פוליסת בריאות

פוליסת בריאות

במדינת ישראל אנשים רבים ביטחו את עצמם בביטוחי בריאות. חלקם מבוטחים דרך קופות החולים וחלקם רכשו פוליסות פרטיות. ביטוחים אלה מזכים את המבוטח בתגמולי ביטוח בשעה שהוא נזקק לטיפולים רפואיים מיוחדים שאינם כלולים בסל הבריאות. יודגש כי מבוטחים רבים זכאים אף לפיצוי כספי בשעה שביצעו את הטיפול הרפואי ללא מעורבות של החברה המבטחת.

הבעיה הראשונית של המבוטחים בעניינים אלו הוא חוסר ידע לגבי זכאותם לקבלת תגמולים בעקבות המקרה הרפואי. משרדנו מסייע למבוטחים להכיר את זכויותיהם בהתאם לפוליסה ולהפנות אותם לסעיפים הרלבנטיים המקנים להם את זכויותיהם.

פרק משמעתי בפוליסות אלה עוסק בניתוחי השתלה אותם עוברים מבוטחים בחוץ לארץ. בשנים האחרונות חל שינוי מהותי בעניין זה בשעה שבתי המשפט קבעו כי המבוטחים אינם זכאים לשיפוי כספי עבור השתלה שאינה עומדת בתנאי החוק, ומשכך משרדנו ממליץ כי המבוטחים יסתייעו בייעוץ משפטי החל מרגע בו עולה הצורך בהשתלה.

פעמים רבות חברות הביטוח דוחות את תביעות המבוטחים בטענה כי למבוטח עבר רפואי הקשור לבעיה הרפואית הנוכחית, שאותו הוא לא גילה עובר לעריכת הפוליסה, ומשכך אין הוא זכאי לתגמולים. במקרים אלו יש להגיש תביעה נגד החברה ולוודא כי היא משלמת את מלוא התגמולים הרלבנטיים.

משרדנו מטפל בתיקים רבים שעניינם מיצוי הזכויות בהתאם לפוליסה הרפואית, וזיכה מבוטחים שתביעתם נדחתה בקבלת תגמולים מלאים מחברת הביטוח.

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