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OHIP covers many health care costs when you are in Ontario. But what about when you are abroad or if you want treatment that isn’t available in Ontario but is available elsewhere in Canada? Siskinds lawyer Maciek Piekosz looks at how OHIP covers you and outlines the steps involved in getting out-of-province coverage for treatment.

The Ontario Health Insurance Plan:

In Ontario, many health care services are provided under the Ontario Health Insurance Plan (“OHIP”), a taxpayer funded system of healthcare.  Tax dollars fund many services provided by physicians in Ontario, such as visits to family doctors, to specialists, and basic and emergency health care services, including surgery and hospital stays.  Generally, a resident of Ontario must have a health card to show that he or she is entitled to health care services paid for by OHIP.[1]  “Elective” services, such as the cost of regular dental services in a dentist’s office, are typically not covered by OHIP.

Will OHIP fund treatment in Canada but outside of Ontario?

A resident of Ontario who is eligible for OHIP coverage may receive OHIP coverage outside of Ontario, but within Canada, in two circumstances:

  1. Emergency medical care required unexpectedly while travelling, working or attending school.

To receive coverage, an Ontario resident must simply present his or her valid Ontario health.  If a card is not presented, the Ontario resident can still receive the health care but will likely be billed directly for the services provided.

  1. Non-emergency planned medical care required outside Ontario but within Canada.

These services must be approved prior to the health services being provided.[2]  To qualify for out-of-province health services funding, you must meet the following criteria:

  • Must be an OHIP eligible resident of Ontario; and,
  • The services must be performed at a publicly funded hospital or facility which participates in a reciprocal hospital billing agreement or in a facility that the ministry has entered into a Preferred Provider Arrangement; and,
  • The requested service(s) must be insured service(s) in Ontario; and must not be “experimental”, part of a trial or survey.
  • The service, if provided in Ontario is one to which the insured person would be entitled to without charge.[3]

Will OHIP fund treatment out-of-country?

If you are travelling abroad and require emergency treatment, OHIP will only reimburse up to a total of $50 per day[4] and ambulance services are not covered if you are outside of the country. For this reason, the Ministry of Health and Long-Term Care (“Ministry”) strongly recommends that you have additional private medical insurance[5].

For non-emergency treatment, your physician must submit a Prior Approval Application to the Ministry for consideration before out-of-country medical services will be covered by OHIP. [6]  The requested out-of-country services may be OHIP insured if the application establishes that the services and treatment being requested are:

  • Performed at a hospital or licensed health facility; and
  • Not experimental or for research or for a survey; and
  • Generally accepted in Ontario as appropriate for a person in the same medical circumstances as the insured person; and
  • Either not performed in Ontario by an identical or equivalent procedure; or
  • Performed in Ontario but the insured person must receive the services outside Canada to avoid a delay that would result in death or medically significant irreversible tissue damage.[7]

Are there options in the event of denial?

If your application is rejected, you have 2 options:

  1. Request an internal review of your application.

The Ministry will re-examine applications as long as additional relevant information is provided for review.  The Ministry will prepare a decision letter upon completion of the review.

  1. Request a hearing before the Health Services Appeal and Review Board (“HSARB”).

If an application has been denied, either initially or following an internal review, you may request a hearing before the HSARB, which is an independent quasi-judicial tribunal tasked with considering appeals from certain government decisions.  HSARB must be advised in writing of your intention to appeal within 15 days of receiving the denial letter.  With your input, HSARB will determine whether an oral, written, or electronic hearing will be necessary to adjudicate your matter.  An oral hearing will be before three members of HSARB, who will consider all relevant documentation, and hear testimony from necessary witnesses.  A representative of the Ministry of Health and Long-Term Care will be arguing on behalf of the Ministry’s denial of approval.[8]

Although you do not require a lawyer to pursue your rights before the HSARB, should your matter proceed to the point of a hearing, consultation with a lawyer may be appropriate to ensure the greatest chance of successfully appealing the denial.
 
If you have any questions regarding an injury at work and your legal rights, or would like more information on this topic, please contact Maciek Piekosz via email at  maciek.piekosz@siskinds.com or call 519-660-7718 for a free consultation.


[1] Health Insurance Act, R.R.O. 1990, Reg. 552. s. 1.4
[2] Health Insurance Act, R.R.O. 1990, Reg. 552. s. 1.9
Currently there is no specific out of province form; however, the Prior Approval Application for Full Payment of Insured Out-of-Country Health Services Form (Form 4520-84) is acceptable. The form can be downloaded at: www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-4520-84~1/$File/4520-84E.pdf
[3] http://www.health.gov.on.ca/en/public/programs/ohip/outofprovince/
[4] Health Insurance Act, R.R.O. 1990, Reg. 552. s. 28.2
[5]Ontario Ministry of Health and Long Term Care, OHIP Out of Country Services, online < http://www.health.gov.on.ca/en/public/programs/ohip/outofcountry/travellers.aspx>
[6] Prior Approval Application for Full Payment of Insured Out-of-Country Health Services Form (Form 4520-84). The form can be downloaded at: www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-4520-84~1/$File/4520-84E.pdf
[7] http://www.health.gov.on.ca/en/public/programs/ohip/outofcountry/
[8] http://www.hsarb.on.ca/

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