OHIP CASE STUDY

Facts of the Case

David Smith visited Barbados for holidays and during his visit, he started feeling acute gastrointestinal pain. After his symptoms worsened, he visited the local physician who recommended after analyzing his blood and ultrasounds reports to consult with his family doctor. When he returned to Canada, his reports showed that he had stage 3 stomach cancer and that he needed immediate medical treatment. Also, due to no availability of slots, Mr. Smith was directed to get the treatment in New York. For this purpose, Mr. Smith files a claim to the OHIP to get coverage for his out-of-country care.  

Problem Statement

Examine ALL stakeholders involved. As the General Manager of OHIP, advise whether you will grant Mr. Smith’s claims for out-of-country care and reimbursement for the medical services in Barbados?

Arguments 

One of the major stakeholders in the case is Mr. Smith, the person in need of urgent medical care. However, his medical condition cannot be treated in Ontario as none of the Ontarian physicians have any slots available in the current month. This means Mr. Smith has no option but to seek out-of-country treatment and therefore, Mr. Smith’s physician recommended him OCC Treatment Program. 

Since such a scenario is not ideal and should not have occurred, Mr. Smith is requesting two things from the Ontario Health Insurance Plan (OHIP). The first thing is coverage for out-of-country medical treatment and the second is reimbursement for the medical services availed in Barbados that Mr. Smith had paid for out of his own pocket.

Now, Mr. Smith can be granted out-of-country (OOC) care from the OHIP on the fulfillment of the following conditions: 

  1. The OOC services received may be covered by OHIP if the “Prior Approval Application for Full Payment of Insured Out of Country Health Services” is approved. 
  2. And in order to receive the coverage, it is important to note that the patient gets treatment at a licensed hospital, not for an experiment, or not performed in Ontario. 
  3. It is also recommended to purchase additional private medical insurance. 
  4. After the approval, it is necessary to note that the department pays only the expenses of the medical services which are approved.
  5. The travel, accommodation, and meals are not covered by the OHIP.

Additional details that need to keep in mind are: 

  1. OHIP will either pay for the actual amount billed by doctors treating you outside of Canada or the rates set out in the Ontario Medical Services Benefits Schedule and paid by them to Ontario physicians (whichever is less).
  2. Also, the inpatient services that would be incurred in an operating, coronary care unit, and intensive care unit will be paid by OHIP but only up to $400 (Canadian) per day and $200 (Canadian) per day for lower levels of care. 
  3. Another factor that needs to be considered is that if Mr. Smith plans to stay out-of-country for more than seven months in any 12-month period than he can keep his OHIP coverage for two years only on the conditions that he has a valid health card, and will be in Ontario for at least 153 days a year in each of the two years immediately before you leave the country. 

Other Stakeholders in the Case

The second stakeholder involved in the case is Dr. Alicia Jones, who is Mr. Smith’s family doctor and primary care physician during this whole treatment. Upon coming back to Ontario, Mr. Smith visited Dr. Jones with complaints of severe stomach pain, after which Dr. Jones referred Mr. Smith to a medical oncologist. However, the referred oncologist would not be able to see Mr. Smith in time due to scheduling issues. Unhappy with the lack of available oncologists, Mr. Smith decided to go to New York where he was diagnosed with stage 3 stomach cancer. The doctor in New York also told Mr. Smith that treatment could begin right away in New York.

When Mr. Smith returned back to Ontario, his diagnosis of stomach cancer was confirmed by Dr. Cho, oncology specializing in the treatment of gastrointestinal cancer.

Reimbursement for the Medical Services Incurred in Barbados

The OHIP will also provide reimbursement to Mr. Smith for the blood tests and the ultrasounds that were conducted in Barbados. In order to get some of the medical expenses reimbursed, an OHIP claim must be submitted within 12 months of receiving – and paying for – the services. This includes emergency services through the Out-of-Country Travellers Program. In order for Mr. Smith to get reimbursed, he needs to fill out the Out of Province/Country Claims Submission form and attach a detailed statement in English or French. 

Conclusion 

As a General Manager of OHIP, I have come to the conclusion that Mr. Smith, a resident of Canada has fulfilled all the requirements mentioned under the OHIP guidelines and the Health Insurance Act and therefore, can be granted the relief but to a certain extent and can not receive full coverage under OHIP. Thus, it is recommended that Mr. Smith gets additional private health insurance coverage as OHIP coverage is limited when the patient gets medical treatment outside of Canada.

References

Law Document English View. (2018, November 19). Retrieved from https://www.ontario.ca/laws/regulation/r09133.

Ministry of Health. (n.d.). Public Information. Retrieved from http://www.health.gov.on.ca/en/public/programs/ohip/outofcountry/prior_approval.

What services does OHIP cover? (n.d.). Retrieved from https://settlement.org/ontario/health/ohip-and-health-insurance/ontario-health-ins

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