Do You Need a Medical Opinion to Sue for Long-Term Care Insurance?
When long-term care insurance claims are rejected, policyholders wonder if private medical opinions are mandatory. Courts rule that functional disputes may not require medical experts.
When an insurance company rejects a claim for long-term care benefits, policyholders and their families face difficult decisions regarding legal action. Alongside daily care burdens and mounting expenses, a primary concern is the cost of litigation, specifically whether a private medical opinion must be financed before filing a lawsuit.
Assessing Policy Definitions and Functional Disputes
The necessity of a medical opinion depends heavily on the policy's eligibility criteria and the nature of the dispute. Under civil procedure regulations, a litigant seeking to prove a medical matter must attach an expert medical opinion to their pleadings. However, in many long-term care claims, the core issue is functional rather than strictly medical: whether the policyholder can independently perform daily living activities and the degree of assistance they require.
This distinction was highlighted in a ruling by the Tel Aviv Magistrate's Court concerning an 84-year-old insured woman suing the Clal-owned insurance company, Dikla. The plaintiff argued she required assistance with bathing, dressing, transfers, mobility, and suffered from urinary incontinence, supported by a health fund nurse's assessment and a National Insurance Institute dependency evaluation. The insurer argued that the documentation failed to prove fulfillment of the policy's long-term care definition.
Court Ruling and Access to Justice
After court proceedings began, the insurance company moved to dismiss the claim outright due to the absence of a medical opinion. Judge Einat Ravid rejected the dismissal request, ruling that a medical opinion was unnecessary in this case because the dispute centered on whether the nurse's functional findings met the policy definitions rather than assessing medical disability percentages or causal relationships.
Demanding a costly private medical opinion as a prerequisite for reviewing a long-term care claim can erect a severe financial barrier for vulnerable elderly plaintiffs. While this ruling allowed the insured woman to proceed without a mandatory medical opinion, legal experts emphasize that this does not constitute a blanket exemption for all long-term care disputes. The necessity of expert testimony must be evaluated on a case-by-case basis depending on the specific evidentiary requirements.
