Critics fume as OHIP denies coverage of local woman’s U.S. appendix surgery

Posted: August 10, 2023

(August 8, 2023)

By: Jennifer Bieman, The London Free Press

France Gelinas

New Democrat MPP France Gelinas is photographed on Monday August 15, 2022. John Lappa/Sudbury Star

A Southwestern Ontario woman who pursued appendix surgery in the U.S. after being unable to access timely medical care in the province has lost her bid to make Ontario’s health insurance program cover the cost.The unidentified woman, referred to as KW in the board’s decision, and her mother lost their appeal of an OHIP decision that denied her reimbursement for medical costs connected to an April 2021 appendix removal surgery she sought in New Jersey after months of failed attempts to seek a diagnosis and treatment here.

That desperate patients are scrambling to find medical care and sometimes opting to pay out-of-pocket in another country for it is an indictment of government handling of the health care file, advocates say.“This is hideous. The first job of a public health care system is to plan for and provide the care that the population needs,” said Natalie Mehra, executive director of the Ontario Health Coalition, a grassroots public health care advocacy group.

“It sounds in this case like she was failed by the system. . . . Things are much worse than they ever have been. The system is starved of staff and the resources they need, in terms of primary care and hospital care.”

The decision upholding OHIP’s denial of coverage by Ontario’s Health Services Appeal and Review Board – the provincial panel that reviews and adjudicates challenges of health system decisions, including OHIP eligibility and public health orders – was released July 27.

The New Jersey surgery was the culmination of months of attempts to seek care in Ontario’s health care system, the board’s decision said.

The woman developed abdominal pain in late October 2020 and underwent more than 20 virtual and in-person consultations with various emergency departments, her family doctor and specialists until April 25, 2021, the decision said.

At least three surgeons in Ontario were unable to accurately pinpoint the issue and never performed a diagnostic surgery or MRI, she alleges in her appeal to the board.

The attempts to seek treatment included visits to the Strathroy General Hospital emergency department and London Health Sciences Centre emergency room on April 24 and April 25 respectively.

Days later, the woman had her appendix removed at a hospital in Teaneck, New Jersey, a 30-minute drive northeast of Newark. Her diagnosis was chronic appendicitis and an umbilical hernia, a weakness or tear in muscle or connective tissue near the belly button that allows intestinal tissue to bulge out.

The mother and daughter submitted an out-of-country claim for reimbursement to OHIP for medical and other expenses – including travel, car rental and medication – connected to the New Jersey surgery.

At a minimum, they were seeking reimbursement for the surgical consult, hospital bill, surgical fee and anesthetic fee totaling nearly $9,800 CAD.

The claim was denied by OHIP in April 2022 because it did not fit the criteria for an emergency, defined as an acute and unexpected illness that arose outside of Canada and required immediate care.

In the appeal, KW’s mother alleged she saw her daughter “continuing to fade” with pain, weight loss and hair loss and “believed she had to act to ensure the survival” of her daughter. She arranged for the surgery in New Jersey, alleging that further delays in her daughter’s diagnosis and treatment would have “life altering or loss of life consequences.”The appeal decision, made by three members of the review board, said the surgery cost was not eligible for reimbursement because it was not an acute, unexpected condition that arose outside of Canada.

In its decision, the board said the woman had not proven the surgery was insured under the out-of-country regulation and had no ability to compel OHIP to cover the procedure for “compassionate reasons.”

“The appeal board recognizes the very difficult circumstances facing the appellant and her mother,” the decision said. “The appeal board further acknowledges the pain and discomfort experienced by the appellant as well as the frustration of not being able to obtain a definitive diagnosis and treatment within Ontario.”

Ontario’s health insurance program provides limited coverage for emergency medical treatment costs incurred outside of Canada, provided the situation meets specific criteria. The out-of-country coverage – scrapped by Doug Ford’s Progressive Conservative government then later reinstated – is not a substitute for private travel insurance or coverage included in workplace benefits programs.The family could not be reached for comment.

With Ontario’s health care budget topping $70-billion a year, and the ranks of talented and dedicated health care workers in the system, no family should find themselves in the situation of this mom and daughter, Ontario NDP health critic France Gelinas said Tuesday.

“It is terrible. I feel like our health care system has failed them, but really it’s our provincial government that has failed them and others,” she said.

Lack of access to timely medical care has broader consequences, she said. When patients are dissatisfied with the care they receive it shakes public confidence in medicare itself, Gelinas said.

“It doesn’t matter what segment of the health care system I speak to, everyone is worried that the love Canadians have for medicare is being put to the test,” she said.

“Patients are looking for solutions of their own. If they’re close enough to the border, a solution is to go across the border and pay. If you are rich, a solution is to find a private clinic and pay. . . . But for the great majority of people, they depend on a program that defines us as Canadians.”

jbieman@postmedia.com

twitter.com/JenatLFPress

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