Having trouble with daily activities? Special services allowance

Many people with physical disabilities, including Parkinson's patients, mostly those who suffer from an advanced disease, require the help of others in performing daily activities as well as supervision during most hours of the day. It is possible that those people, insured by the National Insurance Institute, will be entitled to a special services allowance, whether they receive General disability allowance and whether or not. In fact, a special services allowance is a financial allowance paid by the National Insurance Institute to those entitled to it, depending on the level of functioning and the level of dependence of the insured on others. For the severely disabled who cannot go to work, and rather, those who are even required to hire nursing help, this allowance becomes extremely significant, and helps them live with dignity.

As part of this article, I will review the eligibility conditions for the pension and its rate, how to submit the claim, including the conduct before the National Insurance Committee, and I will also refer to the situation in which the claim was rejected and the possible actions following it.

Who is entitled to a special services allowance?

There are 4 threshold conditions for eligibility for a special services allowance:

• The first condition, is the age of the insured. Insured persons from the age of 18 until 6 months after the retirement age are entitled to the pension, 62 for women and 67 for men.

• The second condition, is being in the Land of Israel. In most cases, those who are not in Israel at the time of filing the claim will not be entitled to an allowance. At the same time, under certain circumstances, an insured who filed a claim and left the country after receiving at least two payments, will be entitled to an allowance for a few months. In addition, there are exceptional circumstances, in which an insured can receive the allowance abroad for a period of up to 24 months as long as he went abroad for work or medical treatment, and even without limitation provided that the insured is on a mission abroad on behalf of the state.

• The third condition, is the receipt of a general disability allowance when the insured has been determined to have a medical disability of at least 60%, or the insured does not receive a general disability allowance, but the medical committees have determined that he suffers from a disability of at least 75% and that he does not receive a special allowance for those injured at work and does not earn more than 5 of the average salary in the economy per month.

• The fourth condition, is that the insured is not in one or another medical institution.

In fact, up to this stage, these are only threshold conditions, which do not go into the depth of the matter and do not examine the situation of the insured. The claimant's entitlement to a special services allowance is determined in accordance with the decision of the medical committee, as will be explained later.

The amount of the allowance

The amount of the allowance to which the claimant will be entitled is determined according to the degree of his dependence on another in the performance of daily activities.

There are 3 levels of eligibility for special services allowance:

• The first, an allowance at the rate of 50% paid to the insured who needs significant help in most daily activities throughout most of the hours of the day, or to the insured who needs constant supervision. As of January 1.1.2020, 1,427, the amount of the allowance is NIS XNUMX per month.

• the second, an allowance at the rate of 112% paid to the insured who needs significant help in all daily activities throughout most of the hours of the day. As of January 1.1.2020, 3,334, the amount of the allowance is NIS XNUMX per month.

• The third, an allowance at the rate of 188% paid to the insured who is completely dependent on the help of the other in carrying out all daily activities throughout the hours of the day. As of January 1.1.2020, 5,341, the amount of the allowance is NIS XNUMX per month.

A lawsuit sumbit

If the insured meets the threshold conditions as stated above, he can submit his claim. As part of the lawsuit, the plaintiff's ability to perform 5 daily activities according to the ADL test (dressing, bathing, eating, mobility and control of braces) is tested, as well as performing 6 additional activities related to household management (putting in food, operating electrical appliances, housekeeping, medication, shopping outside the home and institutional and financial arrangements). It will also be checked whether the claimant poses a danger to himself or others and, as a result, whether there is a need for supervision. In order to submit a claim for special services, the claimant must fill out a dedicated claim form and attach to it the full medical documentation that indicates his medical and functional condition, with an emphasis on his ability to perform daily activities. In the case where the claimant changed his place of work about six months before filing the claim, then it is required to also attach payslips for the last six months. It will be clarified that if another person files the lawsuit on behalf of the plaintiff, for example a relative, then a power of attorney or any other document that allows that person to act on behalf of the plaintiff must be attached to the lawsuit, for example: a guardianship order or Lasting power of attorney.

The claim for special services allowance can be submitted physically to the National Insurance branch closest to the claimant's home as well as by mail or fax. In addition, it is possible to submit the claim online through the website of the National Insurance Institute.

I filed a claim, what next?

After the claimant submits his claim, it will be examined by a doctor on behalf of the National Insurance Institute, and to the extent that he determines that the claim meets the threshold conditions listed above, the claimant will usually be invited to be examined by a medical committee. In certain circumstances, especially medically difficult cases, the doctor who examines the documents can decide that In this case, the presence of the plaintiff is not required for examination by the committee, and in such a situation the diagnosis will be given without his presence. The medical committee is guided by the secretary of the committee, one or two doctors (usually at least one of them is an expert in rehabilitation) and sometimes also a social worker. If a physical examination is indeed required by the committee, then it is recommended to come prepared with a complete list of the diseases, deficiencies and functional difficulties the claimant has, including all the medical documents attesting to this. Furthermore, if all the medical documents were not submitted as part of the lawsuit, they can be physically presented to the committee. It is important to understand that this committee does not examine the claimant's disability, but only its effect on his ability to perform daily activities, and the emphasis should be placed on that. Of course, it is possible, and even recommended, to be accompanied by another person, including a lawyer who works in the field, to the inspection by the committee. A lawyer who specializes in the field will be able to clearly explain to the committee the full medical condition of the claimant and thereby help the committee reach the correct conclusion, and of course reach the optimal result from the claimant's point of view. At the end of the examination, the doctor summarizes the findings and determines the extent of the claimant's dependence on the other. This determination is forwarded to the claims officer of the National Insurance who decides on the claimant's eligibility for a special services allowance and its rate.

Appealed the committee's determinations

Those who filed a claim and are not satisfied with the determinations of the medical committee, Regardless of whether the claim is rejected altogether or whether there is a dispute regarding the start date of the entitlement to the pension or regarding its rate, it is usually permissible to appeal to the Appeals Committee for Special Services with a reasoned appeal within 90 days from the date of receipt of the written decision. In addition, in order for the plaintiff to be entitled to file the appeal, he must show that he meets one of the following three conditions: 1. He receives a general disability allowance and has been diagnosed with a medical disability of at least 60%. 2. He does not receive a general disability allowance, but he has been determined to have a medical disability of at least 75%. 3. He was entitled to a special services pension before reaching retirement age. As part of the appeal, it is necessary to argue why the medical committee erred in its determinations and to attach relevant medical documentation, and even medical evaluations and/or opinions of expert doctors in the field attesting to the difficulty in performing daily activities. As long as and after the appeals committee the determination remains the same, the claimant can file an appeal to the regional labor court within 60 days from the date of the written decision (the appeal will be on legal questions only).

Another case that is worth noting is the rejection of the claimant's eligibility due to the provisions of the law or the regulations so that it is not possible to receive an allowance because of an external source (for example: he receives a mobility allowance, lives abroad, is hospitalized in a nursing facility, etc.), and not because of the medical condition, then an appeal can be filed with the The regional labor law, directly after the first committee, and within 12 months of receiving the decision in writing.

In conclusion, it can be seen that the road to receiving a special services allowance can be fraught with quite a few obstacles and difficulties. Therefore, it is recommended to consult with a lawyer who deals in the field throughout the entire procedure, so that the full range of relevant claims are presented to the medical committee and that the insured arrives prepared, and thus receives the allowance he needs.