A guide to exclusions in long-term care insurance policies: the pre-existing medical condition exclusion, the qualifying period, exclusions for particular situations, and how to check whether an exclusion is relevant to your case before you file a claim.
Why it is better to read the exclusions before rather than after
The exclusions chapter is the part nobody wants to read, and it is exactly why claims fail. It sets out situations in which the policy does not pay, even where the definition is apparently satisfied.
The advantage of reading it early is that you can prepare. If it turns out that a particular exclusion may be relevant, you can collect the documents that address it in advance — rather than meeting it for the first time in a refusal letter.
Sometimes reading it also reveals that the exclusion is not relevant at all, and that saves needless worry.
The most common exclusion: a pre-existing medical condition
Most policies include a clause excluding a condition that existed before the insurance started. The insurance logic is understandable, but the application is complex.
The questions that arise are: when exactly did the condition begin, did the insured person know about it, and is there a causal connection between the earlier condition and the present long-term care condition.
Not every earlier diagnosis falls within the exclusion. Someone diagnosed with diabetes twenty years ago, who became dependent on care following a hip fracture, is not necessarily subject to the exclusion — even if the company argues otherwise. This is a point that sometimes calls for a legal review.
The qualifying period
A qualifying period is an interval from the start of the insurance during which the cover is limited or does not apply. Its purpose is to prevent a situation in which someone joins an insurance policy when they already know the condition is approaching.
It is important not to confuse it with the waiting period. The qualifying period is measured from the start of the insurance; the waiting period is measured from the moment the long-term care condition arose. Both exist in parallel in most policies.
If the insured person joined the insurance at a relatively late stage, it is worth checking the qualifying period and the date the condition began before filing.
Further exclusions worth checking
Beyond the two central exclusions, policies may include others. The list varies between products, so the chapter in the specific policy has to be read.
- Conditions caused in particular circumstances that are expressly excluded
- An age limit at which the cover ends
- Terms relating to staying outside Israel
- Requirements to report changes in the condition or in the place of residence
- Terms relating to continued premium payment while a benefit is being received
- Provisions about cancelling the policy or stopping payment
What to do when you identify a relevant exclusion
If, in reading the policy, you came across an exclusion that looks connected to your case, do not rush to conclude that there is no point in filing.
First, you have to check whether the exclusion actually applies. General wording does not necessarily cover every situation, and sometimes a causal connection is required that does not exist.
Second, it is worth collecting in advance the documents that establish the picture — particularly documentation of the date the long-term care condition began and of the event that led to it.
Third, where a substantive exclusion such as a pre-existing medical condition is involved, this is a situation in which it is worth considering a legal review before filing rather than after the refusal.
Frequently asked questions
What is the pre-existing medical condition exclusion?
A clause excluding a condition that existed before the insurance started. Applying it is complex and depends on questions of timing, knowledge and the causal connection between the earlier condition and the present long-term care condition.
What is the difference between a qualifying period and a waiting period?
The qualifying period is measured from the start of the insurance and limits the cover during the initial period. The waiting period is measured from the moment the long-term care condition arose until payment begins. Both exist in parallel in most policies.
Does every earlier diagnosis fall within the exclusion?
No. A connection is usually required between the earlier condition and the present long-term care condition. An old diagnosis unrelated to the cause that led to the long-term care condition does not necessarily fall within the exclusion.
We found an exclusion that looks relevant — is it worth filing at all?
Do not rush to conclude that there is no point. Check whether the exclusion actually applies, collect documentation of the date the condition began, and where a substantive exclusion such as a pre-existing medical condition is involved, consider a legal review before filing.
Official sources for further checking
This is general information and does not replace personal medical, legal or insurance advice. Eligibility is determined by the documents and rules that apply to each case.
