THUNDER BAY — A review board has upheld a decision from the Ontario Health Insurance Plan to deny coverage of medical expenses for a Thunder Bay woman who travelled to Arizona for treatment.
The case dates back to 2018, when the woman was diagnosed locally with Stage 3 cancer.
When symptoms developed in May of that year, a nurse practitioner referred her to a surgeon, but the diagnosis wasn't made until November.
After two local oncologists advised chemotherapy and radiation, she became concerned about the impact the treatment would have on her body, as well as her inability to work during this period.
She decided to investigate alternative treatment options, and about two weeks later started receiving targeted radiation — tomotherapy — and chemotherapy for her tumour at a Phoenix-area medical centre.
Tomotherapy allows a doctor to use the highest dose of radiation for killing tumour cells while causing less damage to nearby tissue.
The treatment the woman received was effective. In October 2019, an oncologist in Thunder Bay determined that she was cancer-free, with no signs of progression or recurrence.
The following year, she applied to OHIP for reimbursement of the cost of the care she received in Arizona.
OHIP turned her down in September 2020, on the basis that its regulations only allow payment for insured emergency out-of-country health services.
To qualify as an emergency, the provincial health insurance plan requires several criteria to be met:
- the treatment is medically necessary
- the treatment is performed at a licensed hospital or health facility
- the treatment is rendered in relation to an illness, disease, condition or injury that is acute and unexpected, arose outside Canada, and requires immediate treatment
In March 2021, the woman took her case to the Health Services Appeal and Review Board.
She argued that OHIP administrators erred in considering her case as an application for reimbursement for an emergency out-of-country health service.
Patient had no family doctor to advise her about OHIP's 'prior approval' process
She said she did not have a primary health care provider to advise her about the process for receiving prior approval from OHIP, and it was the lack of prior approval that resulted in her claim being rejected.
The woman stated she was confident that if she had followed the prior approval process, she would have been granted coverage because her treatment took place at a licensed facility, it is not performed in Ontario by an equivalent procedure, and because any delay would have resulted in significant irreversible tissue damage and her potential death.
She also maintained that while the treatment is based on innovations accepted within Ontario's medical community, it is so new that it is not yet being used in the province.
The appellant asked the appeal board to treat her claim for reimbursement as if it were an application for prior approval.
She submitted a letter from an oncologist in Arizona who wrote that her condition had "required immediate attention and treatment, particularly in view of the delays experienced in diagnosis."
In response, OHIP provided opinions from Cancer Care Ontario and the Ontario Public Drugs Program.
Taken together, they concluded that the woman's treatment was not received in "emergency circumstances," that tomotherapy is generally considered experimental in Ontario, that it is not generally accepted in Ontario as being appropriate for a person in the same medical circumstances as hers, and that equivalent services are performed in Ontario with no evidence of a delay that would lead to death or significant irreversible tissue damage.
OHIP also submitted that tomotherapy was available in Ontario in December 2018 and that it was not shown to be superior to the type of treatment she was offered in Thunder Bay.
This week, the Health Services Appeal and Review Board released a decision denying the appeal on the basis the services the woman obtained in Arizona are not insured services.
It also ruled that she had failed to demonstrate that she would have met the criteria for the out-of-country prior approval program.
Of note, in her appeal the woman — who had no family doctor at the time her cancer symptoms appeared — highlighted that the out-of-country prior approval process is not well-known to the general public.
She suggested that Ontario consider giving nurse practitioners the authority to complete application forms.
