Melinda Dalton wrote in "Improved OHIP appeal procedure needed for those seeking cross-border care" (Waterloo Record, Nov.28, 2009, here):
"A former OHIP lawyer is calling for a new review of how Ontario handles out-of-country medical funding appeals because, he says, the complicated process leaves patients with little chance of ever having their bills reimbursed.
“This process should not be a safety valve for OHIP and that’s what it is now,” said Perry Brodkin, a Toronto lawyer who specializes in health law.
Brodkin was responding to a Metroland Special Report on cross-border care that shows what Health Minister Deb Matthews acknowledges is a dramatic increase in OHIP spending for out-of-country care. Patients who use the system express concern about the time it takes to get OHIP approval, and the difficult appeals process if refused.
Matthews was not available for comment yesterday.
The Health Services Appeal and Review Board is an independent body that reviews all claims made to OHIP, including pre-approvals and appeals for out of country treatment.
Brodkin, OHIP’s lawyer from 1973 to 1991, has assisted clients who are mounting appeals to the board, primarily by locating specialists who will testify on their behalf at a hearing.
However, he said, most people who appeal an OHIP decision simply can’t afford the help of a lawyer.
They end up mounting complicated appeals on their own, with limited knowledge of what they have to present to legally meet the standards needed for a successful appeal.
Often, it’s their own lack of knowledge that seals their fate, he said.
“People don’t understand that these hearings at the board are like a trial,” said Brodkin, adding patients generally need to convince a specialist to testify on their behalf.
“If you don’t, your appeal will be denied. Nobody tells anybody that . . . In other words, appellants to the board aren’t provided with sufficient information to enable them to have the slightest chance to have their appeal granted.”
Brodkin says after people lose their appeals, many simply think it’s the end of the road and they’re out of options.
“I advise as soon as you receive a decision from the board to contact the ombudsman,” he said.
The Ontario Ombud’s office said it received less than 10 complaints about the board in the last year and about 15 the year before.
Spokesperson Linda Williamson said that’s not necessarily representative of the number of people encountering problems with the board since not everyone is aware of their right to file a complaint with the Ombud’s office.
The Health Services Appeal and Review Board does not track or report on how many of the cases it reviews under OHIP involve refusal for out-of-country care. Last year, the 2008-09 fiscal year, it had 397 requests for appeal under OHIP, but cannot say how many were out-of-country care related.
The board also has not publicly issued an annual report for almost four years.
The Metroland report on Ontarians accessing health care in the U.S. included the story of Janet Nancarrow of Ottawa, who is preparing for an OHIP appeal hearing for her 34-year-old daughter, Lisa, who is taking part in a clinical drug trial at the Mayo Clinic.
Lisa Nancarrow’s doctors and family say the trial is her only option short of end-of-life palliative care. Her mother says that with no outside help, she had to research precedents, find expert witnesses and stay on top of voluminous paperwork, all while accompanying her daughter back and forth to Minnesota for treatments. But there are many more stories like the Nancarrows, including that of the Taylor family from Hamilton.
Stuart Taylor has spent the last two years mounting his appeal to OHIP for reimbursement of his son’s spine surgery at the Laser Spine Institute in Florida. Their initial claim was denied because the Taylors didn’t apply in advance for pre-approval and the use of lasers is considered experimental in Ontario.
Taylor said his family doctor didn’t know the procedure for out-of-country applications and he was told he could apply when he got home. He said he’s been given no help in gathering the large amount of evidence required to prove his case and the appeal has consumed a significant portion of his life.
“We won’t win, I know that. They’ve just got it all stacked up against us,” said Taylor, who remortgaged his house to pay for his son’s $28,000 surgery.
“Mentally, I’d love to abandon it because it’s dragging me down . . . but I can’t imagine (doing that) now after all this work.”
A spokesperson for the board said it could not offer any comment on the appeals process because its mandate is solely interpretation of the act.
Two previous examinations of the OHIP out-of-country system have occurred in the last few years. An investigation by the Ontario Ombud into the case of Suzanne Aucoin, a St. Catharines woman who was denied funding for the chemotherapy drug, Erbitux, in 2006, led the province to eventually reimburse Aucoin $75,000 and issue an apology.
The Ombud’s probe led the Ministry of Health and Long Term Care to order an independent review of the out-of-country care system in 2007. That three-month appraisal - led by Mary Catherine Lindberg, a former assistant deputy minister of health - identified some weaknesses, and led to changes by the ministry. But now Brodkin says another review of the appeals process, by the ministry itself or an independent body, is in order.
“I think the whole process needs to be looked at and reformed,” he said.
The first thing that needs to be looked at, Brodkin said, is the decision-making power of the board, including if their jurisdictional authority should be expanded, “so they can render fair decisions, equitable decisions and don’t have to be bound by the law.”
The board is an independent body, set up by the province, to hear appeals on a wide range of decisions by the Health Ministry, under more than 14 health-related statutes.
Included is the Ontario Health Insurance Act, the law that covers eligibility for public health insurance and also out-of-country care.
“It must render its decision in accordance with the law,” Brodkin said. “It has no discretion. No compassionate grounds. Many people appear before the board and argue compassionate grounds. All those appeals are denied.”
Let's see whether the St.Catharines Standard or Niagara This Week bother to cover this story from a local view, providing quotes from interviews with Niagara Falls Liberal MPP Kim Craitor, from St.Catharines Liberal MPP Jim Bradley, from Liberal health minister Deb Matthews, and from Liberal premier, Dalton McGuinty.
Many Obama supporters don't even believe that any Canadian would have to need to go across the border to the United States for health care; in Ontario, McGuinty's Liberals like to encourage this kind of ignorance.
[McGuinty's Liberals would not want anyone to read this, regarding their Liberal healthcare duplicity.]