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Limited coverage By Esti Ahronovitz Tags: Dikla Insurance  Amira Gabai sits next to her mother, Halina Greenberg, caressing her hand. "Mother," she whispers, "I'm here. It's all right." Her mother stares into space. Every morning, Gabai comes to the Galei Ha'opera old-age home in the center of Tel Aviv. When she decided, after wrestling with the subject for a long time, to place her mother in a nursing home, proximity to her residence was a key factor. "Mother remains near me," she says. "We were always very close." Gabai, an only child, is no longer young, but despite her life experience, nothing prepared her for the wearying and painful mental endurance test involved in caring for an aged parent who needs round-the-clock assistance. Greenberg, well attired, clean, her hair combed, is sitting in an easy chair. Occasionally she speaks a few sentences, divorced from reality. "I don't know what she feels, what she thinks about, what she remembers," Gabai says sadly. One day she was very happy, and told me, 'It's a good thing you came, we have to hurry so we can register for school.'" Advertisement Until two years ago, Greenberg lived on Shlomo Hamelech Street in Tel Aviv. Her small, elegant apartment was her whole world. Twice a day she went to a nearby cafe, always dressed smartly, accompanied by vapors of sweet-smelling perfume. Gabai talks of a sharp, intelligent woman. "Genuine Polish," she says, and allows herself a fleeting smile. Greenberg is a Holocaust survivor who lost her whole family in the cataclysm. She immigrated to Israel after the war. At home, her daughter relates, the subject was never mentioned. "Exactly two years ago, in February, I was at her place, talking to her, when she suddenly asked me, 'Who are you?'" The deterioration was rapid. Cranial bleeding was diagnosed at Ichilov Hospital. "It's a sharp transition," Gabai says. "Suddenly you need diapers." She speaks painfully about the desire to be with her sick parent 24 hours a day, the mental and physical exhaustion, the infinite concern and the feelings of guilt that wracked her. After a year of looking after her mother in her home and also employing a caregiver, she buckled under the burden, and with a heavy heart started to examine the possibility of placing her in a suitable institution. She does not regret the decision. She feels perfectly at home in Galei Ha'opera; the place radiates warmth, the staff is attentive and the care devoted. "And I have a bit more energy," she adds. But Gabai's struggle to ensure her mother's quality of life and preserve her dignity and her rights is not over. In fact, it has just begun. Since 1999, Greenberg paid the Kupat Holim Clalit health maintenance organization, of which she is a member, for long-term nursing care insurance (bituah siudi). When the time came, and her daughter applied to the Dikla Insurance Company for NIS 3,500 a month for three years, she was stunned to have her request turned down. Gabai takes out a short letter she received from the insurance company. In five dry lines, the company states that it learned Greenberg has been incontinent since September 1996 - before she took out the insurance - and that she also suffers from depression and anxiety, for which she receives medication. Accordingly, Dikla decided to annul the nursing-care element of the insurance, beginning from the date of joining the plan, and is returning the money paid. The company signs off by "wishing you firm health." Given the brush-off "The last straw was those four words, 'Wishing you firm health,'" Gabai says. "I decided not to take it lying down. Whom are they wishing firm health to? To an 82-year-old woman, a Holocaust survivor with dementia who can barely communicate?" Last week, Gabai sued Dikla in the Tel Aviv Magistrate's Court via attorney David File, a specialist in this field - for breach of an insurance policy. The suit maintains that Greenberg was not incontinent until her commitment to the nursing home in 2007, long after she took out the policy. As for the claim of depression, the suit notes that Greenberg is a Holocaust survivor, and like many in her situation, suffers from problems deriving directly from the horrors she experienced. Moreover, the suit maintains, there is no connection between her depressive state and her need for nursing care. "My mother comes from the generation that did not take a red cent from the state," Gabai says with pent-up anger. "When she arrived here, she lived in a transit camp in Bat Yam and worked as a cleaning woman. In those days there was no immigrant- absorption basket and no mortgage. All her life she - and my father, too - worked for a living and paid taxes. And suddenly, when you ask for what's coming to you, you're given the brush-off, on the assumption that you will not fight." The situation Gabai describes recalls the well-worn joke about the headquarters of a big insurance company: on the first floor the agents get the clients to sign up for policies, and on the nine other floors clerks and lawyers plan how to avoid paying when the time comes. Next month, Tel Aviv District Court is expected to announce whether it will agree to hear a class-action suit on the subject. That suit was filed by Shlomo Rubinstein, from Haifa. Like Greenberg, Rubinstein, 85, is a Holocaust survivor. In 1999, he was invited, by telephone, to purchase additional insurance, including nursing-care insurance, via the Clalit HMO. Rubinstein accepted the offer and Clalit sent the application form, which he filled out and sent back. His son, Oded, describes his father as a punctilious yekke type (a Jew of German origin) who always paid his bills like clockwork. The policy he purchased provides payment for nursing-care services, should the need arise. Clalit and Dikla started to collect premiums from Rubinstein. According to the lawsuit, he was not asked to make a "health declaration" detailing his medical history. Nor did he receive a copy of the policy. In November 2004, Rubinstein suffered a stroke and after lengthy geriatric hospitalization, the physicians recommended that he request nursing care. The insurance company replied in February 2005: "It emerges that you suffered from a chronic rheumatic disease before you took out the insurance ... There is no nursing-care coverage for an insuree who before taking out the insurance suffered from a chronic rheumatic condition." In insurance parlance, the reason for the refusal to implement the policy is a "pre-existing medical condition." Rubinstein and his son did not give up. Following an exchange of correspondence, Dikla agreed to pay 57 percent of the claim. Rubinstein demanded 100 percent. "When I moved Dad to an old-age nursing home in Haifa, it was a tremendous shock for me," says Oded Rubinstein, a Yehud resident. "I wanted to rehabilitate him so he would not have to stay there. I was so concerned that I arranged for him to have a private caregiver at home. The amounts of money were sick, totaling NIS 22,000 a month." At this stage, Oded Rubinstein decided to implement the nursing-care insurance his father had paid for over the years. "When I received the first reply, that he was not entitled to anything, I didn't understand. Why, I asked, didn't he pay all along? They told me: 'He had rheumatism that he did not declare.' "That's nonsense, because Dad was not asked to provide any medical declaration, and the medical file was available to them in Clalit. When I kicked up a fuss, they told me that to show good will, they would grant him compensation of 57 percent. I think he deserves 100 percent." Where do you get the strength to sue? "I am far from such battles, but when I told Dikla that I was considering a lawsuit, one of the clerks told me, 'The courts don't scare me. I have a battery of lawyers on retainer.' That's what riled me: the arrogant, patronizing reply to a person in my situation." Rubinstein relates that his father is in serious condition. "Catastrophic," he says. Three years have passed since the stroke. A live-in foreign worker takes care of him at home. Occasionally he himself finds the time to go to court for the hearings. "I agreed to go for a class-action suit, because I consider it a mission," he says. "I want to give it to those big-shots in the head. That's what they deserve." Millions of insurees Long-term nursing care insurance is a contract with an insurance company, according to which the insuree pays a monthly sum (the premium) and the insurance company undertakes to participate in financing nursing-care hospitalization or home care. If you are over 65, there is a 16 percent chance that you will need nursing care, and the costs impose a heavy burden on the individual involved and his family. Hiring the services of a caregiver from abroad and paying him or her according to the law can cost NIS 5,000 a month. Residence in a nursing-care facility ranges from NIS 8,000 to double that sum per month, sometimes more. Payments from the National Insurance Institute cover only a small fraction of the cost, and then only for elderly people who pass a financial "means test" and are not in an institution. A person in nursing care can live on for many years, and the economic burden on the family can prove crushing. This is apparently why some 3.7 million Israelis, according to Finance Ministry data, have taken out nursing-care insurance, most of them through the health maintenance organizations, and the others through group insurance, either privately or at their work places. More than half the insurees, 1.9 million, are members of the Clalit HMO and are insured by the Dikla Insurance Company. Clalit owns 35 percent of Dikla, and Harel Insurance Investments and Financial Services holds 56 percent of the shares. And it is against Clalit and Dikla that many of the complaints have been made. In the past four years, hundreds of complaints against Clalit and Dikla have been submitted to the treasury's supervisor of insurance, many of them concerning a "pre-existing medical condition." In contrast to private insurance policies, for which an applicant is required to make a comprehensive medical declaration, Clalit exempted its members from this. Instead, they received a form headed "Application for Clalit Mushlam and Application for Nursing-Care Insurance" (Mushlam is a plan complementing the HMO's regular health services) and were required only to sign. But at the bottom of the form, in cramped rows of print in tiny letters, is an "Important Note." It sets forth a long list of illnesses and medical events, any of which, if discovered in the insuree before he joined the plan, deprive him of the right to nursing-care insurance. Treasury officials are certain that many of those who signed the form did not read the fine print, and were not aware of the qualification. "People of 80 who don't speak Hebrew were invited to sign the form," a treasury source says. The result is that when the insuree wants to implement the policy, he is liable to discover that Dikla is poking around into his past in order to find the illness that will allow the company to deny payment for nursing-care insurance - conditions like Halina Greenberg's depression and Shlomo Rubinstein's rheumatism. In such cases, the company must return the money paid by the elderly person, and bids him or her a fond farewell, with wishes for a speedy recovery. "Most of the insured people who get back the premiums they paid think this is all right - 'At least they returned the money,' they say," attorney File notes. "But it is absolutely not all right. Because those people have a valid insurance policy; they paid premiums. Now they are left without insurance and without payments, and no company will insure an old, sick person again." No one knows how many elderly people Dikla has turned down. According to attorney Ohn Tavor, who filed the class- action suit on behalf of Rubinstein, there are hundreds, perhaps thousands. After he filed the suit, he says, his office was approached by dozens of families who had been turned away by Dikla. "For three weeks the office was inundated with phone calls," he says. "We hired a law intern to take every phone call on the subject and listen to every case." What if the court does not accept the suit? "As a citizen, I am concerned. There is still a large group of aged people who were certain that they were insured and paid a premium every month as required. A serious problem has arisen here, but I see no sign of the health minister or the insurance regulator stepping in and saying that things have to be properly ordered." New definitions of 'independent' The treasury's supervisor of insurance, Yadin Antebi, has in fact launched a struggle against the nursing-care insurance plans of the HMOs. It started with the Maccabi HMO. For years, Maccabi insured its members for nursing-care services. The insurance supervisor declared that this practice constituted a conflict of interest and instructed the HMO to issue a tender for the insurance coverage. Maccabi refused, took the case to the High Court of Justice, and lost. Two weeks ago, the protracted struggle came to an end when Clal Insurance won the lucrative tender to provide services to the 1.3 million Maccabi members who have nursing-care coverage. The treasury maintains that there is also a conflict of interest at Clalit, which holds 35 percent of the shares of Dikla, which insures the HMO's members. A few months ago, Antebi instructed Clalit to sell its holdings in Dikla. Like Maccabi before it, Clalit refused. Talks are now underway to conclude the affair to the satisfaction of the treasury, which has the High Court decision in the Maccabi case as a precedent. In the meantime, following a huge wave of appeals to the supervisor of insurance, the treasury decided three years ago to amend the regulations. One such revision holds that in the absence of a "health declaration," the insurance company will be entitled to refuse to implement the policy only if the insuree's deterioration to a condition in which nursing care is required occurred within a year after he purchased the insurance. The treasury says that in the wake of this change, the number of complaints fell off considerably, though complaints are still coming in about refusals that cite a "pre-existing medical condition." In many cases, the insurance companies say in their defense, the insuree concealed prior illnesses and thus defrauded them. Another loophole that makes it possible for the companies to evade payment concerns the definition of a nursing-care patient. Reasonable insurance coverage is supposed to be given to the insured individual when he is unable to execute four or five (depending on the type of insurance) of the following six actions: get up and lie down, dress and undress, wash himself, eat and drink, control his excretory functions, and move about. A treasury amendment of 2004 defines an individual who cannot execute on his own "at least 50 percent of the activity" as in need of nursing care. According to Dr. Udi Frishman, an expert in insurance and health-risk management who is a consultant to firms in the field and lectures at Tel Aviv University, this is an insufficient definition, which leaves many nursing-care insurees without care or compensation. "How is it possible to measure 50 percent of a function?" he asks. "How is it possible to define someone as possessing more than 50 percent capability in dressing and undressing? What if he can only dress himself but cannot undress himself? Only put on a shirt but not pants? And how will we define 50 percent capability in getting up and lying down? Someone who assumes a prone posture and then cannot get up? Or if he can get up only if his aged wife tries to help him? Is that 50 percent functionality? More? Less? It makes the whole thing a big joke." For Aryeh Biran and his family, from Rehovot, Frishman's example became a gloomy reality. Biran, now 85, was a bus driver for Egged and had group insurance from Clal Health. After his retirement, he worked in the family's Judaica and jewelry business. In June 2006, he had a stroke: his right side was paralyzed and he suffers from muscle atrophy and speech and swallowing disorders. In an instant, Biran, who had a cogent intelligence and a fine sense of humor, became, as his daughter, Pirhiya, puts it, "a sack of potatoes." He was hospitalized for months in a rehabilitation ward, during which time he received the full insurance benefit of NIS 4,700 a month. A few months ago, after he returned to his home in Rehovot, the insurance company gave him another "functional assessment" test, and then rejected his request for nursing-care benefits, claiming he was capable of executing three of the six required functions. Finally, the company agreed to pay half the amount he had received until then. Alongside Biran are his two children, Pirhiya and Yair. The two closed the family business and stayed with their father day and night. They did not leave his bedside while he was in the hospital. Pirhiya never stopped massaging his atrophying muscles and looking for solutions to his condition. The two describe at length the serious illness, mental and physical, beginning back in the hospital, in the face of a staff that was not always attentive, and ending with the insensitive bureaucracy of the HMO. No one gave Biran much of a chance, but after a few months he came out of the rehabilitation ward, able to move about with the aid of a walker. The hospital staff applauded. Today, a year later, his children continue to look after him with infinite devotion. They scurry from the HMO clinic to the drugstore, cook for him, massage him and take him for daily physiotherapy. Pirhiya takes him on outings to the places he worked as a bus driver. They are caring for their father out of love and willingness. They are also paying NIS 5,000 a month to a foreign caregiver who assists them, NIS 4,000 for physiotherapy and another NIS 1,000 for medication. The insurance company representative who came to assess Biran's condition decided that he was mobile. Her report stated: "Independent, with the help of a walker and supervision of another person." She also stated that he is in control of his excretory functions. How can someone who needs a walker and the supervision of another person be considered independent? An excellent question. His children can't figure it out, either. Pirhiya doesn't know whether to laugh or cry. "For my father to walk a few steps," she says, "he first has to be stood on his legs, because he can't get out of bed by himself; then the walker has to be brought, and someone has to be at his side when he walks - and we are talking about a few steps. During the day, he is in a wheelchair." As for excretory functions, in that sphere Biran is far from independence. "To preserve Dad's self-respect, we decided to remove his diapers," his daughter says. "It's not that he is independent and rushes to the toilet. Someone has to bring him a special bottle into which he urinates, and help him stand as he leans against the wall. But for the insurance company, he is in control of his excretory functions. Dear God, he is not even capable of sitting on the toilet seat on his own." The family decided not to remain silent, and sued the insurance company. The suit was recently filed in the Tel Aviv Magistrate's Court. "Dad was a 'graduate of Auschwitz,'" Pirhiya Biran relates. "He came here after the war, and when he was given a rifle to defend the homeland there was nothing more important to him. He was a man of labor, filled with love of the homeland and with pride. He was an officer in the army, and he raised us on those values. He always told me, 'Pay a lot of income tax, grumble a lot - that's a sign that you're earning well. Pay for insurance all your life, and hope you never need it.' That was the motto I was raised under. And we paid. All his life, he donated secretly; every Rosh Hashanah and Pesach he gave small checks to the needy. It's a vanishing generation. I am fighting his last battle for his right to grow old with dignity." Ambiguous wording And that is not all. Not long ago, attorneys Amnon and Sharon Zichroni filed a class-action suit in the Tel Aviv District Court against the Dikla, Clal, Harel and Migdal insurance companies, on the grounds that they were continuing to collect nursing-care premiums even after the insuree entered a nursing-care regimen and began to receive payments from the company. This suit was preceded by another lawsuit on the same subject, in which the court ruled in favor of the late Reuven and Rahel Ashur and was sharply critical of the Dikla company. Reuven Ashur immigrated to Palestine in 1939; Rahel, a Holocaust survivor, arrived after the war. Their daughter, attorney Nira Hirsch, tells of parents who supported Mapai, the forerunner of Labor, were members of the Histadrut labor federation and among the builders of the country. In 1995, the Ashurs took out supplementary insurance with Clalit, which included nursing-care coverage. "They were given a wretched form to sign," Hirsch says. "No one asked them anything, no one explained anything. My father, who was a journalist with [the now defunct daily paper] Davar, and was intelligent and understood things, said it was an excellent arrangement: for a few dozen shekels a month you are insured." In time, Reuven Ashur needed nursing care, and Rahel was diagnosed with Alzheimer's and became wheelchair-bound. The insurance company processed their claim and started to make monthly payments. After some time, Rahel noticed that the company was continuing to deduct the monthly premium of NIS 51. In reply to her question, the company stated that its monthly payment was conditional on continued payment of the premium. "My parents were not needy," their daughter says. "We could have ignored the 50 shekels. But for me and for them, it was a matter of principle." In December 2004, Hirsch, who was then embarking on her legal career, sued the company in the Small Claims Court for the paltry sum of NIS 3,500, which had been collected from her parents. According to the suit, it is inconceivable for an insurance company to continue collecting a premium for an event that has already occurred, and for which her parents were receiving a monthly payment. Hirsch never imagined that her small claim would trigger an earthquake. Dikla sent the court a series of successive written defenses, each amending the previous one and all of them citing peculiar arguments. The file was transferred to Haifa Magistrate Court Judge Israela Kray Geron. Dikla brought witnesses and experts, who tried to explain and justify its demand to continue to collect the premium. One of the arguments, for example, was that the contract did not state that implementation of the policy released the insuree from the obligation to pay a premium. The judge, to put it mildly, sent the company packing. "Ambiguous wording of the policy terms," she noted in her decision, of March 2007, "particularly in regard to the definition of the insurance fee ... prevents Dikla from being able to argue that it was entitled to behave as it did." Judge Geron ruled that the company must reimburse the money and pay court costs. "Dikla was willing to pay me the amount all along, provided I kept my mouth shut," Hirsch says. "I refused. I went all the way with the case because I could not remain silent. I wasn't after the money. My parents were good citizens. They built this land and paid taxes as required. Then, when troubles began, this company starts to play with them, thinking they would not do anything. That outraged me as a human being. I fought against my parents' personal affront, and there are plenty more in the same boat." Dikla, unable to stomach the defeat, appealed the decision two months later, and the case is pending. "The policy contains no insurance coverage that releases the insured person from paying the insurance fee when the event occurs." Rahel and Reuven Ashur did not live to see their daughter's triumph. They both passed away during the trial, in 2005. "If they were alive," Hirsch says, "they certainly would have been very proud."W Bookmark to del.icio.us   Halimi, relived A Jewish teen is tortured where Ilan Halimi died in similar circumstances. Bus-bomb capital Four buses designed to thwart suicide bombings are tested in J'lem.

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