice. Every case depends on its facts. The parties' names have been omitted. This is a first-instance decision and may be appealed.
