Declarations for OHIP coverage of out-of-country treatment
Doctors are wise not to bow to pressure to provide patients with declarations to apply for Ontario Health Insurance Plan coverage for out-of-country treatment.
The issue, frequently a point of contention for patients seeking OHIP-funded treatment in the United States, was recently highlighted in a Toronto Star story about a family on the hook for $100,000 in U.S. surgery bills. The family complains that a surgeon at SickKids Hospital in Toronto “wouldn’t sign off on OHIP coverage for a teenage girl’s potentially life-saving surgery”.
The article suggests that a doctor "blocked" the family's request for funding from OHIP of surgery in the United States, but it is important to remember that OHIP will only cover surgery or other medical treatment performed outside of Ontario if the following criteria are met under subsection 28.4(2) of Regulation 552 of the Health Insurance Act:
(a) the service is generally accepted by the medical profession in Ontario as appropriate for a person in the same medical circumstances as the insured person;
(b) the service is medical necessary;
(c) either: (i) the identical or equivalent service is not performed in Ontario; or (ii) the identical or equivalent service is performed in Ontario but it is necessary that the insured person travel out of Canada to avoid a delay that would result in death or medically significant irreversible tissue damage;
(d) in the case of a hospital service or a service rendered in a health facility, the service, if performed in Ontario, is one to which the insured person would be entitled without charge pursuant to section 7 in the case of an in-patient service or section 8 in the case of an out-patient service; and
(e) in the case of a service performed for an insured person who is admitted as an in-patient at a hospital or for an overnight stay at a health facility in Ontario, the insured person would ordinarily have been admitted to a public hospital as an in-patient.
Based on this section, in order for treatment performed outside of Ontario to be covered by OHIP, a doctor must declare that he or she is of the opinion that all of these elements have been met.
The key criteria are that the service is necessary, it is generally accepted by doctors in Ontario as appropriate (as opposed to, for example, experimental treatment), and that the doctor believes the patient is likely to suffer death or medically significant irreversible tissue damage due to the delay in having the procedure performed in Ontario. If the treatment is not recommended at all, or if the treatment is recommended but the patient is not likely to suffer death or tissue damage from the delay, the service will not be covered by OHIP.
Further, if a doctor completes a declaration in support of the patient’s request for coverage, the Ministry of Health will likely seek a second opinion and will only typically fund a procedure if the ministry's expert agrees with the opinion expressed by the patient's doctor.
The exact wording from Part 5 of the request for prior approval application form reads:
Is this treatment generally accepted in Ontario as appropriate for a person in these medical circumstances? (yes/no)
Is this treatment performed in Ontario by an identical or equivalent procedure? (yes/no)
If "yes", where is this service performed in Ontario?
Is this treatment required out of Canada to avoid a delay in obtaining the treatment in Ontario that would:
A) Result in death? (yes/no)
B) Result in medically significant irreversible tissue damage? (yes/no)
If "yes" to either of the above, how soon is the treatment required?
"If treatment is not available in Ontario: Is this treatment generally accepted in Ontario as appropriate for a person in these medical circumstances? (yes/no)
Is this treatment generally accepted as experimental in Ontario? (yes/no)
Is this treatment performed in Ontario by an identical or equivalent procedure? (yes/no)"
Doctors are often under intense pressure from patients to sign forms to support their efforts to have out-of-country treatment funded by OHIP, and doctors may well want to support their patients in this regard, particularly since the costs of such treatment can be astronomical. But doctors must in all cases ensure that they truly believe what they are declaring to be true, and that they balance their duty to advocate for their patient with their overarching duties of professionalism and honesty. To do otherwise could result in the doctor being charged with one or more acts of professional misconduct.