Will OHIP reimburse me if I require out-of-country medical treatment that isn�t available in Ontario?
Yes – in certain circumstances, the Ontario Health Insurance Plan (“OHIP”) will provide funding for out-of-country medical treatment that isn’t available in Ontario.
In order to qualify for funding, the proposed treatment must be either unavailable in Ontario, or the delay in obtaining the treatment in Ontario would result in death or medically irreversible tissue damage.
Only treatment that is generally accepted as appropriate in Ontario will be covered (e.g. it cannot be experimental or for research purposes), and it must be performed in a hospital or licensed facility where complex medical or complex surgical services are provided.
In order to receive funding, your treating Ontario physician must submit an application to OHIP for prior approval. In cases of emergency, approval may be sought after the treatment is performed.
If approved, OHIP will provide funding for the hospital and physician services received, generally based on the rates charged to major insurers in that jurisdiction (or pre-approved rates in certain facilities).
OHIP will not provide funding for non-hospital and non-physician services, such as transportation, out-of-hospital accommodation and meals, and take-home prescriptions.
If your application for funding is denied, or you receive inadequate compensation from OHIP, you may bring an application before the Health Services Appeal and Review Board (“HSARB”).
In such cases, it is important to contact a lawyer immediately to explore your options, as the law surrounding these applications can be complex, and certain time restrictions will apply.