Ontarians who have valid OHIP coverage can request that an out of country medical treatment or service be covered by OHIP if that treatment or service is:
- 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.
Your Ontario physician must submit a “Request for Prior Approval for Full Payment of Insured Out of Country Health Services” form on your behalf to the Ministry of Health and Long-Term Care prior to the services being performed. The Ministry must provide written notice of their approval before the service or treatment is performed. The Ministry may not cover all expenses associated with the service or treatment. Even with approval, it is a good idea to be informed about what expenses will not be covered.
I cannot stress enough that receiving the written notice of approval from the Ministry before leaving Canada is absolutely key (exceptions made for immediate emergencies are very limited). If an equivalent medical treatment or service can be provided in Ontario or another province of Canada, the Ministry will inform your doctor of this and your application will be denied. The grounds for denying an application can be quite broad. For example, if there’s a neurosurgeon who has provided written confirmation that he or she is available to perform a rare and complex surgery, it doesn’t matter if that neurosurgeon has never performed the neurosurgery on a particular person with that particular illness or disease. Navigating this system can be a heavy burden when the primary goal should be simply getting you the treatment you need. Receiving the right advice can protect your rights, inform you of risks, and hopefully get you the right treatment without having to pay a crushing medical bill from a foreign hospital.
At PooranLaw, we can help you prepare and submit an Out of Country OHIP application. If you have already made an application and have been denied, we can provide advice and representation to appeal this decision.