Even though sex-reassignment surgery (SRS) is recognized in Israel as a medical need that should be funded by the health maintenance organizations, officials at one leading HMO are viewing it as elective surgery, available only for people who carry its supplementary insurance.
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In contravention of the law, the Meuhedet HMO recently refused to finance surgery for two transgenders who needed female-to-male surgery (FtoM) abroad and had been approved for it by the relevant Health Ministry committee. Only male-to-female surgery (MtoF) is performed in Israel; female-to-male surgery must be performed abroad, and the HMOs are required to finance the surgery and all associated expenses. In both cases, the men were to have the surgery performed in Serbia by world-renowned expert Dr. Miroslav Djordjevic.
Meuhedet, however, referred them to its supplementary insurance, which set all kinds of restrictions. For example, under the supplementary policy, they would have to lay out the tens of thousands of shekels for the surgery and only be reimbursed afterward. The insurance also refused to cover the flights, accommodations and accompaniment. In one of the cases, the insurance agreed to cover only one of a series of three necessary operations.
The first case, a man in his twenties, had received his approval from the Health Ministry sex-reassignment committee at the beginning of the year, and required surgery costing 13,000 euros ($14,480). The second case was more complex: the man, in his thirties, had gotten the sex-reassignment committee’s approval in 2009 but was unable to have the surgery because of bureaucratic delays. For various reasons, he needs to have the surgery in three stages – the first of which alone costs some 20,000 euros.
In March 2014, Health Ministry director general Prof. Arnon Afek, who at the time was head of the ministry’s medical administration, issued an unequivocal directive to the effect that SRSs were covered by the “health basket” [i.e., funded by the state], even if they must be performed abroad. “A health service can be performed abroad on condition that it belongs to one of five categories, including birth defects,” he wrote. “A committee that examined the issue at the behest of the medical administration director concluded that sex-reassignment surgeries should be viewed as belonging to the category of birth defects.”
That letter was issued by the Health Ministry after a lengthy period during which no SRSs were being performed in Israel at all, and HMOs were refusing to cover operations abroad. Between July 2012 and September 2014, there was no surgeon available in Israel to perform them, after the only expert who had performed such surgeries stopped doing so. At some point, another surgeon was sent abroad for relevant training and when he returned, male-to-female surgeries resumed. Those requiring female-to-male operations must still go abroad. Estimates are that 10 to 15 people are waiting to have female-to-male surgery.
The Health Ministry said that if an HMO does not want to supply a service, in contravention of the Health Ministry’s position, it must refer members to the ministry’s appeals committee, not to the supplementary insurance. One of the patients, it said, had been found qualified for funding by the appeals committee in January 2015.
Meuhedet said in response that while it does not believe the requested service is included in the National Health Insurance regulations, it would defer to the decisions of the Health Ministry appeals committee. It noted that the second patient had actually had one of his surgeries before the appeals committee had decided in his favor, and he was being asked to submit bills so he could be reimbursed.