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Medical Law - OHIP - General. Doxy.Me Inc. v. Ontario Health et al.
In Doxy.Me Inc. v. Ontario Health et al. (Ont Div Ct, 2026) the Ontario Divisional Court dismissed a JR, this brought against "Ontario Health’s refusal to verify that its video service complies with required standards. The result of Ontario Health’s decisions is that Doxy’s physician clients are not entitled to receive payment from the Ontario Health Insurance Plan (“OHIP”) for any services rendered through its videoconferencing platform."
Here the court briefly sets out the OHIP funding regime under the Health Insurance Act:[2] Under s. 2(1) of the Health Insurance Act, R.S.O. 1990, c. H.6, (the “HIA”) the respondent Minister of Health and Long-Term Care is responsible for the administration and operation of OHIP, which provides insurance against the costs of insured services to all residents of Ontario.[1] Under s. 45(1)(e) of the HIA, the respondent Lieutenant Governor in Council has the authority to make regulations governing insured services, including specifying those services that are not insured services.
[3] Under s. 37.1(1) of Ontario Regulation 552 a service rendered by a physician is an insured service if amongst other things "… the service is referred to in the schedule of benefits and rendered in such circumstances or under such conditions as may be specified in the schedule of benefits”. Under s. 1(1) of Regulation 552, “schedule of benefits” means the document published by the Ministry of Health and Long-Term Care entitled “Schedule of Benefits – Physician Services under the Health Insurance Act …” and includes amendments made to the document. . Ontario (Health Insurance Plan) v. K.S.
In Ontario (Health Insurance Plan) v. K.S. (Div Court, 2024) the Divisional Court dismissed an OHIP appeal under Health Insurance Act [s.24(1,4)], where the primary issue was that a "vaginoplasty without penectomy" was "not a listed procedure in the Schedule of Benefits" "and is, therefore, not an insured service."
Here the court considers the HSARB's OHIP appellate remedies:[49] On an appeal, the Board has the power to direct the General Manager of OHIP to take such action as the Board considers the General Manager should take in accordance with the Act and the regulations: Act, s. 21(1). OHIP argues the Board exceeded its jurisdiction by ordering the General Manager to fund K.S.’s surgery without considering the other eligibility criteria.
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