Getting sick on vacation without private insurance can lead to all kinds of trouble. Understandably, Quebec doesn’t want to subsidize health care obtained outside the province. Getting reimbursement for such care is exceptional and subject to specific conditions found in the Health Insurance Act. To benefit from coverage you must establish the care was medically necessary and unavailable in Canada, or urgent.
In the case of a 70-year-old woman with polyps, both her doctor and a consulting physician recommended a particular procedure because of her past history. They believed the procedure was not performed anywhere in Quebec or Canada and referred her to a clinic in the U.S. She subsequently filed a claim for about $9,000 with RAMQ, which paid $618.79 for professional fees but
refused to pay the hospital costs.
RAMQ admitted the surgical procedure was medically necessary – this is one condition for the Régie to cover costs. But the Régie had learned that the procedure was available in Vancouver; the Health Insurance Act states that the services required must not be available in Canada. The fact that the local physicians had affirmed otherwise was irrelevant. Ignorance was no excuse and the tribunal confirmed that the refusal to pay was justified.
The Appeal Tribunal does not always validate the decision of the Régie to refuse reimbursement. In a recent case a patient went to a clinic in the U.S. for a cancer treatment for which there was only minimal experience in Montreal and Toronto. The case was complex, the risk of death high and the immediacy of the treatment and experience of those carrying it out were crucial. The Tribunal held that in such a case it was not in the spirit of the law to deprive the patient of the right to reimbursement and it overturned the decision of the Régie.
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One problem a patient faces when he falls ill out of the country is establishing “urgency.” In a case where a tourist had suffered from back problems for years, she was treated with painkillers while on vacation in Mexico. She was told, however, that if the problem was not corrected quickly she risked paralysis. As she had experienced lengthy waiting times for treatment in Quebec she decided to get the surgery in Mexico. She also returned to Mexico for follow-up. The decision not to reimburse her was upheld by the Tribunal on the grounds that although her condition was serious, it was not urgent. In spite of this decision the patient was happy as the pain she had endured for five years disappeared after the surgery was performed.
In another case, The Régie reimbursed medical and hospital expenses for a 76-year old who had surgery in the U.S. for urinary tract problems, because it considered the treatment to be urgent. However, further tests performed following the surgery were not reimbursed as the patient could have returned to Quebec to have them done. The Tribunal held that medical advice not to delay treatment was not the equivalent of urgency.
There is often disagreement whether or not treatment is urgent. When reimbursement is refused there are several levels of appeal, assuming you can afford the legal costs. One patient was reimbursed for two surgeries carried out in the U.S. In 2008, RAMQ refused to reimburse the cost of two further interventions in the U.S. on the grounds they were available in Quebec and were not urgent. The patient went to appeal and the Appeal Tribunal held that the further interventions resulted from complications arising out of the first two surgeries and should therefore be reimbursed. Then the Régie went to appeal before a second Appeal Tribunal and won. The patient then appealed to the Superior Court which held, largely on legal technical grounds, that the judgment of the second Tribunal was correct and the Régie should not have to reimburse the patient. The patient then appealed to the Quebec Court of Appeal which, in 2014, again on legal technical grounds held that the decision of the first Tribunal had been reasonable and so the second Tribunal had no grounds to reverse it. The second two interventions became necessary because of complications arising from the first two surgeries and the patient was to be reimbursed. This entire round of appeals took almost six years!
Dura lex, sed lex – the law is harsh, but it is the law. So enjoy your travels, be careful and get additional insurance before leaving.