Surgery insurance: the "top-up to your health fund" (complément de caisse)

Do you have private health insurance that covers operations? Since 1 June 2024, a rule has changed for many policyholders in Israel, and most do not know it. Here is what to check in your contract.

A standard policy, so one you can compare

Since 1 February 2016, all insurance companies must offer surgery insurance on uniform terms. Contracts can therefore be compared on price and type of cover, no longer on hidden clauses. It lets you choose your surgeon and the hospital, and pays for hospitalisation costs, the fees of the surgeon and the anaesthetist, the ambulance, consultations before and after the operation, a private nurse during the hospital stay, and, depending on the contract, physiotherapy, a convalescence allowance or rehabilitation. If a clause is ambiguous, the ambiguity can work in the policyholder's favour.

Two types of contract: "from the first shekel" or "top-up to the fund"

The "from the first shekel" policy covers your surgery costs without you first having to use up your rights with the supplementary insurance of your health fund (shaban, the fund's supplementary insurance). You claim directly from the company. Some contracts even provide an allowance if you pay for both but choose to be operated on in the public system or by the health fund.

The "top-up to the fund" policy is designed for the case where the operation is covered by the shaban but the fund's reimbursement is lower than the real cost. You apply to the fund first, then the company pays the difference. Its premium is lower. Its drawback: two contacts to deal with, and the company requires you to have used up your rights with the fund before it pays.

What has changed since 1 June 2024

To avoid paying twice for the same cover, "from the first shekel" policyholders who are also members of a shaban are automatically transferred to the "top-up to the fund" policy at their first renewal. Here is what you can do:

If you have a "from the first shekel" policy and you have not read your company's letter, read it again: the decision affects how you will be reimbursed on the day of the operation.

Operations with a surgeon "under agreement" or not

When you choose a surgeon who has an agreement with the company, it pays them directly, generally with no reimbursement ceiling. With a surgeon who has no agreement, the company reimburses you on presentation of receipts, up to a ceiling, generally set on what it would pay a surgeon under agreement. If your contract does not state this ceiling, the company must publish it on its website.

Changing health fund: do not lose your cover

The right to a "top-up to the fund" assumes you are a member of a shaban that is currently valid. When you change fund, the new supplementary insurance often imposes a waiting period, and during that time you can find yourself without cover for operations. A temporary cover, called "Ber'ut bitouah", lets you keep continuity without new medical underwriting. It has its own waiting period (3 months in the Kol Zchut example) and generally lasts 60 to 90 days. So only leave your fund once the temporary cover has come into force, and sign up quickly for the shaban of the new fund.

As a francophone insurance broker in Israel, I can go through your contract with you, in French, and check that you are not paying twice for the same cover. Call me on 054 307 0916 or fill in the form below.