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A 'Private' Matter

Ministry of Health and Long-Term Care

Date: 2008

Private

After a decade of unsuccessful treatments and pain, an Ontario orthopedic surgeon recommended Mr. J have ankle replacement surgery.

Since the local wait time was three years, the man was granted $35,000 in out-of-country funding to have the procedure performed in the U.S. – but one month before the scheduled operation, he was turned away because the implants he needed were no longer approved by U.S. authorities.

The U.S. surgeon referred Mr. J to a Canadian colleague at a private clinic in Vancouver, where the surgery cost $19,463.  The Ontario Health Insurance Program (OHIP), but OHIP would only reimburse him $1,066 – the fee for the B.C. physician’s services – because it deemed the other fees charged by the B.C. private clinic ineligible for coverage.

The Ombudsman’s investigation determined that reciprocal agreements between the provinces do not cover reimbursement for costs of prosthetic devices.

However, the Ministry of Health and Long-Term Care reviewed the case and agreed to reimburse "Mr. J" an additional $12,915, which he accepted.