Health Services Appeal and Review Board Denies Appeal of Ayham Hussein's Reimbursement for Out-of-Province Medical Services

Strategic Insights -

Ayham Hussein, a low-income student from Ontario, had appealed a decision by the Ontario Health Insurance Plan (OHIP) to reimburse him only $37.95 for medical services he received in Montreal, Quebec. Hussein had paid $100.00 for the visit and argued that he should be reimbursed the full amount. However, the Health Services Appeal and Review Board (HSARB) found that the Respondent had reimbursed Hussein the maximum allowable amount prescribed under section 29 of Regulation 552 under the Health Insurance Act, and no further amount is payable by the Respondent.

Key Takeaways:

  • The HSARB denied Ayham Hussein's appeal for out-of-province medical services, finding that the Respondent had reimbursed him the maximum allowable amount under the Act and the Regulation.
  • The appeal was based on Hussein's assertion that he should be reimbursed the full amount of $100.00 he paid for the medical services, but the HSARB determined that the reimbursement was in accordance with the Regulation.
  • The HSARB acknowledged Hussein's circumstances as a low-income student with multiple surgeries, but its role is to determine whether the reimbursement met the criteria set out in the Act and the Regulation.
  • The HSARB has no jurisdiction to order OHIP to do something that is not permitted under the Act or the Regulations.
  • The Appellant disagreed with the Respondent's decision to reimburse him only $37.90 of the $100.00 he paid to Clinique En Route, asserting that he had been reimbursed almost the full amount for a similar visit several months prior.
  • The Respondent submitted that it has made payment of $37.90 to the Appellant representing the amount payable for the service in the Ontario Schedule of Benefits, under fee code A007, "intermediate assessment by a family physician".
  • The Regulation allows for payment of medically necessary out-of-province physician services provided to an insured Ontario resident at a rate equal to the amount charged or the fee listed in the Ontario Schedule of Benefits under the Act, whichever is less.
  • The Appeal Board acknowledged the circumstances Hussein faced but determined that it had no jurisdiction to order OHIP to do something that is not permitted under the Act or the Regulations.

Statistics:

  • Hussein paid $100.00 for medical services in Montreal, Quebec, but was reimbursed only $37.95 by OHIP.
  • The appeal was denied by the HSARB on April 4, 2025.
  • The HSARB found that the Respondent had reimbursed Hussein the maximum allowable amount under section 29 of Regulation 552 under the Health Insurance Act.
  • The HSARB has no jurisdiction to order OHIP to do something that is not permitted under the Act or the Regulations.

Sources:

  • Health Services Appeal and Review Board of Ontario (2025-04-04): HEALTH SERVICES APPEAL AND REVIEW BOARD PRESENT: Mitchell Toker, Vice-Chair, Presiding Jennifer Sarjeant, Board Member Heather Willis, Board Member