Who Should Pay?

**This featured case is one example of the concerns people have brought to us. Names have been changed to protect the identity of the people involved.

Christopher was experiencing several worrisome symptoms, including migraine headaches, vision loss, and low blood pressure. Over the next several months, he visited his family doctor and several specialists, but none could provide a definitive diagnosis. With his condition deteriorating and the next specialist appointment months away, Christopher decided to go to an out-of-country clinic for an assessment. He knew that he would be responsible for the cost of the assessment and was prepared to pay for it.

The clinic diagnosed Christopher with a brain tumor and gave him the option of having surgery there within a few days. Alternatively, Christopher could return home to Saskatchewan with the diagnosis and rely on the provincial health system to provide a similar remedy. Based on Christopher’s experiences so far, he chose to go ahead with the operation.

Christopher found out that he should contact the Saskatchewan Out-of-Province Special Committee for Health Services with his request to have the province pay for the operation. The day before the operation, he faxed his request to the committee and copied the Minister, the Deputy Minister, his MLA and his family doctor.

The committee received his request and made a decision not to pay for the surgery. They did not contact the clinic or Christopher to ask for more information. They called Christopher’s home phone number and left him a voice message that the request was declined. They also faxed a letter to his home phone number with the same information. Christopher was away, at the clinic and nobody else was home.

Christopher, meanwhile, had his surgery and when recovered, returned home to find the telephone message and letter. He contacted the Ministry of Health and the Minister, but the response did not change. He then contacted our office.

We investigated the matter and found that:

• The criteria that the Ministry of Health has in place for out-of-country health coverage are valid. These are: the procedure is medically necessary, it is unavailable in Canada, and the funding is approved prior to the procedure. At the same time, there needs to be flexibility in their application. For example, for a procedure to be considered available in Canada, it must be available within a reasonable and meaningful time for the patient.
• It was reasonable for Christopher to take the opportunity for speedy surgery because of his experience in Saskatchewan. Several Saskatchewan health professionals had been unable to diagnose his condition correctly. In Christopher’s case, this constitutes special circumstances that are relevant and should be taken into account.
• It was not reasonable for Christopher to expect that the Ministry could respond to him so quickly when he sent in his request for coverage for the operation the day before the proposed surgery.
• The Ministry knew that Christopher was not at home when they responded to him at his home address. They should have contacted him to let him know about the rules and to let him know if they needed more time to assess his request. The Ministry had an obligation to let Christopher know what his options were so he could assess his financial risk and make an informed decision. It did not do so. As a result, Christopher did not receive any information about whether the procedure was available in Saskatchewan in a reasonable time.

Recommendation

That the Ministry of Health pay to Christopher the monies that it would have paid to the out-of-country clinic had it approved his request for out-of-country health coverage.

Initial Response

The Ministry disagreed on the basis that Christopher travelled for an initial consultation at his own expense, that his remedy about his treatment in Saskatchewan rests with the College of Physicians and Surgeons, that he did not follow process, that they are not able to determine in hindsight what priority he would have had if he had returned to Saskatchewan for treatment, and that the Minister does not have full discretionary authority to authorize payment.

Update

Following release of the above story in the Ombudsman’s Third Quarter Recommendations Report for 2010, the Minister agreed to review the file. On February 3, 2011, he announced that Christopher would be reimbursed as recommended by the Ombudsman.

Status: Accepted

Note: On July 13, 2011, the Ministry of Health implemented the Health Services Review Committee. The committee provides a way for people to appeal decisions made by the Ministry of Health about out-of-province or out-of-country coverage issues. People who appeal to the committee and still believe the decision was unfair may take the matter to our office.