OHIP Coverage Outside Ontario

Ontario Health Insurance Plan ("OHIP") cases receive little media attention, yet arise in Ontario all the time. They revolve around people who obtain treatment, whether in or outside of Ontario, and would like OHIP to pay for it.

In a recent case an Ontario woman fractured her ankle and received physiotherapy in Ontario. Her injury was significant – she was hospitalized for nearly 2 weeks and required a wheelchair for several weeks after she left the hospital.

Around the time of the injury she was planning to relocate to Alberta. Before leaving for Alberta she reportedly obtained information from ServiceOntario that her physiotherapy services would be covered by OHIP until she received her Alberta health card.

When she arrived in Alberta she continued to receive physiotherapy services at a private clinic (she first obtained a referral from an orthopaedic surgeon). She paid out of pocket, expecting to be reimbursed by OHIP. She later submitted her claim to the Ontario government but OHIP denied payment “on the basis that physiotherapy services that are performed in Canada but outside Ontario are insured services only when performed in a hospital”. You read that correctly – health care services rendered outside Ontario may be insured by OHIP depending solely on the facility where they are provided.

The woman appealed to the OHIP Eligibility Review Committee, but the denial was upheld. She then appealed to a tribunal called the Health Services Appeal and Review Board. She argued that “had she been given correct information by ServiceOntario and OHIP, her physiotherapy costs would have been covered”.

 Once again, the woman lost the case.

The Health Services Appeal and Review Board agreed that the physiotherapy provided in Alberta was not an insured service because it had to be provided in a hospital rather than a private clinic. The decision-makers noted “The fact that the Appellant may have been given inaccurate or incomplete information is not a factor that the Appeal Board can take into account in deciding this appeal”.

While this decision may seem unfair, OHIP and the Health Services Appeal and Review Board apply the law in a very technical manner. Seemingly relevant circumstances, such as being provided incorrect information from the government, are not enough to win a case. The bottom line is that anyone receiving health care without a valid health card should either obtain legal advice first to determine whether the service would be covered by OHIP and/or purchase private health care insurance to cover any possible gaps.

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