Kupah Exceptions Committee: A Complete Guide

When a patient needs a drug or medical device that isn't included in the public health basket, one way to seek funding from your kupat cholim (health fund) is by applying to an exceptions committee. This is a public route intended for special cases, in which a reasoned request is submitted and reviewed by the fund's medical staff. In this guide we explain, generally and broadly (the process varies from fund to fund), who the route suits, which documents are usually attached, what the process and timelines look like, what to do if the request is rejected, and how private insurance fits into the picture. The information here is a general, empowering explanation and not medical or legal advice.

What the exceptions committee is and who it's for

Every kupat cholim operates an exceptions committee whose role is to review members' requests to fund a drug or medical device not included in the health basket. Generally, the route is intended for special cases – for example, when the requested treatment may save life, extend life, or prevent risk of severe disability, and there is no adequate alternative within the basket.

It's important to understand that the committee does not approve every request, and it may weigh both medical considerations and additional factors. That said, every member has the right to apply and submit a reasoned request. If the matter concerns medication, you can read more in our guide on out-of-basket drugs, and if it concerns a device or technology, in our guide on medical technology.

Which documents are required

The quality of the documents greatly affects the request's chances. Generally, it's customary to attach:

• The kupah's request form, completed as required.
• Full, relevant medical documentation – hospitalization summaries, tests, discharge letters, and up-to-date results.
• A reasoned recommendation from the treating physician, detailing the medical condition, the severity of the illness, the treatments tried within the basket and the response to them, and the medical rationale for the requested treatment.
• Up-to-date documentation of the medical condition and prior correspondence with the kupah on the matter.

A clear, reasoned medical opinion is usually the heart of the request. Sometimes it's worth considering a second opinion to strengthen the medical file.

How the process works and the timelines

Generally, the request is submitted to the kupah's medical division. If it is deemed suitable for discussion, a hearing date is set and the applicant is notified – usually some time in advance (for example, at least a few days before). Exceptions committees generally convene periodically (for example, once a week) and review several cases per session.

Timelines and procedures vary from fund to fund, so the numbers here should be treated as examples only and verified with your specific kupah. It's advisable to document every request and keep submission confirmations.

What to do if the request is rejected

A rejection isn't necessarily the end of the road. Generally, you can appeal the decision, and sometimes add documents or further opinions and submit a renewed request. If the appeal is not accepted, you can turn to the regional labour court, which is the body authorized to hear a dispute between a member and a kupat cholim.

Before taking a legal step, it's worth consulting relevant support and patient-rights bodies, and making sure all medical documentation is organized and up to date.

How private insurance fits in

The exceptions-committee route is a public route through the kupah, and it is separate from private coverage such as an out-of-basket-drugs rider in a private health-insurance policy. So it's sometimes worth examining both routes in parallel: private insurance may cover a treatment the committee declined, and vice versa – the committee may approve what isn't covered by the policy.

If you're considering a claim on your private insurance, see our guide on how to file a claim. An organized review of the policy can save precious time.

How Ravit can help

Ravit reads your policy documents that you send directly on WhatsApp, and lets you ask in free, natural language – with no forms. She answers based on what's written in your own policy, with a pointer to the relevant clause so you can verify it yourself, and when she isn't sure enough she says so honestly rather than guessing. That way you can understand faster whether the treatment you need might be covered, alongside the public exceptions-committee route.

The information in this article is general only and does not constitute medical, insurance, legal, or pension advice, and is not a substitute for reading your policy terms or consulting a licensed professional. Coverage, amounts, and conditions vary between policies and change over time — always verify against your own specific policy and an authorized professional.