In Ontario, the Health Insurance Act (“HIA”) establishes that the Ontario Health Insurance Plan (“OHIP”) operates for the purpose of providing for insurance against the costs of “insured services”, on a non-profit basis, on uniform terms and conditions available to all “insured persons”.1 Every resident of Ontario is entitled to become an insured person.2 The following services are insured services:
- Prescribed services of hospitals and health facilities;
- Prescribed medically necessary services rendered by physicians; and
- Prescribed health care services rendered by prescribed practitioners.3
With one exception described below, the HIA prohibits any contract of insurance for the payment or reimbursement of the costs of any insured services performed in Ontario for any insured person.4 Furthermore, the Health Care Accessibility Act generally prohibits physicians and hospitals from accepting payment from insured persons for the provision of insured services.5
An “out-patient” is defined by the Regulations to the HIA as a person who receives medical services without being admitted to and assigned a bed in a hospital in-patient area. An insured person is not entitled to insured services in a hospital as an out-patient unless he has been either received in the hospital and examined as an out-patient by a physician, or referred to the hospital as an out-patient by a physician or other health care practitioner.6 The out-patient insured services to which an insured person is entitled without charge include laboratory, radiological and other diagnostic procedures, together with the necessary interpretations.7 This would normally encompass MRI exams, which are provided in hospitals on an out-patient basis and which are usually “medically necessary”.
However, there are exceptions set out in the HIA and the Regulations thereto which can render an MRI exam an “uninsured service” by bringing it outside of the sphere of insured services which an insured person is entitled to receive without charge, and for which a hospital or physician is prohibited from accepting payment. These exceptions are as follows:
- Automobile Insurance: Automobile insurance policies are specifically excluded from the HIA’s general prohibition against contracts of insurance for the payment or reimbursement of the costs of insured services.8 Pursuant to the Compulsory Automobile Insurance Act, a motor vehicle can not be driven on an Ontario highway unless it is insured by a contract of “automobile insurance”, which is insurance against liability arising out of bodily injury to or the death of a person, or loss of or damage to property, caused by a motor vehicle or the use or operation thereof.9 All auto insurance policies are deemed to provide for the “medical benefits” set out in the Statutory Accident Benefits Schedule to the Insurance Act. These benefits include all reasonable and necessary expenses for medical and hospital services, and any related assessments or examinations, incurred by an insured person as a result of an automobile accident.10
- WSIB: Services that a person is entitled to receive under the insurance plan established pursuant to the Workplace Safety and Insurance Act are not insured services.11 Specifically, a worker who sustains a personal injury by accident arising out of and in the course of his employment is entitled to such health care as may be necessary, appropriate and sufficient as a result of the injury, with the costs of such health care to be paid by the Workplace Safety and Insurance Board.12“Health care” includes professional services provided by a physician or other health care practitioner, and services provided at hospitals and other health facilities.13
- Third Party Services: Under the HIA, a “third party service” is a service that is provided by a physician, hospital or other service provider in connection with a request or requirement, made by a third party, that the service be provided to an insured person, or that information relating to an insured person be provided to the third party. The third party that makes the request or requirement is liable for payment to the service provider for the service provided to the insured person.14 Regulations to the HIA specifically exclude from the definition of insured services any third party service which is received wholly or partly for the production of a document, or the transmission of information to the third party, if the document or the information relates to:
- admission to/continued attendance in a school/educational program
- admission to/continued attendance in a recreational/athletic club/program
- an application for/continuation of insurance
- an application for/continuation of a license
- entering/maintaining a contract
- an entitlement to benefits, including insurance or pension benefits
- obtaining/continuing employment
- an absence from/return to work
- legal requirements/proceedings15
- Screening: “Screening” in the medical context is defined as the examination of a person with no symptoms to detect unsuspected disease. It usually relates to the detection of coronary disease or different types of cancer. Most forms of screening are not considered “medically necessary” and therefore do not constitute an insured service under the HIA.
- Non-Residents: Under the HIA, only persons who are “ordinarily resident in Ontario”, as well as other persons deemed to be residents under the Regulations to the HIA,16 are entitled to become insured persons, and thereby entitled to receive insured services without charge. Therefore, medical services provided to non-residents in Ontario are not insured services under the HIA.
- Health Insurance Act, R.S.O. 1990, c. H.6, s. 10.
- Health Insurance Act, s. 11.
- Health Insurance Act, s. 11.2(1).
- Health Insurance Act, s. 14(1).
- Health Care Accessibility Act, R.S.O. 1990, c. H.3, ss. 1(2), (3).
- Health Insurance Act, R.R.O. 1990, Reg. 552, ss. 11(1)(b), (c).
- Health Insurance Act, Reg. 552, s. 7(3).
- Health Insurance Act, s. 14(1).
- Compulsory Automobile Insurance Act, R.S.O. 1990, c. C.25, ss. 1(1), 2(1).
- Insurance Act, O. Reg. 403/96, Statutory Accident Benefits Schedule, ss. 14(1), (2).
- Health Insurance Act, s. 11.2(2).
- Workplace Safety and Insurance Act, 1997, S.O. 1997, c. 16, Schedule A, s. 33(1).
- Workplace Safety and Insurance Act, 1997, ss. 32(a), (b).
- Health Insurance Act, ss. 36.1(1), 36.2(1).
- Health Insurance Act, Reg. 552, ss. 8, 8.2.
Health Insurance Act, Reg. 552, s. 1.1.