A Long Wait

Ministry of Health and Long-term Care (OHIP)

Date: 2009

A 70-year-old man had developed end-stage renal failure and was in need of a kidney transplant. He was told by his hospital that patients on the Ontario kidney transplant waiting list had to wait a minimum of 5-6 years for an organ. His doctor advised him that if he waited that long, he would be at an age and in a physical condition where he would not be able to undergo surgery. In mid-2002, he was put on a waiting list for transplant in Buffalo, New York. and his doctor applied to have the $40,000 cost covered under the Ontario Health Insurance Plan (OHIP) Out-of-Country program.

On January 16, 2006, a kidney became available and the man’s transplant was performed in Buffalo. A week later, however, he received a letter from OHIP denying his application for coverage, stating in part that he had not established that his condition was so dire that he could not have waited for a kidney to become available in Ontario. The man appealed the decision to the Health Services Appeal and Review Board (HSARB).

The HSARB also denied him, relying in part on the opinion of an expert witness who was called by OHIP. The expert stated that based on the available statistics the man’s wait time would have been 5.5 years, only 1.2 years longer than he waited to receive a transplant in Buffalo. Based on this information, the HSARB found the coverage of the U.S. operation would be unjustified.

The man complained to the Ombudsman that the Ministry’s expert had provided incorrect information to the HSARB. An Ombudsman investigator found that the OHIP expert’s transplant data included data from the Hospital for Sick Children, a pediatric facility that does not do adult transplants. Excluding that data, the average wait time for a kidney transplant for someone in the complainant’s situation in Ontario would have been 6.4 years, not 5.5 years.

As a result of this new information, the OHIP expert clarified the opinion he had given and the HSARB agreed to reconsider the man’s case.