Macabi Long Term Care

Group long-term care policy for members of Maccabi Healthcare Services
Dear Member, I am happy to tell you that we have created a new long-term care insurance policy for you, giving you more rights and considerably increasing the financial scale of the cover provided. The new long-term care scheme is considered to be the leading and most comprehensive insurance of its kind in Israel, and has also received the blessing of the Commissioner of Insurance at the Ministry of Finance. The scheme provides the best answer for patients needing long-term care and the family members supporting them, both in hospital and at home. The new insurance cover is provided by Clal Health, which was chosen by tender and offers both the best quality and most professional service for the insurance cover provided by the new policy, and the lowest monthly premium for the expanded rights. Maccabi Healthcare Services is the Policyholder, and will continue to ensure that you receive full insurance cover and the best and most dedicated long-term care when you need it. If you need long-term care - this policy for Maccabi members gives you security and peace of mind.
Wishing you good health,
Dr. Ehud Kokiya Director-General Maccabi Healthcare Services
Dear Member, I would like to congratulate you on joining the many people for whom we provide nursing insurance cover, through Maccabi Healthcare Services. I believe that you have taken an important and wise decision, one that will give you peace of mind and quality of life in the future. I am happy to present you with this booklet, giving full information about the nursing insurance schemes created specially for members of Maccabi Healthcare Services. In the booklet you will find information about the insurance cover, how to receive the services, how to join, and guidelines in the event of any future claim. Thanks to this insurance policy, you will be able to receive the best treatment and care when you need it. Remember: the Maccabi Long-Term Care call center at Clal Health is available to answer any question you may have, at 1-700-505-520.
Wishing you many years of good health,
Reuven Kaplan CEO Clal Health Insurance Ltd.
Table of contents
Summary of general details about Maccabi Long-Term Care . . . . . . . . . . 6 Group long-term care insurance policy . . . . . . . . . . . . . . . . . . . . . . 12 Insurance premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Useful information on the terms of the policy . . . . . . . . . . . . . . . . . . 36 Individual policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Guide to buying long-term care insurance . . . . . . . . . . . . . . . . . . . . 43 Guidelines for submitting a long-term care claim . . . . . . . . . . . . . . . . 72 * The binding policy is the Hebrew version
Summary of general details about Maccabi Long-term care

Group long-term care insurance policy for members of Maccabi Healthcare Services (in accordance with full disclosure regulations)
Subject
General
Section
Name of Policyholder Insurer Coverage in the policy
Terms
Maccabi Healthcare Services, hereinafter: Maccabi Clal Health Insurance Ltd. Nursing home hospitalization - monthly compensation in respect of the cost of the Beneficiary's stay in a nursing home. Home nursing care for a Beneficiary staying at home - providing nursing services by means of a nursing agency, or fixed monthly payment for the employment of a foreign worker, or fixed monthly payment.
Length of insurance period
From the day that the insured joins the policy until June 30, 2013. With regard to insured members who were covered by the Nursing Fund - from the determining date of July 1, 2008 until June 30, 2013 (the Initial Insurance Period). Subject to the agreement of Maccabi and the Insurer with regard to the necessary adjustments, and the approval of the Commissioner of Insurance.
Subject
Section
Continuity
Terms
At the end of the insurance period, and in the event that the group policy is not renewed or is terminated for any reason whatsoever by the Insurer, wholly or in part, with regard to all or some of the insured parties, and so long as the insurance event has not occurred, the Insurer will contact in writing each insured party or some of the insured parties for whom the policy is not renewed, and who have been covered by this policy for at least three years, and will offer them the option of transferring to a continuation policy within 90 days of the Insurer's notification. The amount of the insurance in the continuation policy will be in accordance with that stated in this policy, and the ceiling of the period of entitlement for nursing payments will be as defined in this policy (60 months). An insured party transferring to a continuation policy will receive a discount of at least 20% on the insurance premium offered by the Insurer at the time for an individual policy with similar terms, for the entire period of the continuation policy. The transition to the follow-on policy will provide insurance continuity (without any health declaration and without repeat underwriting or revision of previous medical condition), with no qualification period. The insured will be entitled to purchase reduced insurance remuneration in the framework of the continuation policy.
Conditions for automatic renewal
The policy will be extended for a period of up to three years, at the sole discretion of the Policyholder, who will inform the insured of this at any time in the course of the Initial Insurance Period, up to a date that is no less than six months None 30 days None
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Qualification period Waiting period Co-payments
Subject
Change in terms
Section
Change in the terms of the policy during the insurance period
Terms
12 months after the determining date, and each 12 months thereafter, the Policyholder will be entitled to ask for changes in the terms of the policy, with the approval of the Commissioner of Insurance, in order to apply changes or conditions laid down in laws, regulations or instructions of the Commissioner of Insurance that are valid at the time. As detailed in the table of premium variables on pp. 34-35 of this booklet. The insurance premiums are known for a period of five years, varying each year in the course of the insurance period according to the age group to which the insured party belongs, and are linked to the known consumer price index (CPI) of July 1, 2008, that is, the May 2008 index published on June 15, 2008. Subject to the authorization of the Commissioner of Insurance, the Policyholder may, at its sole discretion, instruct the Insurer to increase the insurance premium each year, but not before 36 months have elapsed from the determining date. The Insurer will inform all insured parties in advance and in writing. In addition, the Insurer may change the insurance premium beyond the increase in the CPI, if such an increase is necessary as a result of legislation, or on instruction from a government authority, as agreed with the Policyholder. The Insurer and/or the Policyholder may not cancel the policy during the insurance period, other than in the following cases, when the insurance will be cancelled subject to the provisions of the Insurance Contracts Law 5741 - 1981: If the premiums are not paid on time. If the insured party has concealed from the Insurer a substantive fact that would have caused the Insurer not to have accepted him/her into the policy. The insured party may cancel the policy at any time by giving written notification.
Insurance premiums
Amount and structure of the premiums
Changes in insurance premium during the insurance period
Conditions for cancellation
Conditions for cancellation of the policy by the Policyholder or the Insurer
Subject
Exceptions
Section
Exceptions -limits to the Insurer's liability
Terms
Section 10 of the policy.
Exceptions exceptions in respect of a previous medical condition Additions to nursing insurance Definition of the insurance event
Section 11 of the policy.
Poor health and functioning by the insured as a result of illness, accident or defective health, as a result of which he/she is unable to carry out alone a substantial part (at least 50% of the actions) of at least three out of the six everyday activities detailed in the definition of the insurance event, or the insured's poor state of health and functioning due to cognitive impairment (as defined in the definition of the insurance events) determined by an expert physician in this field.
Length of period of insurance payments Type of insurance payments
Up to a ceiling of 60 months.
For a Beneficiary hospitalized for nursing care compensation For a Beneficiary receiving home nursing treatment - home nursing service provided by a nursing agency, or compensation in the form of a regular monthly nursing allowance for employing a foreign worker, or compensation in the form of a regular monthly nursing allowance.
Subject
Section
The amount of the insurance
Terms
For nursing home hospitalization: Silver Shield members - compensation at the rate of 40% of the cost of nursing hospitalization, up to a ceiling of NIS 5,000 a month (section 6.1.1 of the policy) Gold Shield members - compensation at the rate of 80% of the cost of nursing hospitalization, up to a ceiling of NIS 10,000 a month (section 6.1.2 of the policy) For home nursing care: a.Home nursing care from a nursing agency (according to the daytime weekday rates): Silver Shield members - 25 hours nursing care a week (section 7.1.1a of the policy) Gold Shield members - 36 hours nursing care a week (section 7.1.1b of the policy) or b.Compensation in the form of a fixed monthly payment for a foreign worker: Silver Shield members NIS 3,500 a month (section 7.1.2a of the policy) Gold Shield members NIS 4,500 a month (section 7.1.2b of the policy) or c.Compensation in the form of a fixed monthly payment for nursing care: Silver Shield members NIS 3,000 a month (section 7.1.3a of the policy) Gold Shield members NIS 4,000 a month (section 7.1.3b of the policy)
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Subject
Section
Exemption from payment of premiums Scale of insurance premiums The insured party's rights in respect of an increase in premium Paid-up value
Terms
During the period that the Beneficiary is entitled to receive payments, he/she will be exempt from paying premiums. As detailed in the table of premium variables on pp. 34-35 of this booklet. None
None
Connection between the amount of the insurance and the age of the insured Deducting compensation from other insurance policies
There is no connection between the amount of the insurance and the age of the insured at the time of the event, or the age of the insured on joining the policy. There is no deduction in respect of nursing compensation or nursing services provided by the state, including under the National Insurance Law. In the event of other third-party liability - in accordance with the provisions of the Insurance Contract Law.
The binding terms are the full terms of the policy

* The binding policy is the Hebrew version
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Maccabi Long-Term Care

Group long-term care insurance policy for members of Maccabi Healthcare Services
1. Introduction
This policy testifies to the fact that, for payment of the premiums and subject to the terms and provisions and the exceptions detailed below, the Insurer will provide the entitled Beneficiary with a nursing allowance. The nursing allowance will be given in respect of an insurance event taking place during the insurance period, in accordance with that stated in this policy, its terms and restrictions.
2. General definitions
In this policy and any appendix attached to it, the following terms will have the meaning appearing alongside them: 2.1. 2.2. 2.3. 2.4. "The Insurer" Clal Health Insurance Ltd. (hereinafter: the "Company"). "The Policyholder" Maccabi Healthcare Services Ottoman Society no. 227/99 (hereinafter: " Maccabi"). "Maccabi Shield" - Maccabi Shield - Cooperative Society for Mutual Insurance Against Illnesses Ltd. "Member of Maccabi Healthcare Services" - a person who is registered and entitled to receive healthcare services from Maccabi under any law and/or according to the regulations as detailed in the Maccabi Regulations (hereinafter: "Maccabi member"). "Child" - the son or daughter of a Maccabi member, from birth to the age of 18, registered as a Maccabi member. "The Nursing Fund" - a scheme providing nursing cover for members of Maccabi Healthcare Services who joined and/or were joined to it prior to the date of the start of this policy, according to the regulations of the above Fund, as members of the Maccabi Shield Society. The above nursing cover comprises two plans: the "Silver Shield" and the "Gold Shield" , and anyone who joined one of the above plans. "The Insured" - a person meeting one of the following conditions: 2.7.1. A member of Maccabi Shield and the children registered with him, who, prior to the determining date, was/were included in one of the two Nursing Fund plans, "Silver Shield" or "Gold Shield", other than a person who, on the determining date, met the definition of needing nursing care according to the definitions set out in the regulations of the Nursing Fund and/or a person who had began to receive a
2.5. 2.6.
2.7.
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nursing allowance from the Nursing Fund and/or a person meeting the definition of needing nursing care but not entitled to receive a nursing allowance from the Nursing Fund for any reason whatsoever. 2.7.2. A Maccabi member and the children registered with him, who, prior to the determining date, was/were not a member/members of Maccabi Shield and was/ were not included in the Nursing Fund, who has/have filled out and signed a written application to join this insurance at the "Gold Shield" level and the Insurer has agreed to insure him/them. To preclude doubt, it is clarified that all Insured parties under this policy are insured personally, regardless of the insurance or lack of insurance of their spouses, and that the policy will not be revoked with regard to Insured parties in the event of the death or divorce of their spouses. However, in cases where both parents of a child (or children) have cancelled their insurance under this policy, the child's (or childrens) insurance under this policy will also be cancelled automatically. Should one parent cancel the policy (the "Leaving Parent"), his/ her childs (childrens) insurance will not be cancelled unless the leaving parent decides to include the child (children).
2.7.3.
2.8. 2.9.
The Beneficiary - an Insured party as defined above, to whom an insurance event has occurred and who is entitled to receive a nursing allowance under this policy. "The Insurance event" / "Entitling Situation" - one or more of the following two events: 2.9.1. The Insured's poor state of health and functioning due to an illness, accident or health deficiency, as a result of which he is unable to perform alone a substantial part (at least 50% of the action) of at least three of the following six actions: 1. Getting up and lying down - the Insured's independent ability to change
position from lying to sitting and/or to get up from a chair, including carrying out this action from a wheelchair and/or bed.
2. Getting dressed and undressed - the Insured's independent ability to put
on and/or take off all kinds of items of clothing, including putting together and/or assembling a medical belt and/or artificial limb.
3. Washing - the Insured's independent ability to wash in a bath tub, shower
or any other accepted way, including getting in and out of the bath tub or shower.
4. Eating and drinking - the Insured's independent ability to feed himself
in any way or means (including drinking, and not eating, with the help of a straw), after the food has been prepared for him and served to him.
5. Continence - the Insured's independent ability to control his bowel
movements and/or urination. Failure to control one of these actions,

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meaning, for example, permanent use of a stoma or catheter in the bladder, or permanent use of diapers or other absorbent pads will be considered as incontinence.
6. Mobility - the Insured's independent ability to move from place to place.
Carrying out this action independently and without the help of another person, making use of crutches and/or a cane and/or a walker and/or other device, including a mechanical or motorized or electronic device that is not a wheelchair, will not be considered as impairment of the Insured's independent ability to move. However, confinement to bed or a wheelchair will be considered as the Beneficiary's inability to move, even if the Insured has the ability to move the wheelchair independently.
2.9.2. The Insured's poor state of health and functioning due to "cognitive impairment" determined by a physician specializing in this field. For this purpose, "cognitive impairment" - impairment of the Insured's cognitive actions and deterioration of his intellectual abilities, including deficient reactions and judgment, deterioration of long-term and/or short-term memory, and lack of orientation in space and time, requiring supervision for most hours of the day, as determined by a physician specializing in the field, due to a health condition such as Alzheimer's or other forms of dementia.
2.10.
"Nursing Allowance" 2.10.1. Nursing home hospitalization - compensation of the Beneficiary in respect of actual expenses paid by the Beneficiary or by his representative for hospitalization in a nursing home as stated in section 6 below. At-home nursing care - the provision of nursing services at home, or an allowance as stated in section 7 below.
2.10.2. 2.11.
"Nursing Allowance Ceiling" 2.11.1. With regard to a Beneficiary staying in a nursing home a. b. According to the Silver Shield plan. According to the Gold Shield plan.
As stated in section 6.1.1, 6.1.2 below. 2.11.2. With regard to a Beneficiary receiving home nursing care a. b. According to the Silver Shield plan. According to the Gold Shield plan.
As stated in section 7.1.1, 7.1.2, 7.1.3 below. 2.12.

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"Maximum Period of Entitlement to Nursing Allowance - a cumulative period of no more

than 60 (sixty) months (including the accumulation of parts of months), starting after the end of the waiting period, and in respect of which the Beneficiary is entitled to receive nursing compensation. 2.13. "Waiting Period" - a period of 30 days starting on the date that the insurance event occurred, during which the Beneficiary is in a continuous nursing state as defined in the policy, whether at home or in hospital. With regard to this period, the Beneficiary will not be entitled to receive a nursing allowance in respect of the insurance event. To preclude doubt, the Beneficiary will be required to pay the insurance premium during the waiting period too. 2.14. 2.15. Insurance Premiums" - the premiums that the Insured is required to pay by the Policyholder under the terms of the policy. Nursing Home - an institution and/or nursing ward and/or ward for the infirm, including mentally infirm, or a ward in a senior citizen's home or general hospital, or in any other institution approved by the Ministry of Health and/or by the Ministry of Social Affairs as a nursing home or institution, or approved by the Insurer or its representatives, whose sole or main business is the hospitalization of patients needing nursing care. "Nursing Agency" - a corporation whose sole or main activity is to provide nursing services, which has the licenses and permits required by law and by any authority to do so, and which has an agreement with the National Insurance Institute to provide nursing services at home. "Insurance Start Date" - with regard to Insured parties as defined in section 2.7.1 above, who have transferred without a break from the Nursing Fund - the determining date as defined below. With regard to new Insured parties as defined in section 2.7.2 above - on the 1st of the month following the month in which they join this insurance, as stated in section 3.2.2 below. 2.18. 2.19. "The Determining Date" - July 1, 2008. "Application to Join" - a personal application form to join the insurance, including a declaration of health, representing an integral part of the policy, filled out and signed by a Maccabi member wishing to join this insurance as an Insured party. "Age" -will be calculated in full years, according to the number of full years from birth to the date in question.
2.16.
2.17.
2.20.
3. Validity of the policy 3.1. Members who were covered by the Nursing Fund: An Insured person who was a member of the Nursing Fund prior to the determining date will be transferred without a break, without a health declaration, and without repeat underwriting or examination of his previous medical state, and will be insured under this
15
policy as of the determining date, according to the plan to which they belonged in the Nursing Fund, but with the rights accruing to the plan under this policy, other than Insured parties as above whom, on the determining date, were in need of nursing care as defined in the Nursing Fund regulations, and/or had begun to receive a nursing allowance from the Nursing Fund, and/or met the definition of being in need of nursing care but, on the determining date, were not entitled to receive a nursing allowance from the Nursing Fund for any reason whatsoever. To preclude doubt, it is clarified that there is no qualification period for an Insured person as above, and he will not be required to fill out an application form and/or make a declaration of health when this policy comes into force. 3.2. New members: A Maccabi member joining this insurance on the determining date or thereafter will be covered by this policy under the Gold Shield plan as of the date of joining, subject to all the following cumulative conditions: 3.2.1. 3.2.2. An application to join has been submitted to the Insurer by means of the Policyholder, filled out and signed as required. The date of joining under this policy will be the 1st of the month following the month in which the member joins, as given in the Maccabi documents sent to the Insurer each month. This date will represent the start of insurance cover for the Insured under the policy. The Insurer has approved the application and agreed to include the member in the policy as stated below. The inclusion of applicants in this insurance requires the completion of a declaration of health, and will be effected after a process of medical underwriting to be carried out by the Insurer. A newborn infant whose parents or mother are Maccabi members will be automatically included in this insurance, in the plan under which the mother is insured on the date of joining. The Insurer will send a letter to the newborn infant's mother, through Maccabi, informing her that the infant has been included in the insurance. The above letter will note the sections of the policy relating to the scale of cover of newborn infants, and the exceptions set out in the policy relating to genetic defects. Should an application to join the insurance under this policy be rejected by the Insurer, the applicant can appeal the rejection within 60 days of the date of receiving the decision. The appeal will be heard before the appeals committee with regard to joining, to be set up and convened from time to time. Notice of the Insurer's decision with regard to rejecting an application for
3.2.3. 3.2.4.
3.2.5.
3.2.6.
3.2.7.
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insurance will be given by the Insurer to each applicant for insurance, as well as to the Policyholder. The same is true with regard to decisions of the appeals committee. 3.2.8. An applicant for insurance who does not receive an answer to an application to join submitted by him, after producing a health declaration and all other medical and evidentiary material for the Insurer as required, within 60 days of the date that the said documents are received by the Insurer, will be automatically insured from the starting date of the insurance, under the regular conditions and without any exceptions. From the date that the applicant signs the declaration of health until the date that the Insurer agrees to insure him, or until the date that he confirms the Insurer's conditions for accepting him into the insurance, and no later than 60 days from the date that the documents as stated in section 3.2.8 are received by the Insurer, there has been no change in his health and physical state that would affect the Insurer's agreement or the terms of the Insurer's agreement to the application to join had it been known. The applicant to join the insurance has given the Policyholder a bank standing order to pay the insurance premiums, signed by him, or authorization to debit his account If payments have been made to the Insurer on account of the insurance premiums before the Insurer has agreed to insure the applicant, receipt of said payments will not be considered by the Insurer or by the Policyholder as the Insurer's agreement to draw up the insurance. Payment of insurance premiums after the Insurer's agreement to accept the applicant, and failure to reply to an application to join submitted by the applicant within 60 days as stated in section 3.2.8 above, will be considered as acceptance of the applicant into the insurance. Members who have transferred to this insurance from the Nursing Fund and were only covered in the Nursing Fund under the Silver Shield scheme will be entitled to upgrade their cover to the Gold Shield scheme under this policy, subject to the underwriting terms agreed between the Insurer and the Policyholder. These Insured parties will be required to make a declaration of health and medical underwriting only with regard to upgrading to Gold Shield cover.
3.2.9.
3.2.10.
3.2.11.
3.2.12.
4. The insurance period:

4.1. The insurance period with regard to each Insured party will begin on the given date with regard to him in section 3 above, and will end on June 30, 2013, hereinafter: the "Initial Insurance Period". At the end of the Initial Insurance Period, Maccabi Shield and the Policyholder will be entitled, at their sole discretion, to inform the Insurer at any time during the Initial
4.2.
17
Insurance Period, up to a date that is no less than 6 (six) months before the end of the Initial Insurance Period, that they want to extend the Initial Insurance Period for a period that is no greater than three years, hereinafter: the "Additional Insurance Period", subject to the agreement of Maccabi and the Insurer with regard to the necessary adjustments, and the approval of the Commissioner of Insurance. 4.3. Without derogating from that stated above, 12 months after the determining date, and each 12 months thereafter, the Policyholder will be entitled, after consultation with the Insurer, to request changes to the terms of the policy, with the authorization of the Ministry of Finance Capital Markets, Insurance and Savings Commissioner (hereinafter: the "Commissioner of Insurance"), in order to implement changes or conditions set out in laws, regulations or instructions by the Commissioner of Insurance that are valid at the time. In any event of non-renewal of the policy by the Insurer or the Policyholder, the Insurer will be obliged to provide cover under the policy only for those insurance events that have occurred prior to the end of the insurance period, and for which a claim has been submitted prior to the end of the limitation period as stated in section 18 below.
4.4.
5. Continuity:
5.1. In the following cases, and provided that an insurance event under this policy has not occurred, the Insurer will enable Insured parties who have been insured under this policy for at least three years before termination of the insurance to transfer to an individual policy with the Insurer for a lifelong insurance period (hereinafter: the "Continuation Policy"): 5.1.1. The Insured's membership of Maccabi has come to an end or the insurance period with regard to a particular Insured party has come to an end. In this case, the Insured will be given the possibility of transferring to a Continuation Policy within 90 days of the date of termination of his insurance. The start of the insurance period under the Continuation Policy will be retroactive as of the date of termination of the insurance under this policy. The insurance under this policy is not renewed or is terminated for any reason whatsoever by the Insurer with regard to all or some of the Insured parties. In this case, the Insurer will write to all Insured parties (or those for whom the policy is not renewed) and offer them the possibility of transferring to the Continuation Policy within 90 days of the date of notice by Insurer. The start of the insurance period under the Continuation Policy will be retroactive as of the date of termination of the insurance.
5.1.2.
If there is a change in legislation during the period of this policy, affording Insured parties similar nursing cover to that which exists in this policy, the Continuation Policy will provide additional insurance cover in respect of the cover provided in the group insurance policy that is not given by virtue of the law, in accordance with an agreement between the Policyholder and the Insurer.
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5.1.3.
The terms of the Continuation Policy will be as follows: an Insured party transferring to the Continuation Policy will receive a reduction in premiums of at least 20% on the insurance premiums offered by the Insurer at the beginning of the insurance period under the Continuation Policy with regard to all those insured by it under a similar policy. This reduction will be in force throughout the insurance period of the Continuation policy. The amount of the insurance under the Continuation Policy will be as determined in sections 7.1.2, 7.1.3 and 6.1.2, respectively, of this policy, and the period of payment of insurance compensation under the Continuation Policy will have a ceiling for entitlement to a nursing allowance as defined in this policy. The transition to the Continuation Policy will provide insurance continuity (without a declaration of health and without repeat underwriting or examination of previous medical condition), without an qualification period. The Insured will be entitled to purchase reduced insurance compensation in the framework of the Continuation Policy.
5.1.4.
5.1.5.
5.1.6.
6. Nursing allowance for a Beneficiary hospitalized in a nursing home:

When an insurance event occurs, after the waiting period and subject to the terms of this policy, the Insurer will indemnify a Beneficiary in a nursing home in respect of actual hospitalization expenses in the nursing home, at the following rates and for the following period: 6.1. Ceiling of nursing allowance for a Beneficiary hospitalized in a nursing home The ceiling of compensation during the period of entitlement to a nursing allowance, that is, up to 60 months, will be as detailed below: 6.1.1. 6.1.2. 6.2. Silver Shield members compensation at a rate of 40% of expenses for nursing home hospitalization, up to a ceiling of NIS 5,000 a month. Gold Shield members - compensation at a rate of 80% of expenses for nursing home hospitalization, up to a ceiling of NIS 10,000 a month.
Manner of payment of nursing allowance 6.2.1. The nursing allowance under section 6.1 above will be paid against presentation of an original receipt by the Beneficiary or his representative, together with a legal tax invoice, for payment in practice of the nursing home hospitalization expenses. Payment will not be made against photocopies of receipts and invoices or true copies of the original. Notwithstanding that stated, if the Beneficiary has submitted a request to another entity for payment, full or partial, in respect of the insurance event, a true copy of the original can be submitted together with confirmation from the entity to whom the original document was submitted
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with regard to the amount claimed from the other entity. In such a situation, the Insurer will indemnify the Beneficiary in accordance with the provisions of the Insurance Contract Law, providing that in any event the total compensation to the Beneficiary does not exceed the lower of the following two amounts: a. b. The Beneficiarys total expenses in practice The amount of the compensation to the Beneficiary as stated in this policy.
6.2.1.1. Compensation will be paid in all cases in which the expenses were paid out in practice prior to the date of compensation. Compensation will be paid to the Beneficiary or to his legal representative. 6.2.2. The insurance compensation will be paid by the 15th of each month in respect of the previous month, subject to confirmation by the Insurer of the receipts or invoices or business receipts that are the subject of the payment.
7. Nursing allowance for a Beneficiary receiving home nursing care: 7.1. When an insurance event occurs, after the waiting period and subject to the terms of this policy, the Insurer will provide a Beneficiary staying in his home with home nursing care services, provided in practice to the Beneficiary by means of a nursery agency as defined above in section 2.16 with which the Insurer is connected, or will compensate the Beneficiary with a fixed monthly allowance, as chosen by the Beneficiary or his representative from the three options as detailed in the following tracks: 7.1.1. Receiving nursing care from a nursing agency (Israeli carer): a. b. Silver Shield members 25 hours a week Gold Shield members 36 hours a week
7.1.1.1. The Beneficiary will be entitled to receive nursing care from a nurse, for the number of hours as stated above, for a period of no more than 60 months, so long as the Beneficiary meets the definition of an entitling condition as defined in section 2.9 above, at the weekday daytime rate. 7.1.1.2. The Beneficiary can convert the said nursing care hours to the proportionate number of evening / nighttime or Friday / Saturday hours. One weekday nursing care hour will be calculated at not less than the hourly rate for daytime care paid to a not-for-profit organization for the purpose of the National Insurance Institute Nursing Law, as published from time to time. 7.1.1.3. The cost of the service will be paid by the Insurer to the service provider with which it has an agreement. 7.1.1.4. A Beneficiary wishing to increase the scope of the service beyond the quota detailed above will bear the cost of the treatment and/or supervision, to be
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paid directly to the service provider, at a rate that will be determined in advance in the agreement with the service providers. 7.1.1.5. If there is no nursing agency in the area where the Beneficiary is staying that is able to provide the service as stated above, the Insured will be offered the foreign worker employment track in accordance with section 7.1.2, or an allowance as stated in section 7.1.3, below. 7.1.2. Compensation by fixed monthly payment for the employment of a foreign worker: a. b. Silver Shield members NIS 3,500 a month Gold Shield members NIS 4,500 a month
The Beneficiary will be entitled to a nursing allowance and will receive payment of a fixed monthly amount as detailed above. The monthly allowance will be paid to him each month if the following cumulative conditions are met: 1. Before the start of said allowance payments, the Beneficiary has produced confirmation of lawful employment of a foreign worker. 2. He produces said confirmation once every 12 months, and/or at the Insurers request at an earlier date. 3. The allowance period will be up to 60 months, as long as the Beneficiary meets the definition of an entitling condition as stated in section 2.9 above. 7.1.3. Allowance by fixed monthly payment as detailed below: a. b. Silver Shield members NIS 3,000 a month Gold Shield members NIS 4,000 a month
Should the Beneficiary or his representative decide not to choose one of the two alternatives in section 7.1.1 or 7.1.2 above, the Beneficiary will receive a nursing allowance as detailed above, in accordance with that stated in this policy, for an allowance period of up to 60 months, as long as he meets the definition of an entitling condition as stated in section 2.9 above.
8. Transferring between plans and tracks:

8.1. The Beneficiary or his representative will be entitled, at any time, to change their decision with regard to the manner of utilization of entitlement under the terms of this policy, and transfer from the at-home nursing care track - both receipt of the service in practice and an allowance in respect of employing a foreign worker or regular payment, to the track of compensation in respect of hospitalization in a nursing home as stated in section 6 above. In addition, all Beneficiaries will be entitled to transfer from the nursing home hospitalization track to the at-home nursing care track and the reverse, to transfer from the track in which
21
the service is received in practice to the track providing an allowance for employing a foreign worker, or to the regular payment track, as stated in the terms of the policy. 8.2. The application to transfer from one track to another as stated above will be made by application in writing by the Beneficiary or his representative to the Insurer, who will organize implementation of the requested change in accordance with the procedures set out by the Insurer. If the Beneficiary or his representative chooses the track providing a fixed monthly nursing allowance for a foreign worker and has not yet arranged or completed the necessary processes for employing a foreign worker, he can choose to receive nursing services from a nursing agency or to receive an allowance. If he chooses to receive payment, he will be paid a nursing allowance in accordance with the nursing track as stated in section 7.1 .3 above, in accordance with his entitlements under the terms of the policy. When his application for a foreign worker is approved, he will receive the nursing allowance according to the foreign worker payment track as of the date of approval by law or the date that the foreign worker starts working in practice, the later of the two dates.
8.3.
9. Nursing allowance - general:

9.1. The nursing allowance from the Insurer will be paid to the Beneficiary within 30 days of the date that the information and documents required for clarifying its liability are received by the Insurer. The Beneficiary will not be entitled to receive a nursing allowance under this policy in respect of the waiting period. The nursing allowance under this policy is given in addition to and independent of any nursing payment or nursing service that are given to the Beneficiary by the state in respect of the Insurance event, including under the National Insurance Law (combined version) 5755 - 1995. In any situation where the Beneficiary is entitled to receive a nursing allowance in respect of part of a month, the ceiling for the nursing allowance will be proportional to that portion of the month. It will not be possible to accumulate entitlement to nursing payments in respect of nursing services under section 7.1 and its subsections, or to nursing home compensation under section 6.1, that has not been utilized to the full ceiling of the nursing allowance by the Beneficiary in a particular month in order to increase the nursing allowance in respect of the Beneficiary in another month. That stated in this section will also apply to partial months, with the necessary changes. The periods when the Beneficiary receives a nursing allowance, whether under section 6 or under section 7 and their subsections above, under this policy or under the Nursing Fund, are cumulative periods and in any event will not cumulatively exceed the ceiling of the period of entitlement to a nursing allowance.
9.2. 9.3.
9.4.
9.5.
9.6.
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9.7.
If the Beneficiary is entitled to a nursing allowance under this policy, and a guardian has been appointed for him by the court, the Insurer will pay the insurance compensation to the guardian appointed as stated. The Beneficiary's entitlement to receive a nursing allowance will stop on the date when the Insurance event ceases to exist, or when the ceiling of the entitlement to a nursing allowance is reached, or on the death of the Beneficiary, the earliest of these dates. If the Beneficiary dies during the period of entitlement, the nursing allowance will be paid to his estate as stated in section 9.10 below. Repeat nursing care condition - If the Insurer stops paying the Beneficiary a nursing allowance under this policy, due to an improvement in his condition such that he no longer needs nursing care and is not entitled to a nursing allowance, before the full ceiling of the period of entitlement to a nursing allowance is reached, and afterwards the Beneficiary returns to a condition entitling him to a nursing allowance under this policy, the Beneficiary will be entitled to a nursing allowance as of this date, without an additional waiting period. The cumulative period during which the Beneficiary is entitled to receive a nursing allowance before and after the break will not exceed the ceiling of the period of entitlement to a nursing allowance. To preclude doubt, it is clarified that even in the event that the new nursing care situation is not related to the previous nursing care situation, no additional waiting period will apply. The Beneficiary's death - should the Beneficiary die while entitled to receive a nursing allowance, and providing the ceiling of the period of entitlement to a nursing allowance has not been reached, his heirs must report to the Insurer. If a Beneficiary dies, the full nursing allowance for that month will be paid, other than for those who receive nursing care services through a nursing agency. Exemption from paying insurance premiums - during the period in which the Beneficiary is entitled to a nursing allowance, the Beneficiary will be exempt from paying the insurance premium. It is agreed is that the Insurer is required to inform the Beneficiary or his representatives of exemption from payment of insurance premiums immediately on the start of payment of the nursing allowance, and will also inform the Policyholder of this fact. It is emphasized that during the waiting period the Insured is also required to pay the insurance premium as determined in section 2.13 above. To preclude doubt, if the Insurer ceases payment of the nursing allowance in respect of the Beneficiary before reaching the ceiling of the period of entitlement to a nursing allowance, the Beneficiary's obligation to pay insurance premiums will be renewed as of the date that his entitlement to a nursing allowance comes to an end. The Insurer is required to give notice of resumption of payments of premiums, both to the Beneficiary and/or his representatives and to the Policyholder.
9.8.
9.9.
9.10.
9.11.
9.12.
Voiding of the policy after reaching the end of the period of entitlement to a nursing allowance - on reaching the ceiling of entitlement to a nursing allowance in full, the policy will be cancelled with regard to the Beneficiary, who will not be entitled to any additional
23
amount or service under this policy.
10. Exceptions to the Insurer's liability

The Insurer will not be liable for the provision of a nursing allowance under this policy in respect of an insurance event taking place within one or more of the periods detailed below: 10.1. 10.2. The insurance event occurs to a child who is not yet 12 months old. The insurance event occurs before the start date of the insurance or after the end of the period of insurance. The Insurer will not be required to provide a nursing allowance under this policy in respect of an insurance event that occurs as a result or in respect of one or more of the events given in the following sections: 10.3. 10.4. 10.5. Participation in an illegal activity. Chronic drunkenness or the use of drugs other than by doctor's prescription. The Insured party's service in the IDF or another security entity, or participation in any kind of security activity, including military or police action, warfare, revolution, hostile action, nationalist action, riots, strikes, and including passive participation in these events. Flying in any kind of aircraft, other than as a regular passenger on a civil commercial flight or a private flight in a civilian aircraft approved by the qualified authorities. Acquired Immune Deficiency Syndrome (AIDS) or any other similar illness or syndrome. Traffic accident. The term "traffic accident" will be interpreted in accordance with the Compensation for Victims of Traffic Accidents Law 5735 - 1975, or any other law that replaces it. Nuclear fission or meltdown, radioactive pollution. Any congenital defect or illness, for genetic for other reasons, including a defect or injury caused due to the pregnancy or birth with which the Insured is born, providing this has been determined by documented medical diagnosis within 12 months of birth.
10.6. 10.7. 10.8.
10.9. 10.10.
11.Stipulation due to previous medical condition - applying to new members only:

This stipulation applies only with regard to Insured parties joining this insurance after the determining date, and does not apply to Insured parties who were members of the Nursing Fund on the determining date. 11.1. 11.2. The Insured will not be entitled to receive a nursing allowance in the event of an insurance event for which the actual cause was the normal course of a previous medical condition. "Previous medical condition meaning - a set of medical circumstances with which the Insured was diagnosed before the date of joining the insurance, including due to illness or
24
accident; for this purpose: "the Insured was diagnosed" - by means of documented medical diagnosis, or in a process of documented medical diagnosis carried out during the six months prior to the date of joining the insurance. 11.3. Validity of stipulation due to previous medical condition: this stipulation, with regard to an Insured aged less than 65 on the date of starting the insurance period, will be valid for a period of one year from the start of the insurance periods. With regard to an Insured whose age on the date of starting the insurance period is 65 or more, the stipulation will be valid for a period of six months from the start of the insurance period. Validity of stipulation due to a particular medical condition of a particular Insured party: notwithstanding that stated above, a stipulation regarding the Insurer's liability or the scope of cover in the event of a particular medical condition detailed with regard to a particular Insured party, due to medical underwriting carried out for the Insured party, will be valid for the period given in the insurance list alongside the particular medical condition. Non-application of the stipulation: this stipulation will not apply if the Insured has informed the Insurer of his previous state of health, and the Insurer has not explicitly restricted the particular medical condition mentioned in the Insured party's notification.
11.4.
11.5.
12. The claim:

12.1. 12.2. The Beneficiary will inform the Insurer of the occurrence of a medical event, as close as possible to the date on which it occurs. The obligation and the right to submit and establish a claim applies to the Insured or his representative, and only to them. It is hereby clarified that the Policyholder may not submit and will not submit a claim to the Insurer under this policy, at its initiative or on behalf of the Insured. The Beneficiary will produce for the Insurer all the documents that the Insurer requires for clarifying its liability under this policy, and will sign a waiver of confidentiality to enable the Insurer to obtain both medical information and functional information about the Beneficiary. The Insurer will be entitled, at its expense, in a reasonable manner, and within a reasonable period of time as agreed between it and the Policyholder, to carry out any action and to have the Beneficiary undergo functional and/or medical testing by a doctor or other medical service provider on its behalf, at its sole discretion. These obligations apply to the Insured / the Beneficiary both before and during the period in which he is entitled to receive a nursing allowance. An Insured party who does not receive a response to a claim submitted by himself and/or his representative, after providing the Insurer with all the medical and/or other documents required as stated above, and after agreeing to undergo functional evaluation or other medical testing if this is required of him, or an Insured party who has undergone functional evaluation as stated but has not received a response to his claim thereafter, may consider himself to be a Beneficiary whose entitlement has been proved under the terms of this policy
12.3.
12.4.
25
and for cover by the Insurer. This holds true if 60 days have passed since the claim was submitted to the Insurer as stated above, or if 45 days have passed since implementation of a functional evaluation by the Insurer. 12.5. 12.6. Functional evaluation of the Beneficiary will be carried out by the Insurer or by a person acting on its behalf, after coordination with the Beneficiary or his representative. In the event of an improvement in the Beneficiary's condition such that he is no longer in an entitling condition, the Beneficiary must inform the Insurer of this immediately, and no later than within 30 days of the improvement in his condition. In the event of the death of the Beneficiary, and if no other person on his behalf as stated is entitled to receive the nursing allowance under the policy, the Insurer will pay the estate of the Insured party the balance of the nursing allowance that should have been paid to the Beneficiary for the period in which he was entitled to receive it, and that was not paid prior to his death. If a nursing allowance was paid to the Beneficiary and/or to his estate in respect of a period for which he was not entitled to it, whether due to an improvement in his condition and/or due to his death as stated above, the Insurer will be entitled to its repayment. The above amounts will be repaid to the Insurer linked to the CPI, without interest.
12.7.
12.8.
13. Appeals committees

13.1. If the Insured partys claim for a nursing allowance is rejected, wholly or in part, for medical and/or other reasons, he will be sent a reasoned notification by the Insurer, drawing his attention to his entitlement to submit an appeal to the appeals committee within 60 days of the date of receiving notification. The Insured will be entitled to submit documents and a medical and functional opinion to the appeals committee as he sees fit, or as requested by the committee. In addition, the committee will enable the Insured and/or his representative to appear before it. The Insurer will give the committee all the material in its possession relating to the claim, whether given to it by the Insured or obtained other than from the Insured. The appeals committee will be authorized to discuss the claim, and accept or reject it in accordance with the terms of the policy. Decisions of the appeals committee will be taken by a majority of votes. In the event of an equal number of votes, the director of the insurance department at Maccabi or a person appointed by the executive director of Maccabi will have the right to decide, and his decision will be final, may not be appealed, and will be binding with regard to the Insurer. The Insurer will be bound by the decision of the appeals committee, which will be considered as the Insurer's decision in all respects.
13.2.
13.3. 13.4. 13.5.
13.6.
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13.7.
The decision of the appeals committee or an appeal to the committee will not affect the Insured party's right to appeal to legal instances for clarification of his rights under the policy. For the purposes of this section, "appeals committee means a committee comprised of three representatives of Maccabi and three representatives of the Insurer; four of them two from each party - will make up a legal quorum; and the committee's working methods will be agreed between Maccabi and the Insurer. It is emphasized that at least one of the representatives on the appeals committee will be a doctor by training, and at least one other representative will be a lawyer by training. Appeals committee regarding joining the insurance policy
13.8.
13.9.
If the application of a applicant wishing to join the insurance as stated in section 3.2 .6 above is rejected, he will be entitled to submit an appeal against his rejection to the appeals committee within 60 days. The above appeals committee will comprise a representative of the Policyholder and a representative of the Insurer. The applicant for insurance will present the committee with all his reasons, both medical and others, and may also present written opinions from his physicians. If the members of the above appeals committee do not reach an agreed decision, they will be entitled, by common consent, to bring in a physician in the relevant field whose decision will be binding.
13.10.
13.11.
14. Linkage:
14.1. 14.2. All payments made to the Insurer and by the Insurer under this policy will be linked to the index as detailed below: All of the Insurer's payments under the policy will be linked once a quarter, at the beginning of each quarter, to the rate of increase or decrease in the current index as compared with the base index. All insurance premiums to be paid by the Insured to the Insurer will be linked once a quarter to the current index as compared with the base index (that is, payments will be linked to the index whether the current index is higher or lower than the base index). If payments are made by bank transfer, the date on which payment is made will be the date on which the money is actually transferred to the Insurer or the Insured. The following terms will have the meaning appearing alongside them: "Linkage to the index" - multiplication of the said amount by the ratio between the last index published before the calculation of index linkage and the base index; "Index" -the consumer price index (including fruit and vegetables) determined by the
14.3.
14.4. 14.5.
27
Central Bureau of Statistics, including any other official index replacing it, even if published by any other government institution that replaces it; "The base index" - the index known on the determining date; "The current index" - the index known at the start of the quarter in which the payment is made.
15. Insurance premiums and methods of payment:

15.1. Insurance premiums for each Insured party are as detailed in the table of insurance premiums attached to this policy, and vary in the course of the insurance period according to the age group and insurance group in which the Insured party is insured. Insurance premiums for new members under the policy who, on the date of joining, are aged over 50 will be as stated in the table of insurance for new members over the age of 50, attached to the policy. Insured parties who, on the determining date, pay registration fees together with their insurance premiums will continue to pay them according to the spread of registration fees by Maccabi Shield, until payment is completed. The Insured party will pay the insurance premiums once a month, as customary for the Policyholder, by direct debit authorization or any other means that the Policyholder uses with regard to its members. Payment of the insurance premiums to the Insurer will be made collectively by the Policyholder or its agents for all the Insured parties. If the insurance premiums, or part of them, are not paid to the Policyholder on time, the Policyholder will give details of the Insured party to the Insurer, for collection or for cancellation of the policy with regard to an Insured party who has not paid the insurance premiums. During the first 180 days that the Insured party has not paid the insurance premium, the Policyholder will send two warning letters to the Insured party in question, on behalf of the Insurer, at times to be agreed between the Policyholder and the Insurer. 15.6. In the above letters, the Insurer or the Policyholder on its behalf will warn of the Insured party's non-payment and the consequences of non-payment, which is liable to affect the Insured's rights under the policy. If warnings as stated in section 15.5 and 15.6 above have been sent and the late insurance premiums have not been paid to the Insurer, an additional notification will be sent to the Insured party on behalf of the Insurer with regard to cancellation of the policy. After notification has been sent as stated above, insurance under the policy will be cancelled by the Insurer, subject to the Insurance Contract Law. It is hereby clarified that until said period of 180 days has elapsed, and until the policy has been cancelled as stated above, the policy will remain valid despite the delay in payment of the insurance premiums.
15.2.
15.3.
15.4. 15.5.
15.7.
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15.8.
If the Insured party responds by paying the late insurance premiums as stated above, the Insurer will be entitled, in addition to the insurance premiums, to charge the Insured party an addition of interest on the late payment as set by the Accountant General, from the initial date of the delay and until the date of payment in practice. The Policyholder will be entitled, at its sole discretion, to instruct the Insurer to increase the insurance premiums once every 12 months, subject to authorization by the Commissioner of Insurance, but no earlier than 36 months after the determining date. If the Policyholder decides to increase the insurance premiums, the Insurer will inform the Insured parties of this, in advance and in writing. In addition, and without derogating from that stated above, the Insurer will be entitled to change the insurance premiums under this policy beyond the increase in the index, if said increase is required as a result of legislative provisions or the instructions of a government authority, in accordance with that agreed with the Policyholder and with the advance authorization of the Commissioner of Insurance. Insured parties under this policy will be exempt from paying insurance premiums during their compulsory service in the IDF. Additionally: 15.11.1. Insured parties under this policy who have reached the age of 18 will be exempt from paying insurance premiums in respect of this policy for a period of 12 full months, until they reach the age of 19. An Insured party who completes compulsory military service and continues to be insured under this policy will be entitled to make up the period of up to 12 months without payment of insurance premiums, if he has not utilized this entitlement in full prior to his military service.
15.9.
15.10.
15.11.
15.11.2.
15.12.
Depositing money prior to acceptance of the insurance proposal: 15.12.1. If money is paid to the Insurer on account of the insurance premiums before the Insurer has agreed to insure the applicant, this payment will not be considered as agreement by the Insurer to draw up the insurance. Rejection of the insurance proposal, or referral for the completion of data, or returning to the Policyholder with an insurance counter-proposal will be carried out within no more than three months from the date of receiving the first regular deposit; or, if the Insurer has contacted the Policyholder or the Insured party, as relevant, with a request for completion of data or with an insurance counterproposal, six months from the date of receiving the first regular deposit. If the Insurer has not rejected the insurance proposal, and has not returned to the Policyholder with a counterproposal or requested completion of data, and has not informed the Policyholder that the Insured party has been accepted under the insurance within the said period, the Insured party will be considered as having joined the insurance under regular conditions.
15.12.2.
15.12.3.
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16. Option of purchasing individual nursing policies:

16.1. Each Insured party will be entitled to purchase individual nursing policies from the Insurer (the Individual Policies) for the Insured party's lifetime, in addition to the nursing allowance under this policy. The Insured will be given the option of purchasing Individual Policies of two types: 16.2.1. 16.2.2. A lifetime individual policy providing compensation in the event of the occurrence of an insurance event. An individual policy extending the period of the insurance payments beyond the period of entitlement to a nursing allowance in force under this policy (after entitlement under this policy has been fully utilized for a period of 60 months). The period of entitlement under this individual policy will be for the Insured party's lifetime.
16.2.
16.3.
A member of the Nursing Fund before the determining date who has transferred directly to this policy and wants to purchase an individual policy will complete the application form, which includes a health declaration, and will undergo medical underwriting by the Insurer in accordance with the form in use by the Insurer for policies of this kind. The terms of insurance under the Individual Policies will be according to the form of individual policies in use by the Insurer at the time of purchase. Insurance premiums collected by the Insurer from the Insured in respect of Individual Policies will be at least 20% lower than the lowest insurance premiums approved by the Commissioner of Insurance in use by the Insurer at that time in respect of equivalent individual policies for the plan selected by the Insured, for an insured party of a similar age and state of health. Said discount will be in force throughout the life of the Insured. The insurance premiums in respect of increasing insurance compensation under this policy for life will be decided between the Insurer and the Policyholder. In addition, the Insurer undertakes to confirm the individual policy with the Commissioner of Insurance. An Insured party who joins the insurance after the determining date and wants to purchase the Individual Policies will fill out an application form and will be asked to make a declaration of health and undergo medical underwriting in accordance with the form in use by the Insurer for policies of this kind. In the case of an Insured party aged over 65, the Insurer may asked him to be examined by a doctor on its behalf. To preclude doubt, that stated above will apply also to those who were members of the Nursing Fund and who transfer without a break to insurance under this policy, if they wish to purchase said Individual Policies. The Insured will pay the insurance premiums in respect of the Individual Policies directly to the Insurer, without the involvement of the Policyholder
16.4. 16.5.
16.6.
16.7.
16.8.
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17.Limitation of the Insurer's liability outside the borders of Israel

The Insurer's liability in respect of an insurance event occurring to the Beneficiary when staying outside the borders of Israel will be limited to providing a nursing allowance as stated in the policy, for a period of three months only, unless the Insurer has agreed, in advance and in writing, to accept liability on a different scale. In any event, the nursing allowance will be paid only in Israel. On the Beneficiary's return from abroad, payment of the nursing allowance will continue on the basis of medical documents and in accordance with the terms set out in this policy.
18. Period of limitation

The period of limitation applying to a claim for payment of insurance compensation under this policy is three years from the date that the insurance event occurs.
19. Transfer provisions

19.1. When this policy comes into force, its provisions will apply with regard to all those transferring from the Nursing Fund, in place of the provisions of the Nursing Fund, other than for those who, on the determining date, meet the definition of needing nursing care under the regulations of the Nursing Fund and have not been transferred to this policy. A Beneficiary who has been defined as needing nursing care under the regulations of the Nursing Fund (hereinafter: a Need of Care Case) will continue to receive nursing services in accordance with the Nursing Fund regulations, whether or not he receives a nursing allowance and/or received a nursing allowance. It is hereby clarified that said Beneficiary will not be entitled to insurance and insurance compensation under this policy. Notwithstanding that stated above, if the Beneficiary ceases to fall into the category of Need of Care Case under the regulations of the Nursing Fund, as a result of an improvement in his functional condition, it is agreed that such a Beneficiary will become an Insured party under this policy from the date that he ceases to meet the definition of Need of Care Case due to an improvement in his functional condition, and from this date will pay insurance premiums to the Insurer as stated in this policy, providing that after the improvement in his functional condition, the Insured party does not meet the definition of the insurance event. If an insurance event as defined by this policy occurs to the Insured in the future, he will be entitled to receive a nursing allowance under this policy for the remaining period of his entitlement to a nursing allowance, that is, up to the ceiling of the period of entitlement to a nursing allowance less the number of months that he was entitled to receive compensation under the regulations of the Nursing Fund. 19.3. If the Insurer rejects the claim of an Insured party who was covered by the Nursing Fund and who transferred to this policy without a break as stated in section 3.1 above, on the grounds that the insurance event took place before the determining date, the burden of proof that the definition of Need of Care Case existed with regard to the Beneficiary prior to the determining date lies with the Insurer.
19.2.
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19.4.
If the Insurer proves that the insurance event occurred prior to the determining date, the Insured party will be returned to the responsibility and care of Maccabi Shield in accordance with the regulations of the Nursing Fund. If the Insurer claims, as stated, that the insurance event occurred prior to the determining date, the matter will be brought up for discussion by an exceptions committee, whose members will be representatives of the Insurer and representatives of Maccabi Shield and the Policyholder. The Insurer will be bound by the decision of the appeals committee. There is nothing in the decision of the appeals committee to derogate from the right of the Insured party to appeal to legal instances for clarification of his entitlement to insurance compensation under the policy.
19.5.
If the Insured party's claim is rejected as stated in section 19.3, the Insurer will return in full the insurance premiums paid as of the determining date by the Insured, with the addition of late payment interest as determined by the Accountant General, within 30 days of the date of rejecting the claim, and the claim will be dealt with in accordance with the regulations of the Nursing Fund. It is clarified that the Insurer will not be entitled to turn to the Insured to collect insurance payments that have been paid to him in practice under this policy. Notwithstanding that stated in section 10.2, if it emerges that an Insured party who was covered by the Nursing Fund and who transferred to this policy without a break as stated in section 3.1 above became a Need of Care Case prior to the determining date but submitted his claim 12 months after the determining date, he will come under the responsibility of the Insurer under this policy. Taxes and duties: The Insured is liable for payment of all government and other taxes applying under this policy or imposed on the insurance premiums and on insurance compensation or any other payments that the Insurer has to pay under this policy, whether these taxes exist on the date that the policy becomes valid or are imposed at a later date. It is clarified that the insurance premiums on the determining date include all taxes and imposts that apply on this date.
19.6.
19.7.
20.
20.1.
General:
It is clarified that the Policyholder is not the delegate or representative of the Insurer in any way whatsoever, and that the Insurer alone will be responsible for fulfilling its undertakings towards the Insured parties under this policy. The address of the parties for the purpose of giving notice with regard to the provisions of this policy are: The Policyholder: Maccabi Healthcare Services The Insurer: Clal Health Insurance Ltd. The Insured: the latest address of the Insured as appearing with the Policyholder.
20.2.
32
Any notification sent by registered mail according to the addresses given above will be considered to have been received by the addressee within 72 hours of the letter including the notification being sent by mail, and proof that the letter was handed in at the post office will serve as proof of its delivery.
33
Table of insurance premium variables

Premiums for the Gold Shield Nursing plan
18-29
Age 0-17 Year 1 0 2.22 10.1 11.62 11.62 30.5 34.95 34.95 52.62 59.19 86.86 99.89 109.08 Year 2 0 3.03 13.03 16.26 16.26 39.69 46.66 46.66 63.13 74.03 99.89 112.82 123.22 Year 3 0 3.84 15.86 21.11 21.11 49.59 58.28 58.28 75.75 92.52 112.82 125.24 135.54 Year 4 0 4.85 19.09 25.25 26.36 56.96 64.14 69.99 83.43 106.45 126.35 137.76 146.35 Year 5 0 5.45 20.1 26.36 27.37 57.87 64.94 72.32 85.75 108.78 128.78 140.19 148.77
30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-74 75-80 81-110
Premiums for the Silver Shield Nursing plan

Age 0-17 18-29 30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-74 75-80 81-110 Year 1 0 2.22 7.17 8.18 8.18 22.52 25.76 25.76 37.57 42.32 64.14 75.35 80.09 Year 2 0 3.03 9.19 11.51 11.51 29.29 34.44 34.44 45.15 52.82 73.83 85.24 90.5 Year 3 0 3.84 11.31 14.95 14.95 36.56 43.03 43.03 54.14 66.05 83.43 94.54 99.59 Year 4 0 4.85 13.53 17.98 18.69 42.02 47.27 51.61 59.49 75.95 93.43 104.03 107.57 Year 5 0 5.05 14.34 18.69 19.49 42.82 48.08 52.12 60.1 76.46 93.93 104.54 108.07
* The premium will increase gradually in the coming four years as detailed in the policy. * 18-year-olds are given a one-year exemption from payment of the premium. Soldiers in compulsory military service continue to be covered without payment of a premium. After demobilization from compulsory service the balance of the one-year exemption will be paid.
34
Additional premium for upgrading from Silver Shield to Gold Shield

Age Monthly premium Up to 54-55 53 0 10 56-57 20 58-59 30 60-62 40 63-66 70 67 80 68 100 69 110 70 120
Additional premium for new members

Age Monthly premium
* The above premium will be paid in addition to the premium given for the Gold Shield track, for five years. Up 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 to 53
10 30 50 70 90 110 130 150 170 200 220 240 270 300 320 350 380
* The above premium will be paid in addition to the premium given for the Gold Shield track, for five years. * The premiums given in the above tables are updated to July 2008, and will be updated quarterly according to the consumer price index.
35
Useful information about the terms of the policy Questions and Answers
What is lomg-term care insurance?
long-term care insurance is an insurance plan under which the insured person pays monthly insurance premiums according to his age. This payment guarantees that if, in the future, he is in need of nursing care and cannot function independently in his everyday life he will be entitled to monthly compensation from the insurance company. This will enable him to receive nursing services, participation in expenses, or compensation as stated in the policy.
Why has Maccabi Healthcare Services entered into a new long-term care insurance scheme with an insurance company?
In 2001, the Commissioner of Insurance instructed Maccabi Shield to transfer its members to an insurance company. After a protracted legal struggle, the Supreme Court determined that Maccabi Shield, in coordination with the Commissioner of Insurance, had to decide on the transfer of its members to an insurance company. In the wake of this decision, Maccabi put together a very advanced long-term care insurance policy to meet the needs of members requiring nursing care, and published a tender among the insurance companies. The tender was won by Clal Health Insurance Ltd. which submitted the best offer both in terms of quality of service, and in terms of price (premiums)
What are the main improvements that have been made to the policy?
1. Entitlement to nursing hospitalization and at-home nursing care has been increased to one high level of entitlement. 2. In the Gold Shield plan, participation in the costs of nursing hospitalization has been increased to 80% of the cost, and up to NIS 10,000 a month. 3. The period of entitlement in the Gold Shield plan has been extended to five years. 4. Insured members preferring to remain in their own home can choose between receiving nursing services and receiving financial compensation. 5. The deduction of entitlement to nursing care under the National Insurance Law has been cancelled. In other words, under the new policy members will be entitled to nursing care at home in addition to, and irrespective of, their entitlement from the NII. 6. The definition of an insurance event - need of care condition has been adapted to that of the Commissioner of Insurance.
36
7. The entry age for the insurance has been extended - it is possible to join the Gold Shield plan up to the age of 70 (subject to medical condition). 8. A section has been added regarding exemption from payment of premiums when receiving the nursing allowance.
What role does Maccabi Healthcare Services play in the long-term care insurance?
Maccabi Healthcare Services is the policyholder, and therefore undertakes to supervise and maintain regular contact with Clal Health in order to ensure that all members of the long-term care insurance receive their full entitlement under the policy, and the most professional and dedicated care when they are in need of nursing.
Who is entitled to cover under the health insurance?

Existing members: Members of Maccabi Shield and their children who were covered by the Nursing Fund on June 30, 2008 - insurance liability for their nursing care will be transferred to Clal Health according to the plan by which they were covered previously, Silver Shield or Gold Shield, with the exception of members of Maccabi Shield who were considered to be need of care cases under the regulations of the Nursing Fund prior to the date of transfer to Clal Health (before July 1, 2008). New members: Members of Maccabi Healthcare Services and children registered with them who, on July 1, 2008 were not members of Maccabi Shield and/or not covered by long-term care insurance, on condition that the member has filled out an application to join the Maccabi Long-Term Care Gold Shield plan, for himself and his children, and that the insurer has agreed to insure them (it is not possible to join the Silver Shield plan).
If I was a member of the Nursing Fund on June 30, 2008, am I automatically insured under the Maccabi Long-Term Care policy?
As of July 1, 2008 you will automatically be insured under the policy, and will not need to fill out an application form or undergo medical underwriting. All claims by existing members as defined above, if any, will be examined solely under the provisions of the Maccabi Long-Term Care policy.
I didnt joined the Nursing Fund previously; how can I join the long-term care insurance now?
You can submit an insurance proposal form at any Maccabi branch, or join through the Maccabi Long-Term Care call center at Clal Health: 1-700-505-520.
How do I know that my family and I are covered?

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Each quarter you will receive details of the payments you have made for the relevant period and the insurance plan under which you are covered, sent directly to you by Maccabi Healthcare Services.
Will the premium and the monthly allowance (in the event of payment to an insured party) remain the same?
The premium will increase gradually over the coming four years, as detailed in the table of insurance premium variables and in the terms of the policy. The premium varies according to the age of the person insured. The ceiling of nursing compensation is fixed for the entire period of the insurance. The premium and the nursing allowance that is paid out are linked to the cost of living index and are updated quarterly.
How long are the qualification and waiting periods for the policy?
The policy has no qualification period. The waiting period in the event of an insurance event is 30 days from the occurrence of the event.
Who is considered to be a need of care patient entitled to insurance compensation under the policy?
An insured person who is unable to carry out alone a significant part (at least 50% of the action) of three of the following six actions: moving around independently, getting up and lying down, getting dressed and undressed, eating and drinking, getting washed, being continent; or an insured person whose health and functioning are poor due to "cognitive impairement", as a result of which they require supervision for most hours of the day.
What does the new long-term care insurance offer members of Maccabi Long-Term Care?
The plan guarantees people who require nursing care a monthly nursing allowance, so long as this care is needed, for a period of five years in one of the following tracks: Indemnification for nursing hospitalization expenses, as follows: Silver Shield members - indemnification at a rate of 40% of the expenses for nursing hospitalization, up to a ceiling of NIS 5,000 a month. Gold Shield members - indemnification at a rate of 80% of the expenses for nursing hospitalization, up to a ceiling of NIS 10,000 a month. At-home nursing care Providing service or financial compensation according to one of the following three options: Receiving nursing care from a nursing agency (Israeli carer):
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Silver Shield members - 25 hours a week Gold Shield members - 36 hours a week The cost of the service will be paid by Clal Health to the service provider with which it has an agreement. Compensation by means of a fixed monthly allowance for employing a foreign carer: Silver Shield members NIS 3,500 a month Gold Shield members NIS 4,500 a month This payment is conditional on producing a legal permit to employ a foreign worker when the claim is being examined, and again once every 12 months and/or as required by the insurer at an earlier date. Compensation by means of a fixed monthly nursing allowance - as detailed below: Silver Shield members NIS 3,000 a month Gold Shield members NIS 4,000 a month
Do I have to decide on my chosen track at the start of the insurance, or at another time?
The choice of insurance compensation track is made after the claim is approved by Clal Health. During the period that nursing compensation is being received, it is possible to change from one track to another at any time, at the sole discretion of the insured person.
If I choose to receive service from an Israeli carer, what do I have to do?

Clal Health is responsible for finding you a suitable Israeli carer. All you have to do is to apply to the claims center, which is staffed by a social worker who will accompany the entire process until a suitable Israeli carer is found. The salary of the Israeli carer will be paid directly by Clal Health. The family may ask for the nursing carer to be replaced if, in their opinion, the chosen carer does not meet the requirements of the person in need of nursing.
What does the insured person have to do in the event of a long-term care claim?
Fill out a claim form, attach the documents detailed on the form, and send it to the address that appears on the form. The claim form includes personal details, and the following documents must be attached: 1. Relevant medical material, including hospitalization summaries, if any. 2. In the event of mental infirmity, a diagnosis from a neurologist or psycho-geriatric physician.
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Can I cancel the policy?

The policy cover can be terminated at any time, by written notification to Clal Health.
Who is not covered by the insurance?

Members of Maccabi Shield Nursing Fund who were in need of nursing care under the regulations of the Nursing Fund before the date of the transition to Clal Health (before July 1, 2008) will not be entitled to inclusion in the new insurance under the policy, and will be handled by the Maccabi Shield Nursing Fund according to their entitlement under the existing Nursing Fund regulations. Members of Maccabi Healthcare Services who were not insured by the Maccabi Shield Nursing Fund on July 1, 2008, and whose new long-term care insurance proposal has been rejected by Clal Health will not be covered by the insurance. In addition, section 10 of the policy lists the situations in which a nursing allowance will not be paid to the insured person under the policy.
What is the insurance period under the policy?

The insurance period is five years. At the end of five years, Maccabi Healthcare Services has the option of extending the insurance period by a further three years, under terms to be determined at the time. Maccabi Healthcare Services will work towards continuation of the group long-term care insurance for an unlimited time, for further periods of five years at a time, by means of an insurance company, subject to the approval of the Commissioner of Insurance. If the period of insurance comes to an end, or in the event that the insured person leaves the health fund, a person who has been insured under the policy for at least three consecutive years will be entitled to transfer, without a break (without the need for further proof of health or qualification period), to the private policy marketed at the time by Clal Health that reflects the closest cover to that provided under this policy. This will be under the terms and at the premium in force for private policies, according to the insured person's age at the time, with a discount of 20%. Transition to the private policy while maintaining continuity of rights as stated will be allowed within 90 days of the date of termination of the insurance by the insured person.
Is it possible to increase the amount of the nursing compensation provided by the policy, or extend the period of payment beyond five years?
There is an option to purchase a private policy marketed by Clal Health at a discount of 20% on the insurer's usual rate. Joining this private policy is subject to filling out a declaration of health, medical underwriting, and approval by Clal Health. For further details, you can contact the Clal Health call center at 1-700-505-520.
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Where can I get further information about the long-term care insurance?
For questions and explanations about the terms of the new long-term care insurance policy, you can call the Maccabi Long-Term Care call center at 1-700-505-520. For questions regarding payment of the monthly insurance premiums for the long-term care insurance, please call the Maccabi Nonstop call center at 1-700-50-53-53, or*3555.
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Individual policy
We are living at a time when life expectancy is getting longer, medicine is making progress, and a new way of looking at things is required. As a Maccabi member, you will receive exceptional terms to expand your nursing cover for your entire lifetime. To check your entitlement: Maccabi Long-Term Care call center 1-700-505-520 or ask your insurance agent
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Appendix Guide to purchasing long-term care insurance

State of Israel Ministry of Finance - Capital Markets, Insurance and Savings Department
Please note:
1. This guide contains general information only. The binding terms between an insurer and an insured party are the terms of the policy and its accompanying documents. 2. This guide was written by the Commissioner of Insurance of the Ministry of Finance, and is updated to September 2006. The updates that may apply from time to time will appear, among other places, on the Ministry of Finance website at www.mof.gov.il
Table of contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 What is a need-of-care condition? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 How much does it cost to treat a need-of-care individual? . . . . . . . . . . . . . . . . 45 What am I entitled to receive from the state if I am in need of long-term care? . . . . 46 What is long-term care insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 What types of long-term care plans do insurance companies offer? . . . . . . . . . . . 49 What coverage do insurance companies give in long-term care insurance? . . . . . . . 50 In what situation will I be entitled to a nursing allowance from the insurance company? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 When will I be entitled to start receiving a monthly payment from the insurance company, and for how long? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
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What is the premium structure in long-term care insurance? . . . . . . . . . . . . . . 51 For how long will the insurance be valid? (Or: what is the insurance period?) . . . . . 52 How might an illness or medical condition before joining the insurance affect the scale of insurance cover? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Is there any tax benefit in long-term care insurance? . . . . . . . . . . . . . . . . . . 54 What should I check before purchasing long-term care insurance? . . . . . . . . . . . 54 What are the stages of purchasing long-term care insurance? . . . . . . . . . . . . . . 55
Appendices
Appendix A - Glossary of terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Appendix B - Additional types of individual long-term care plans . . . . . . . . . . . 60 Appendix C - How much does it cost to purchase long-term care insurance . . . . . . 62 Appendix D Significant details for comparing individual insurance plans . . . . . . 64 Appendix E - List of insurance companies selling long-term care insurance in Israel . 65 Appendix F Additional telephone numbers and websites . . . . . . . . . . . . . . . 66 Appendix G - Legislation and guidelines. . . . . . . . . . . . . . . . . . . . . . . . . 67 Appendix H - Basic conditions for long-term care insurance plans in the health funds (correct to September 2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
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1. Introduction
Insurance, particularly long-term care insurance, is a complex product requiring a relatively thorough understanding. Most people are not aware of their rights in these fields, or the differences that exist between the plans that the insurance companies offer. The purpose of this guide is to help you understand what a need-of-care situation is, and what costs are involved for a person in this situation, what you are entitled to receive from the state if you are in need of long-term care, and what insurance plans are offered by the insurance companies in the market. In this guide, we will also try to help you analyze your insurance needs for yourself and your family, and the options that are available to you. The guide offers a review of the long-term care insurance market and contains basic information on purchasing long-term care insurance. After studying the guide, we recommend that you turn to professionals in the field for explanations and assistance in purchasing insurance cover.
2. What is a need-of-care condition?

A need-of-care condition is when an individual cannot perform unaided a substantial part of the basic activities of everyday living, or is in need of supervision due to cognitive impairment (such as in the event of Alzheimer's). The following is the list of basic everyday activities: 1. 2. 3. 4. 5. 6. Getting up and lying down Getting dressed and undressed Washing Eating and drinking Continence Independent mobility
A person who is recognized as cognitively impaired or who is unable to perform unaided a substantial part of the activity in a certain number of the everyday activities listed above is defined as being a need-of-care case. The chance of a person being unable to perform alone at least one of the everyday activities increases with age: approximately 5% of people aged 65 74 are limited in their abilities, as compared with around 30% of people aged 80 or above.
3. How much does it cost to treat a need-of-care individual?

The cost of caring for a need-of-care individual varies according to where they are staying: The monthly cost of daily help at home is NIS 5,000, or even more if 24-hour supervision is required. The main cost is the employment of a full-time carer. To this must be added other costs such as diapers, medicaments, and the carer's living expenses.
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The monthly cost of private hospitalization in a nursing institution is between NIS 10,000 and NIS 20,000.
It should be noted that the length of time that a person remains in a need-of-care condition depends on his state of health, life expectancy, medical technology, and more.
4. What am I entitled to receive from the state if I am in need of long-term care?

By law, the main responsibility for caring for a person in a need-of-care condition lies with his family. Non-medical care of such a person is not a service provided by the health funds under the state National Insurance Law.The following entities provide partial assistance, after an examination of the individual's state of health and financial situation: the Ministry of Health, the Ministry of Social Affairs, the National Insurance Institute, and the health funds. Anyone wanting additional services or to supplement what is available from the state has to pay for it himself. The NII and the Ministry of Health provide the main government assistance, in accordance with set rules, as follows: The National Insurance Institute - at-home assistance Under the Long-Term Care Insurance Law, operated by the NII, people who have reached retirement age, live at home, and require the assistance of another person to carry out everyday activities, or supervision at home for their own safety, can receive a long-term care allowance from the state according to the tests and terms of entitlement set out in the law. Those who are found to be eligible will receive help from a carer coming to their home for a few hours a week, from 5 hours a week for the lowest level of eligibility (slight disability) to 15.5 hour hours a week for the highest level of eligibility (serious disability)1. This is relatively limited assistance, which is not sufficient for a person needing supervision for the majority of the day. The Ministry of Health - assistance for hospitalization in a nursing institution: If a need-of-care individual or his family decides on hospitalization in a nursing institution, an application can be made to the Ministry of Health for assistance in financing the nursing hospitalization. The state participates in the expenses of hospitalization in nursing institutions with which it has an agreement, subject to an examination of the individual's medical needs and social situation, to see whether he is an appropriate candidate for hospitalization in an institution of some kind 2 , as detailed below: A.
Functioning tests - examining the medical need-of-care condition

The definitions of the Geriatric Department at the Ministry of Health are as follows:
1Details
of the allowance are published on the NII website, www.btl.gov.il, under long-term care" on the subject can be found on the Ministry of Health website, www.health.gov.il, and on the website of the Geriatric
2 Information
Department at the Ministry of Health, www.health.gov.il/geriatric
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A need-of-care patient suitable for placement in a nursing institution A person whose state of health and functioning have deteriorated as a result of a chronic illness or permanent physical or mental deficiency, suffering from medical problems requiring skilled medical monitoring in a framework of a medical nature for an extended period, to whom one or more of the following conditions apply: a. b. c. He is restricted to bed or wheelchair; He cannot control his bladder or bowel functions He moves with great difficulty due to pathology or complications of various illnesses.
A cognitively impaired patient suitable for placement in a nursing institution An ambulatory patient suffering from reduced mental functioning (cognitive deterioration [dementia]) in the spheres of: memory, judgment, orientation, intellect, to such a degree that he is in need of full help with everyday activities, including: washing, dressing, eating, use of the bathroom (incontinence), guidance in mobility, and supervision. B.
Tests of income and economic entitlement - examination of social situation

The level of assistance given for nursing hospitalization by the state is determined by means testing. First of all, the data regarding the need-of-care person and his partner are examined: regular income, financial assets and real estate assets of the individual and his partner, including: pension, NII allowances, savings, rent. If these sources of income are not sufficient to cover the full cost of hospitalization in practice, the regular income of the adult children of the person in need of care is also taken into account: income and tax credits are examined according to salary slips only (taking into account students, mortgage expenses, etc.).
It is the person in need of long-term care who chooses the institution in which he wishes to be hospitalized. Financial assistance continues as long as the person remains in need of care, including in the case of cognitive impairment (in practice, usually until the person's death).
Who is not entitled to financial assistance from the Ministry of Health?

One of the following: 1. A person in a complex nursing condition (a need-of-care case suffering from additional serious illnesses such as cancer or bedsores) who is under the care of the health fund in the framework of the health basket provided by the National Health Insurance Law. Under the law, the patient and
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his family are required to make co-payments for complex nursing hospitalization. 2. A person in the process of rehabilitation (in hospital or in the community) who is under the care of the health fund in the framework of the health basket provided by the National Health Insurance Law. 3. A person defined as frail. According to the Ministry of Social Affairs definition: "an elderly person who, by virtue of his poor functioning, requires partial help with everyday activities". This refers to functional disabilities that are less severe than those of the need-of-care case, and such people can usually remain in the community. If such a person wants an institutional arrangement, they can apply to the Ministry of Social Affairs for assistance in financing accommodation in an institution for the frail3.
For your convenience, below is a table summarizing the situations in which it is possible to receive help from the state:
Functional state A need-of-care individual living at home A need-of-care individual in an institution Assistance from: Main conditions
National Insurance Intended for people over retirement age. A Institute carer for to 15.5 hours a week Ministry of Health Help in financing the cost of the institution, according to functionality and means testing Co-payment is usually required for prolonged hospitalization in a general hospital Rehabilitation in hospital or in the community Functional disability that is less severe than that of a need-of-care individual
A person in a complex nursing Health Fund care condition A person in the process of rehabilitation A frail individual in an institution Health Fund Ministry of Social Affairs
75% of patients in need of nursing care live at home, and 25% in nursing institutions. 5. What is long-term care insurance?
Long-term care insurance is a contract with an insurance company, called "an insurance policy for long-term care cover". Under this contract, a person pays a monthly premium and the insurance company undertakes, in accordance with the terms of the insurance policy, to participate in funding long-term care hospitalization or nursing care at home if the insured individual's situation changes and he becomes a need-of-care case, for as long as this condition continues, but no longer than the period of compensation defined in the policy.
Information on this subject can be found on the Ministry of Social Affairs website: www.molsa.gov.il, under Service for the Elderly
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6. What types of long-term care plans do insurance companies offer?

In addition to the rights provided by the state through the National Insurance Institute and the Ministry of Health, as detailed in section 4 above, the insurance companies sell policies intended to help finance the expenses of a person in need of nursing care. The long-term care insurance offered by the insurance companies includes group policies and personal policies (individual insurance). Group insurance is intended for a group of people, whose representative draws up the engagement with the insurance company. In such insurance, there is an entity representing the insured parties, called the policyholder. The policyholder draws up the contract with the insurance company, and discusses the terms of insurance for all members of the group. The insurance contract is usually drawn up for short periods of three years or more (and not for the lifetime of the insured individual). Continuation of the insurance for the group at the end of the period depends on renewal of the agreement between the insurance company and the policyholder (for further details, see section 11). The terms of the group policy are uniform for all members of the group, and a uniform premium is charged for each age group (the premium increases as the age-group goes up). There are cases in which the amount of the insurance (the compensation) varies according to age-group, and is higher for those joining the insurance at a younger age. The long-term care insurance offered by the insurance companies is, for the most part, made up of group insurance policies sold to members of the health funds. Group insurance policies are also sold to groups of employees and organizations. Individual insurance is a personal insurance policy marketed as a direct contract between the insured and the insurance company. The insured purchases the insurance through an insurance agent, or directly from the insurance company. The premiums paid by each insured individual is calculated according to his age, state of health, the monthly compensation chosen (the amount that he will receive if he becomes a need-of-care case), and the length of the compensation period. The insurance period is the entire lifetime of the insured individual (the insurance company may not cancel the insurance during the period, only the insured individual himself), the premium may vary with age or be fixed for the entire insurance period, but from the age of 65 and up it is always fixed (does not vary with age), and the insured can usually accumulate rights during the insurance period. It is worthwhile checking with your health fund whether you have long-term care insurance through the fund. Approximately half of the members of health funds have long-term care insurance. Please note that the health funds market the long-term care insurance separately from their other healthcare services (Clalit Mushlam, Maccabi Siudi, Meuhedet Adif / C, and Leumit Kesef / Zahav), and it is given for an additional monthly payment. If you are not insured through your health fund, it is worth checking the terms of the long-term care insurance for health fund members, and if possible, joining it. If necessary, the insurance cover can be supplemented by purchasing an individual policy.
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7. What coverage do insurance companies give in long-term care insurance?

The insurance plans (of all the different types detailed above) offer an insured person who is in need of nursing care a monthly payment for a defined period of time. The monthly payments can be in the form of compensation or indemnification. Compensation: if the insured is in a need-of-care condition, in accordance with the terms of the insurance plan that he has purchased, he will be entitled to a monthly amount that has been agreed in advance, regardless of money received from other sources, if any. The average compensation purchased in individual policies is NIS 6,000 a month. All the individual policies sold today are of the compensation type, under which the insured can choose the level of monthly compensation that he wants on joining the plan. Indemnification: reimbursement of actual expenses for hospitalization in a nursing institution, up to a certain, predefined amount. With policies offering indemnification, it is important to know that if you have indemnification type insurance cover under other policies providing long-term care insurance, it is only possible to receive, from both policies together, an amount that is no greater than the total expenses in practice for hospitalization in a nursing institution.
8. In what situation will I be entitled to a nursing allowance from the insurance company?
The conditions for defining a need-of-care situation are detailed in each policy. The insured individual will be entitled to receive payments from the insurance company only if these conditions exist. The common definition of entitlement to a nursing allowance among insurance companies is based on the insured's inability to carry out basic everyday actions, alone and unaided, as detailed in section 2 above, and on the need for supervision for most of the hours of the day in the case of cognitive impairment (for example, due to Alzheimer's). The condition of the insured person is examined on the basis of medical documents and tests of functioning submitted to the insurance company. The smaller the number of everyday activities given in the policy as a condition for receiving a nursing allowance, the more beneficial the policy is for the individuals insured.
Please note!
In policies issued or renewed after September 2003, insurance companies are obligated to provide insurance cover from the stage that the insured is unable to carry out three out of six everyday activities, or if he is in a state of cognitive impairment (for example due to Alzheimer's) and needs supervision for the majority of the day.
9. When will I be entitled to start receiving a monthly payment from the insurance company, and for how long?
Qualification period: a period of time on joining the long-term care insurance, usually three months, during which the insured is required to pay a premium for the insurance policy but is not entitled to cover in the event that he becomes a need-of-care case. For example, if the qualification period set out in the policy is three months, the insured will not be entitled to
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receive payments if he becomes a need-of-care case during the first three months from the start of the insurance period. Waiting period: the period that the insured is required to wait from the moment that he is first in need of nursing care and until he is entitled to receive the monthly payment. The waiting period is usually three months. During this period, the insured finances the costs of treatment, and at the same time continues to pay the insurance premium. For example, if the waiting period set out in the policy is three months, the insured will be entitled to receive monthly compensation only as of the fourth month after becoming a need-of-care case. Compensation period (period of payment of the insurance compensation): the period of time set out in advance in the policy, during which the insurance company undertakes to pay the insured a monthly financial payment (this usually involves a certain amount rather than a service/treatment). In other words, an individual who meets the definition of a need-of-care case during the insurance period, and has waited out the waiting period, is entitled to a monthly financial payment according to the number of months or years agreed in the policy. There are policies that provide payment for the rest of the insured's life, and there are policies that provide payment for a limited period of time (usually three, five or eight years). When receiving payments from the insurance, the insured is exempt from paying premiums for as long as he remains in a need-of-care condition. For example: if the insured purchases a policy with a compensation period of five years, at the end of the waiting period he will begin to receive monthly compensation payments for five years, as long as he remains in a need-of-care condition. If his state of health improves and he is no longer a need-of-care case as defined by the terms of the policy, payment of the monthly compensation will stop and the insured will go back to paying the insurance premium. In the event that he is once again in a need-of-care condition, he will be entitled to receive monthly compensation for the duration of the remaining compensation period: that is, if he has already received compensation for a year and is again in need of nursing care, he will be entitled to receive monthly compensation for a further four years. On the other hand, if the insured has purchased a policy providing lifetime compensation, he will be entitled to compensation for as long as he is in need of nursing care, for an unlimited time, even if he has been in a need-of-care condition, his condition has improved, and then he is again in need of nursing care.
Please note!
Research studies from 2004 show that a person hospitalized in a nursing institution remains there for an average of three years. However, as a result of the increase in life expectancy, along with the increase in the number of people suffering from cognitive impairment, this period appears to be getting longer. It is therefore important to check your policy to see how long you will receive payment from the insurance company if you are in need of nursing care (that is, the length of the compensation period).
10. What is the premium structure in long-term care insurance?

In long-term care insurance policies, it is hard for insurance companies to commit to a known
51
premium that will not change over time, due to the limited data and uncertainty characteristic of long-term care insurance. The insurance companies may therefore change their schedule of premiums for all insured parties once every few years in the course of the insurance period. Group policy: These are usually policies whose premiums vary according to age group. In addition, the insurance company may raise the premiums for all insured parties, on fixed dates, according to the agreement signed between the policyholder and the insurance company. An insured individual who chooses to terminate the insurance will not continue to be insured, even with reduced cover, since no money or rights are accumulated for the specific insured individual in the group policy, unlike in an individual policy as stated in the following section. Individual policy (personal policy: The premium structure in a personal policy for long-term care insurance can be one of two: a. b. A premium that varies by age up to the age of 65, and from the age of 65 - a fixed premium (which does not vary by age) for life; A premium that is fixed for life, and does not vary by age.
In personal policies with a fixed premium, the insurance company accumulates rights for the insured in respect of each premium payment. In a policy of this kind, the insured pays a premium that is higher than his insurance risk in the younger age groups, and the surplus amount is accumulated towards the older age groups. An insured individual who terminates the insurance will continue to be insured at a reduced rate of cover according to the amount that has accumulated for him (paid-up value). That is, an insured who has paid the premium for a number of years and then stops paying it will receive partial payment from the insurance company when he is in need of nursing care. The amount of compensation that he will receive in this situation depends on the number of years that he has paid the premium, and the rules laid down by the Commissioner of Insurance. A table of partial compensation according to the number of years of payment appears in the policy. In personal policies with a variable premium, it should be noted that on transition to a fixed premium, at the age of 65, there is usually a significant increase in the insurance premium.
Please note!
The level of premiums in long-term care insurance (personal and group) is not guaranteed, and it is possible that the insurance company will raise its premiums for all insured parties, both in the fixed premium and in the variable premium track. In addition, it is important to note that the "paid-up value" section is intended to protect the insured in the event that he cannot continue to pay the premiums. Therefore, in comparing between individual policies it is worth taking this section into account in considering whether to buy a policy with a fixed or a variable premium.
11. For how long will the insurance be valid? (Or: what is the insurance period?
The insurance period is the period for which the policy provides insurance cover to a particular
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individual. A person who becomes in need of nursing care during the insurance period is entitled to claim the insurance compensation. On the other hand, a person who becomes in need of nursing care before the start of the insurance, during the qualification period, or after the insurance period has come to an end is not entitled to compensation from the insurance company Long-term care insurance is intended to provide long-term support. It is therefore very important, when considering joining a group insurance, to check the length of the insurance period and whether the insurance company has the right to terminate the insurance at any point in time. In personal policies, the insurance period is the lifetime of the insured individual. In other words, the insurance company may not cancel the insurance in the middle of the period, unless the insured has stopped paying the insurance premium, or there has been a failure of disclosure by the insured, subject to the provisions of the law. The insurance can only be cancelled by the person paying the premiums. On the other hand, in a group policy the insurance company is committed to an insurance period of only a few years. In other words, after the period agreed between the parties as the length of time that the individuals in the group are covered by the policy has come to an end, the insurance company or the policyholder can terminate the insurance. In this context, it should be pointed out that in recent years there have been a number of instances of group insurance that have been terminated with regard to all the insured individuals. For group policies that have been issued or renewed as of July 2004, the insurance company is obligated to enable individuals insured under the policy for more than three years to transfer to a personal long-term care policy with similar terms, but at the cost of a personal policy, without re-examining their medical condition (that is, without medical underwriting, as detailed in section 12 below). This right is given to an insured who leaves a group, or if the insurance for all members of the group comes to an end. In the personal policy joined by the insured, the insurance company cannot unilaterally terminate the insurance at any time during the insured's life, providing that he continues to pay the insurance premiums. However, it is important to note that the premium for a personal insurance policy is liable to be considerably more expensive than the premium for a group insurance policy.
Please note!
Before purchasing any kind of group insurance, it is important to check under what conditions the insurance company will cancel the agreement, whether it is possible to transfer to a personal policy in the event of cancellation of the policy, and under what terms.
12. How might an illness or medical condition before joining the insurance affect the scale of insurance cover?
When signing an insurance contract, one is usually required to make a declaration of health and previous illnesses, and sign a waiver of medical confidentiality. This form enables the insurance company to verify the declaration by checking the medical file, either on entering into the insurance, or on making a claim. On the basis of the health declaration, the insurance company can decide on personal exceptions to the insurance cover, or even decide not to accept an individual into the insurance. This process is called medical underwriting. If there are previous illnesses, it is possible that the insurance company may accept the individual for insurance at a higher premium,
53
or with specific limitations regarding the insurance cover. In some long-term care insurance policies there is a general stipulation that the insurance company may restrict the insurance cover, or even not pay insurance compensation to the insured, if the insurance event is due to the insured's medical condition prior to joining the insurance. Under the provisions of the law, in policies issued or renewed as of March 2004, the insurance company can limit the validity of the insurance cover under the policy in respect of the previous medical condition for a maximum of one year from the starting date of the insurance, if the insured's age is under 65 on joining the insurance, or six months if he is aged over 65. A stipulation in respect of the previous medical condition will not be valid if the insured has informed the insurer of his previous state of health and the insurer has not explicitly stipulated this state of health on the page of insurance details.
Please note!
The insurance company may refuse to pay insurance compensation to an insured individual on the grounds that the insurance event is the result of a medical condition that existed in the insured prior to signing the insurance contract. Today, in most policies, the insurance company can reject a claim in respect of a previous medical condition that existed for a maximum of one year from the date of joining the insurance. If the insured is asked about his state of health and does not reveal it to the insurer, or does not give a full response to questions, the insurance company can cancel the policy, in accordance with the provisions of the law. Before purchasing a long-term care insurance policy, it is important to check whether the insurance company has defined any personal exceptions that could affect the validity of the insurance cover, and if there are limitations to the validity of the insurance (policy) in respect of a previous medical condition, in particular in cases where an existing policy is replaced by a new one.
13. Is there any tax benefit in long-term care insurance?

There is no tax benefit for the payment of premiums for long-term care insurance. The insurance compensation is not liable for tax.
14. What should I check before purchasing long-term care insurance?

1. How much will the insurance cost each month until old age? 2. Will the premium vary with age, or is it fixed over the years? 3. What will happen if I want to stop the insurance or cannot pay the full premium in the future? That is, will the amounts that I have paid be credited to me (is there a "paid-up value" section and what are its terms)? 4. What are the terms of the policy, and in particular:
54
What is the monthly payment I will receive from the insurance company if I become a need-of-care case? For how many years will I receive this compensation from the insurance company?
Are there personal limitations to my entitlement due to my health declaration? Is there a general exception or limitation regarding a previous medical condition, and for how long is it valid? What are the exceptions for limitations that exist in the policy (not necessarily in relation to my state of health)? The insurance company is required to emphasize these exceptions. How long is the waiting period? How long is the qualification period? Are the insurance payments in the form of indemnification (reimbursement of expenses against receipts) or compensation? Is there a deduction in respect of other sources?
5. In a group long-term care policy: For how many years has the insurance contract with the group been signed? (Pay attention, the policy is usually valid only for a certain number of calendar years, after which the insurance company can change the terms or terminate the insurance contract). In the event that the insurance is not renewed at the end of the period, or if I choose to leave the group, how much will it cost me to continue the policy on a personal basis, and under what conditions?
15. What are the stages of purchasing long-term care insurance?

The first stage in purchasing long-term care insurance is to define the insurance needs and examine sources of income. It is recommended to increase your knowledge in the field of long-term care insurance before purchasing insurance cover, among other ways by checking out the relevant issues on the website of the Capital Markets, Insurance and Savings Department in the Ministry of Finance, the websites of the insurance companies, and by speaking to insurance agents4 or other professionals in the field. a. Define the insurance needs for yourself and your family The first step to take is to review the insurance needs for yourself and your family, and your reasons for purchasing the insurance. Please note, long-term care insurance provides protection and financial security for old age, and you therefore need to examine your state of health in the long range. At the same time, it is worth taking into account that young people can find themselves in need of nursing care, usually as a result of an accident. Below are the main questions you should ask yourself when deciding on the need for long-term care insurance: 1. Are you single or do you have a family and children? 2. Do you have a family history of needing nursing care or of illnesses resulting in a need-of-care situation?
The relevant laws, guidelines and websites appear in Appendices C - E.

55
3. Do you want to insure against a need-of-care event that is liable to be a financial burden on you or your family in the future? b. Examine the sources of income that are available to you After considering whether you need long-term care insurance, you should examine the sources of income that are available to you: 1. Do you have savings, investments and/or property that could help you finance longterm nursing care (at home or in an institution) in your old age? 2. Do you think that your family would be able to help you if you were in need, financially and physically, and to what degree? 3. Do you already have a long-term care insurance policy (a group policy through your place of work, health fund or other entity, or a personal policy)? 4. Do you think that you would be entitled to help or funding from the National Insurance Institute or the Ministry of Health? After defining the insurance needs and examining the sources of income that you have available to you, you can decide on the scale of insurance cover (the amount of the monthly compensation) that you need. If you already have long-term care insurance from any source (please note that most members of health fund supplementary insurance plans already have long-term care insurance through their health fund), you must consider whether you need additional insurance. It is very likely that purchasing new insurance will create a state of over-insurance, which could have an impact on your budget and your financial plans for the long-term, the same way that under-insurance could affect your savings and other assets. In this situation, it is possible that you do not need additional insurance. The second stage is to make a comparison between the individual policies that exist in the market. You should check and study the different types of long-term care insurance that exist before choosing the most suitable policy to you. Not all policies are the same. There are policies for different periods of compensation, at fixed or variable premiums. Your choice should be based on your needs, and what you can allow yourself. In addition to studying the consumer guide, which contains basic information about purchasing long-term care insurance, you should also take advice from a professional such as a licensed insurance agent. The agent can market policies from one or more insurance companies. It is recommended to contact a number of agents in order to find out about the greatest range of policies from different companies. Choose the agent from whom you purchase the insurance with care, as someone who is reliable and professional, and it is also recommended to check that the agents hold a license from the Commission of Insurance5 , since he will receive a commission on your purchase. The role of the insurance agent is not just to sell you an insurance policy. A professional
5
It is recommended to check the agents' licenses through the "insurance agents and agencies system", on the Commissioner of Insurance's website: www.mof.gov.il/hon/bituach.htm
56
agent will help you define your needs, review and compare the insurance plans that he offers, explain, advise, answer all your questions, and help you if you have a claim. In order to compare insurance policies, you can also make use of the due disclosure forms that all insurance companies are required to send to everyone insured with them. This form gives a summary of cover and other information dealing with the proposed insurance cover. The form will help you understand the proposed insurance cover and compare insurance plans. Make sure that you receive this form. After examining the scale of insurance cover that you require, and examining the options available on the market, you should check how much it will cost. Personal long-term insurance care is relatively expensive. Make sure that you are able to pay the monthly premium, and that the expense is not too much of a burden on your monthly budget. You should check whether the premium varies by age in the course of the insurance, and if you will be able to afford the monthly premiums at all stages. Remember, failure to pay the premium will result in cancellation of the insurance, or in reduced cover.
57
Appendix A Glossary of terms

Insurance plan (policy) - an insurance contract signed between an insurance
company and a person purchasing the contract (policyholder) pay to the insurance company for the insurance plan
Insurance premium - the monthly payment that the insured person is required to Insurance period - the period during which the policy provides insurance cover
to a particular person; a person who becomes a need-of-care case during the insurance period is entitled to claim the insurance compensation the insurance; during this period the insured is required to pay the premium for the insurance policy that has been purchased, but is not entitled to cover in the event of becoming a need-of-care case need-of-care case and being entitled to receive the monthly compensation; during this period, the insured bears the costs of treatment
Qualification period - a period of a number of months from the date of joining
Waiting period - the period that the insured is required to wait between becoming a
Insurance compensation payment period - the period of time that the insured is
entitled to receive insurance compensation; this period is determined in advance in the policy
Conditions for receiving payment from the insurance company (the insurance
event) - the conditions under which, according to the policy, a person is considered to be a need-of-care case; the insured will only be entitled to receive compensation from the insurance company if these conditions exist compensation from the insurance company; the policy contains "general exceptions" (for example, terrorism, drug abuse), which apply to everyone purchasing the policy, and there are also personal exceptions" relating to the medical condition of the insured before joining the insurance occurs by way of an amount agreed in advance, without the need to prove any kind of expense an original receipt, up to a certain amount defined in advance; insurance indemnification payments from other sources can be deducted
Exceptions and stipulations - situations in which the insured will not receive
Compensation - insurance payments paid to the insured when the insurance event
Indemnification - reimbursement of expenses to the insured, usually against
58
Paid-up value - a term that exists in individual fixed-premium policies only:
enables an insured who has paid the premium for certain number of years and decided to stop making payments to receive partial compensation from the insurance company if he becomes a need-of-care case
59
Appendix B Additional types of individual long-term care plans

The following are three examples of other long-term care insurance plans (over and above the standard insurance described in detail in the guide). The first two examples are an expansion or addition to long-term care insurance that the insured already holds:
1. Supplementary cover in long-term care insurance

The majority of insurance companies operating in the field of long-term care insurance currently offer plans with a long waiting period6 (three or five years, instead of a few months). These plans are intended to supplement the cover provided by another long-term care policy held by the insured (hereinafter, the "base policy" - an individual policy, group policy through a health fund, or other group policy). These policies usually have a lifetime compensation period, that is, after the waiting period of a number of years is over, the insurance company will pay the insured the amount of compensation that has been purchased, every month for the remainder of his life, so long as he is in an entitling condition. Entitlement to the insurance compensation under the supplementary policy is determined according to the terms set out in the policy or the terms set out in the base policy, the earlier of the two. In other words, in a situation where a person is considered in need of care under the base policy that he holds, he will be entitled to receive insurance payments under the supplementary policy (after the waiting period), even if he is not considered in need of care under the terms of the supplementary policy. Below are examples of situations in which a person is likely to purchase this insurance: A person who has purchased a long-term care insurance policy through the health fund. The policy states that the insurance payments will be made for a period of only three years - this person can purchase a supplement to the cover in the policy, in which the waiting period is three years. In this way he will continue to receive a certain amount of money of his choice, from the insurance company from which he has purchased the supplementary policy. Since the maximum payment period in the majority of long-term care insurance policies for health fund members is limited, this supplementary cover is offered to help health fund members who have purchased long-term care cover. A person who has purchased an individual policy for long-term care insurance providing lifetime monthly compensation of NIS 3,000, and wants to increase the amount that he will receive after three years, on the assumption, for example, that his savings will only help him finance nursing care for a few years.
2. Insurability appendix
An insurability appendix is an appendix attached to a long-term care insurance policy. It can be purchased for an additional premium. Purchasing this appendix enables the insured, on reaching the age of 65, to purchase an additional nursing allowance (that is, to increase the amount of
6
The period that the insured is required to wait between becoming a need-of-care case and beginning to be entitled to receive the monthly payment
60
the monthly compensation) without the need for repeat medical underwriting. A person who becomes a need-of-care case before the age of 65 cannot purchase an additional allowance as stated above.
3. Long-term care insurance with one-time (capital) compensation

There are policies which enable the insured to purchase long-term care insurance guaranteeing a one-time compensation payment on occurrence of an insurance event, in an amount chosen by the insured, without the monthly insurance payments that are customary in the majority of insurance plans on the market.
61
Appendix C How much does it cost to purchase long-term care insurance

Individual insurance
Below are examples7 of the monthly premiums that a man or woman will have to pay at different ages during their lives, and for different periods of compensation, for a monthly compensation of NIS 5,000 in an individual policy (a policy with a fixed premium, including policy factor):
Compensation period
3 years Age 40 50 60 70 80 Man NIS 90 NIS 125 NIS 175 NIS 325 NIS 680 Woman NIS 115 NIS 165 NIS 250 NIS 480 NIS 1000 Man NIS 130 NIS 170 NIS 250 NIS 420 NIS 870 5 years Woman NIS 160 NIS 220 NIS 325 NIS 645 NIS 1,345 NIS 185 NIS 245 NIS 355 NIS 660 NIS 1,285 Lifetime Man Woman NIS 260 NIS 350 NIS 500 NIS 950 NIS 2,170
So for example, a man who wants to buy a long-term care insurance policy at the age of 60 and receive the amount of NIS 5,000 from the insurance company for a period of five years will have to pay NIS 250 every month. A woman who wants to buy a long-term care insurance at the age of 70 and receive the amount of NIS 5,000 from the insurance company for the remainder of her life will have to pay NIS 950 every month.
Transferring from a group policy to a personal policy

As stated in section 11 of the guide (how long will the insurance be valid), in the event that the longterm care insurance is terminated for all members of a group insurance of any kind, or in the event that an individual decides to leave the group for reasons detailed in this section, the insurance company has to offer the group or the particular individual the option of transferring to an individual policy. In the majority of cases, the individual policy is considerably more expensive than the group policy.
7Note:
the prices appearing in the tables below are only an example and are not binding. The prices are correct for the point in time when they were written, and do not include underwriting and other supplements.
62
Below are examples of the monthly premiums that a man or woman will have to pay at different ages, for monthly compensation of NIS 3,000 for a period of three years, on transferring from a group policy (this example relates to a policy for a member of one of the health funds) to an individual policy from the insurance company (fixed premium):
Man Age of insured Group Individual Change Group
Woman Individual Change NIS 160 Approx. x 4 NIS 210 Approx. x 4 NIS 530 Approx. x 8.5
65 NIS 50 70 NIS 70 80 NIS 70 NIS 400 NIS 185 NIS 145
NIS 95 Approx. x 3
NIS 50
NIS 210
NIS 115 Approx. x 2.5
NIS 70
NIS 280
NIS 330 Approx. x 6
NIS 70
NIS 600
63
Appendix D Significant details for comparing individual insurance plans

What is the insurance period? What is the payment period? Is the payment compensation or indemnification? If compensation - how much is the monthly compensation? If indemnification - what is the ceiling of indemnification and are other sources deducted? What is the qualification period? What is the waiting period? Is there an exception regarding a previous medical condition? Are there personal exceptions that are liable to reduce the cover? In an individual policy - is there a paid-up value and when is it possible to start receiving it?
64
Appendix E List of insurance companies selling long-term care insurance in Israel

Name of company Telephone Address
12 Abba Hillel Silver St., Ramat Gan 2 Even Gvirol St., Tel Aviv 2 Besser Towers, 1 Ben Gurion St., Bnei Brak 2 Aryeh Shenkar St., Tel Aviv
Website
Ayalon Insurance Co. Ltd. Eliahu Insurance Co. Ltd. Dikla Insurance Co. Ltd. Hachsharat Hayishuv Insurance Co. Ltd. Hamagen Insurance Co. Ltd. Phoenix Insurance Co. Ltd.
03-7569210 03-6920911 03-6145777 03-7962666 03-9201010 03-7332222
www.ayalon-ins.co.il www.eliahu.co.il www.dikla.co.il www.ildinsur.co.il
1 Hayetzira St., Kiryat www.ha-magen.co.il Aryeh, Petach Tikva 53 Derech Hashalom, Givatayim 2 Abba Hillel Silver St., Ramat Gan 48 Menachem Begin Ave., Tel Aviv 52 Menachem Begin Ave., Tel Aviv 2 Efal St., Petach Tikva 115 Allenby St., Tel Aviv www.phoenix.co.i
Harel Insurance Co. Ltd.
03-7547777
www.harel-ins.co.il
Clal Insurance Co. Ltd. Clal Health Insurance Ltd. Migdal Insurance Co. Ltd. Menora Insurance Co. Ltd.
03-6387777 03-6388388 03-9168888 03-7107777
www.clalbit.co.il www.health.clalbit.co.il www.migdal.co.il www.menora.co.il
65
Appendix F Additional telephone numbers and websites

Ministry of Health Telephone: 02-6705705 Website: www.health.gov.il The National Insurance Institute Telephone: 08-6509999 Website: www.btl.gov.il Ministry of Social Affairs service for the elderly Telephone: 02-6708170/200 Website: www.molsa.gov.il Eshel the association for planning and developing services for the elderly in Israel Telephone: 02-6557551 Website: www.eshelnet.org.il or www.eshelinfo.org.il The Commissioner of Insurance public inquiries department Telephone: 02-6211400 Fax: 02-5695352 Website: www.mof.gov.il/2001/general/pniyot.asp
66
Appendix G Legislation and guidelines

The National Insurance Law (combined version) 5755 1995, Section 10 longterm care insurance Regulations for the Supervision of Insurance Transactions (Terms of insurance contracts) (Provisions regarding previous medical condition) 5764 2004 National Health Insurance Law 5754 1994 Patients Rights Law 5756 1996 Insurance circular letter 2001/9 Due disclosure to insured on joining a health insurance policy Insurance circular letter 2002/3 Due disclosure in group health insurance Insurance circular letter 2002/6 Individual long-term care insurance Insurance circular letter 2003/9 Definition of the insurance event in long-term care insurance Insurance circular letter 2004/11 Group long-term care insurance
67
Appendix H Basic conditions for long-term care insurance plans in the health funds (correct to September 2006)*
Subject
Definition of the insurance event
Clalit Health Services (through Dikla Insurance Co. Ltd.)

The insureds inability to perform unaided 3 out of 6 everyday activities or an insured suffering from cognitive impairment 9 months 3 months 3 years
Leumit Health Fund (through Harel Insurance Co. Ltd.)

The insureds inability to perform unaided 3 out of 6 everyday activities or an insured suffering from cognitive impairment 3 months 2 months 5 years
Qualification period Waiting period Length of insurance period
Earliest date for a possible change in terms / rates
June 2007
March 2009
*The terms of the insurance plan marketed to members of Maccabi Healthcare Services are updated to July 2008
68
Meuhedet Health Fund (through Phoenix Insurance Co. Ltd.)

The insureds inability to perform unaided 3 out of 6 everyday activities or an insured suffering from cognitive impairment None 1 month 7 years
Maccabi Healthcare Services (through Clal Health Insurance Ltd.)

The insureds inability to perform unaided 3 out of 6 everyday activities or an insured suffering from cognitive impairment None 30 days 5 years Maccabi has an option to extend the insurance period for an additional 3 years, at a premium to be agreed by the parties Terms: June 2013 Rates: July 2011
Terms: April 2010 Rates: April 2007
Continuation of table on the following page
69
Subject
Monthly insurance compensation payments
Clalit Health Services (through Dikla Insurance Co. Ltd.)

The maximum amounts in the event of inability to perform 4 activities or cognitive impairment, in NIS:
Entry age At home In an institution
Leumit Health Fund (through Harel Insurance Co. Ltd.)

The maximum amounts in the event of inability to perform 3 activities or cognitive impairment, in NIS:
Entry age At home In an institution
Up to 45 50 - 64 65 - 74
4,478 3,134 2,015
7,463 5,224 3,358
Up to 64 65+
4,200 2,350
6,500 3,600
In the event of an accident to an insured aged less than 50, additional 75+ 1,343 2,239 The amounts are linked to the CPI, and compensation of NIS 2,000 will be the base index is that published on January given if he is in an institution, or NIS 1,400 if he is at home. 15, 2004. For 3 activities, 50% of the amount in the table will be received. In an institution, payment will be 60% of expenses in practice, up to the maximum amounts in the table for 4 activities, and up to 50% of the amounts in the table for 3 activities. The amounts are linked to the CPI, and the base index is that published on February 15, 2004. The determining date for deciding the age of the insured is April 1, 2004, or the date of joining the insurance, the later of the two.
Insurance compensation payment period Form of payment
3 years At home compensation In an institution - indemnification
5 years Compensation
Consideration of payments given by insurance companies or other entities Complies with the Commissioners instructions
In the event of indemnification from another source, if the insured is in an institution
Other pay ments are not taken into consideration
Yes
Yes
70
Meuhedet Health Fund (through Phoenix Insurance Co. Ltd.)
Maccabi Healthcare Services (through Clal Health Insurance Ltd.)
At home, can choose one of the following three options, At home and change from one to another as detailed in the Can choose one of the following three policy: tracks, and change from one to another at any time:
Option Israeli carer
Foreign carer
Additional 2 years 21 hours a week 6 days a week: 24 hours a day; 7th day: 4 hours (substitute carer)
1st 3 years 36 hours a week As in first years + copayment of NIS 1,800 a month 60% of the
Silver Shield 25 hours a week Compensation of NIS 3,500 a month NIS 3,000 a month
Gold Shield 36 hours a week Compensation of NIS 4,500 a month NIS 4,000 a month
Option Israeli carer Foreign carer Financial
The amounts are linked to the CPI, and the base index is that published on June 15, 51 65: NIS 4,500 amount in all 2008. compensation The right are given in full, regardless of the 66+: NIS 3,000 age groups age of joining the insurance (no reduction of *Calculated age age on the determining date (April rights in old age) 1, 2006) or on the date of joining the insurance, the In an institution later of the two. Gold Shield: payment will be 80% of the In an institution expenses in practice, and no more than NIS 10,000 a month. Silver Shield: payment will be 40% of the expenses in practice and no more than NIS In an At home Entry age 5,000 a month. institution
Financial Up to 50: NIS 5,000
60% of the Up to 50 7,000 amount in all age 51 - 65 6,500 groups 66+ 4,500 The amounts are linked to the CPI, and the base index is that published on February 15, 2004.
5 years At home service from a carer, or compensation In an institution - indemnification In the event of indemnification from another source (other than the state), if the insured is in an institution 5 years At home service from a carer, or compensation In an institution - indemnification In the event of indemnification from another source, if the insured is in an institution
Yes
Yes
71
Instructions for submitting a claim in a need-of-care case

When you become aware of the need to make a claim under the policy, it is necessary to contact the insurer and receive its approval for obtaining the insurance compensation: Documents to be presented to the insurer when making a claim:
A long-term care claim form (filled out by the insured) the form includes personal details and a waiver of medical confidentiality, permitting any doctor and/or other entity or institution in Israel and/or abroad to pass on to the insurer all medical information in its possession relating to the insured. If the insured is not competent to sign, a guardian may sign for him, and the guardianship form should be attached to the claim form. The following should be attached to the claim form:
1. Medical documents, including hospital discharge letters, indicating the medical problem (if any)
Please note!
2. In the event of cognitive impairment, attach a diagnosis from a neurologist or psychiatrist 1. The claim will only be approved if it meets the provisions of the policy.
What will happen next?
2. The claim form can be downloaded from the website: www.maccabisiudi.co.il On receipt of the documents, the insurer will examine the insurance cover under the terms of the policy. Shortly after submitting the claim, the insured will be asked to undergo examination by a doctor, nurse, or occupational therapist, on behalf of the insurer and at its expense, to determine whether the condition of the insured entitles him to receive insurance compensation according to the terms of the policy. The examination will be arranged in advance, and will take place in the insured's home or in the nursing home in which he is staying. In cases where clarifications are required - the insurer will contact you and ask for additional material. In certain cases, the insurer will request the medical file of the insured directly from the health institutions. In any event, you will receive the decision of the insurer in writing. If it turns out that you are not entitled to the insurance compensation, you will be sent written notification detailing the reasons. Reservations with regard to the insurer's decision to reject the claim can be addressed to the call center, which will provide guidance in submitting an appeal to the appeals committee.
For clarification after submitting a claim, please contact the call center at tel: 1-700-505-520
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Ways of contacting Maccabi Nursing Care (Maccabi Siudi)
Tele phone: 1-70 0 -505 -520 Fax: POB Zip code: 03-6387807 3 719 0 , Te l Av i v 61370
w w w. m a c c a b i s i u d i . c o . i l
* The binding policy is the Hebrew version
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Notes
74

Macabi Long Term Care

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Macabi Long Term Care

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Group long-term care policy for members of Maccabi Healthcare Services

Group long-term care policy for members of Maccabi Healthcare Services

Wishing you good health,

Dr. Ehud Kokiya Director-General Maccabi Healthcare Services

Group long-term care policy for members of Maccabi Healthcare Services

Wishing you many years of good health,

Reuven Kaplan CEO Clal Health Insurance Ltd.

Group long-term care policy for members of Maccabi Healthcare Services

Group long-term care policy for members of Maccabi Healthcare Services

Summary of general details about Maccabi Long-term care

Length of insurance period

Group long-term care policy for members of Maccabi Healthcare Services

Conditions for automatic renewal

Qualification period Waiting period Co-payments

Group long-term care policy for members of Maccabi Healthcare Services

Amount and structure of the premiums

Changes in insurance premium during the insurance period

Conditions for cancellation

Conditions for cancellation of the policy by the Policyholder or the Insurer

Group long-term care policy for members of Maccabi Healthcare Services

Section 11 of the policy.

Length of period of insurance payments Type of insurance payments

Group long-term care policy for members of Maccabi Healthcare Services

Group long-term care policy for members of Maccabi Healthcare Services

The binding terms are the full terms of the policy

Group long-term care policy for members of Maccabi Healthcare Services

Maccabi Long-Term Care

Group long-term care policy for members of Maccabi Healthcare Services

5. Continence - the Insured's independent ability to control his bowel

movements and/or urination. Failure to control one of these actions,

As stated in section 7.1.1, 7.1.2, 7.1.3 below. 2.12.

"Maximum Period of Entitlement to Nursing Allowance - a cumulative period of no more

4. The insurance period:

Group long-term care policy for members of Maccabi Healthcare Services

6. Nursing allowance for a Beneficiary hospitalized in a nursing home:

Group long-term care policy for members of Maccabi Healthcare Services

8. Transferring between plans and tracks:

Group long-term care policy for members of Maccabi Healthcare Services

9. Nursing allowance - general:

amount or service under this policy.

10. Exceptions to the Insurer's liability

10.6. 10.7. 10.8.

11.Stipulation due to previous medical condition - applying to new members only:

Group long-term care policy for members of Maccabi Healthcare Services

12. The claim:

Group long-term care policy for members of Maccabi Healthcare Services

13. Appeals committees

13.3. 13.4. 13.5.

Group long-term care policy for members of Maccabi Healthcare Services

Group long-term care policy for members of Maccabi Healthcare Services

15. Insurance premiums and methods of payment:

Group long-term care policy for members of Maccabi Healthcare Services

16. Option of purchasing individual nursing policies:

Group long-term care policy for members of Maccabi Healthcare Services

17.Limitation of the Insurer's liability outside the borders of Israel

18. Period of limitation

19. Transfer provisions

Group long-term care policy for members of Maccabi Healthcare Services

Group long-term care policy for members of Maccabi Healthcare Services

Group long-term care policy for members of Maccabi Healthcare Services

Table of insurance premium variables

Premiums for the Silver Shield Nursing plan

Group long-term care policy for members of Maccabi Healthcare Services

Additional premium for upgrading from Silver Shield to Gold Shield