Can you still receive Out-of-country medical funding under OHIP?

  • November 13, 2020
  • Anoop Kalsi

Ontarians have been able to seek reimbursement for out of country medical care in certain circumstances. On January 1, 2020 of this year, the Ontario Government eliminated this program. The removal of this out-of-country program was the subject of a legal challenge.

Ontarians who incur medical expenses while abroad have two options available to them to seek reimbursement: (1) seek prior approval from OHIP’s General Manager under the Out of Country Prior Approval Program; or (2) seek reimbursement after the fact from OHIP’s Out of Country Traveller’s Program (“OOCTP”). The decision before the Superior Court dealt with the second option.

Regulation 552 under the Health Insurance Act (HIA) allowed for the reimbursement of out-of-country medical expenses by OHIP. On July 25, 2019, the Ontario government approved Regulation 259, which removed the out of country reimbursement program. This change came into force on January 1, 2020.

On September 23, 2020, the Ontario Superior Court decided that the Ontario government’s decision to eliminate the Out-of-Country medical coverage program had to be reversed. The Court found that it was beyond the government’s authority to eliminate the program.

You can read the Court’s decision here (link).

The Applicant’s successfully argued that Regulation 259 violated section 45 of the HIA, which expressly prohibits the Lieutenant Governor in Council from enacting regulations that would disqualify Ontario from receiving funding under the Canada Health Act (CHA). Regulation 259 violated the portability requirement which Ontario must continue to meet in order to be eligible for Federal funding for health care. To satisfy the portability requirement, the provincial plan must provide payment for insured services that are delivered while an Ontario resident is temporarily outside of Canada. This payment must be at a rate that is similar to what would have been paid if the service had been provided in Ontario.

The Court determined that when the Regulation 259 was passed, it failed to satisfy the portability requirement which would disqualify it from receiving full cash contribution. The Court determined that the part of Regulation 259 that revoked the Out-of-Country program was beyond the powers of the Government and could not remain in effect.

As a result of the Court’s decision, the Out-of-Country Medical program remains in force and effect. This decision is welcome news for anyone who may require medical care abroad, and are unable to obtain prior approval for the funding for the care.

Bakerlaw has experience in assisting clients in requesting approval of out of country medical costs. We can assist you with the completion of applications to the Ministry of Health for out-of-country treatments. We can also assist you if an application for prior approval or retroactive funding is denied. You can read more about our work in this area here (link).

To discuss your application or appeal for out-of-country funding, please contact us using our online confidential intake form (link).

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