Cosmetic Surgeon Ordered To Repay Patient Where Procedure Was Covered By OHIP

A recent decision by the Health Services Appeal and Review Board confirmed a decision by the General Manager of OHIP to require a surgeon to repay a patient for the cost of a cosmetic breast augmentation - despite the fact that the procedure, for which the patient agreed to pay privately, was completed 8 years earlier.

The patient in this case underwent a breast augmentation procedure on a private basis. Years later, another physician noted that because she had a health condition (breast aplasia) the breast augmentation procedure she underwent was an insured service, eligible for OHIP coverage. At the time it was performed, the surgeon did not attempt to bill OHIP for the procedure, and billed the patient privately. Even though the procedure was performed in 2004, the patient sought reimbursement for the procedure from OHIP in 2012 when these facts came to light. The General Manager of OHIP determined that the procedure for which the patient paid personally in 2004 was, in fact, an insured service for which the surgeon was not permitted to charge privately. The General Manager required the surgeon to reimburse the patient for the cost of the procedure.

The lesson for physicians who charge privately for procedures is that they must ensure, before billing patients privately for a procedure as an uninsured service, that the service is truly uninsured. They must determine whether the procedure could be billed to OHIP as an insured service, and if so, bill the service to OHIP.