OHIP Reimbursement Dispute: KA vs. OHIP

An Ontario woman (“KA”) had a recurrent cerebrospinal fluid leak. She received treatment in Ontario, but eventually went to Los Angeles for additional treatment that was not available in Ontario. Over several months KA had surgery, blood patch procedures, various tests and other forms of treatment.  KA was routinely reimbursed by the Ontario Health Insurance Plan (“OHIP”) for her out-of-country treatment.

In Ontario every insured person is entitled to payment for insured services. While most insured services are provided in Canada, there are times when a person must travel outside of the country to receive care. Generally speaking, there are two circumstances in which a person may be reimbursed for out-of-country health service charges:

(1)    when the person is outside Canada and an emergency arises that requires immediate medical treatment; or

(2)    when the person receives approval from OHIP before receiving the treatment. This tends to happen if the particular service is not performed by any health professionals in Ontario.

On June 1, 2011, a medical issue arose and KA sought last minute approval from the Ministry of Health and Long-Term Care (the “Ministry”) to insure a surgery she would undergo the following day. KA’s application was not processed until after the surgery was completed. This put KA’s application in an awkward position between the two circumstances identified above: her circumstances were urgent, but not necessarily an emergency; at the same, she was unable to obtain approval in advance of the surgery due to the urgency of the situation.

The Ministry decided that it could not grant prior approval after the services were rendered or underway because the services were not provided in emergency circumstances. Therefore, it did not consider the services to be insured services and declined to fund the treatment. KA appealed this decision.

The appeal was heard by the Health Services Appeal and Review Board (the “Board”), a tribunal that makes decisions about OHIP eligibility for coverage and payment for services (among other things). The Board was required to determine whether the medical services KA received were rendered in “emergency circumstances”. If the Board found that her medical circumstances created an immediate risk of death or medically significant irreversible tissue damage and that it was essentially impossible for her to give notice before services were rendered, then she would be eligible for reimbursement. If it found that she had time to seek approval, her application would be denied.

The Board analyzed the relevant sections of the Health Insurance Actprevious Board decisions and the meaning of “emergency circumstances”. It considered medical evidence, witness testimony and KA’s prior OHIP approvals.

The Board released its decision on January 23, 2013 and stated the following:

In this case, the Appeal Board finds on the evidence that the Appellant’s [KA’s] condition was such that she faced “immediate risk” so urgent that while she took steps directly and via her Ontario physicians to seek prior approval for out-of-country medical treatment from the Respondent, she required treatment before prior approval could be obtained.

The Board found that the services KA received were insured services of OHIP and therefore KA ought to be reimbursed for the out-of-country medical treatment for which she personally paid.

If you have questions about OHIP funding or wish to appeal a refusal of funding, please contact Lisa Feldstein Law Office.

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