MRI Law in Ontario

In Ontario, the Health Insurance Act (“HIA”) establishes that the Ontario Health Insurance Plan (“OHIP”) operates for the purpose of providing insurance against the costs of “insured services,” on a non-profit basis and on uniform terms and conditions available to all “insured persons.”1 Every resident of Ontario is entitled to become an insured person.2 The following services are insured services:

  • Prescribed services of hospitals and health facilities
  • Prescribed medically necessary services rendered by physicians
  • Prescribed health care services rendered by prescribed practitioners3

With one exception described below, the HIA prohibits any contract of insurance for the payment or reimbursement of the costs of insured services performed in Ontario for any insured person.4 Furthermore, the Health Care Accessibility Act generally prohibits physicians and hospitals from accepting payment from insured persons for the provision of insured services.5

An “out-patient” is defined in the Regulations to the HIA as a person who receives medical services without being admitted to, and assigned a bed in, a hospital in-patient area. An insured person is not entitled to insured services in a hospital as an out-patient unless they have either been received in the hospital and examined as an out-patient by a physician, or referred to the hospital as an out-patient by a physician or other health care practitioner.6 The insured out-patient services to which an insured person is entitled without charge include laboratory, radiological, and other diagnostic procedures, together with the necessary interpretations.7 This normally includes MRI exams, which are provided in hospitals on an out-patient basis and are usually “medically necessary.”

However, exceptions set out in the HIA and its Regulations can render an MRI exam an “uninsured service” by removing it from the category of insured services that an insured person is entitled to receive without charge—and for which a hospital or physician is prohibited from accepting payment. These exceptions include:

  1. Automobile Insurance

    Automobile insurance policies are specifically excluded from the HIA’s general prohibition against contracts of insurance for the payment or reimbursement of the costs of insured services.8

    Under the Compulsory Automobile Insurance Act, a motor vehicle cannot be driven on an Ontario highway unless it is insured by a contract of automobile insurance providing coverage for bodily injury, death, or property damage caused by a motor vehicle.9

    All automobile insurance policies are deemed to include the “medical benefits” listed in the Statutory Accident Benefits Schedule under the Insurance Act, including necessary medical and hospital services and related assessments incurred as a result of an automobile accident.10

  2. WSIB

    Services that a person is entitled to receive under the insurance plan established under the Workplace Safety and Insurance Act are not insured services.11 A worker who sustains a personal injury by accident arising out of and in the course of employment is entitled to necessary, appropriate, and sufficient health care, with the cost paid by the Workplace Safety and Insurance Board.12 “Health care” includes professional services provided by physicians or other practitioners, and services provided at hospitals or other health facilities.13

  3. Third-Party Services

    Under the HIA, a “third party service” is a service provided by a physician, hospital, or other service provider at the request of a third party, either for the service itself or for information relating to an insured person. The requesting third party is responsible for payment.14

    The Regulations specifically exclude from insured services any third-party service provided wholly or partly for preparing a document or transmitting information relating to:

    • school or educational program attendance
    • recreational or athletic program participation
    • an application for or continuation of insurance
    • an application for or continuation of a licence
    • entering or maintaining a contract
    • entitlement to benefits (insurance or pension)
    • obtaining or retaining employment
    • legal requirements or legal proceedings15

  4. Screening

    “Screening” refers to examining individuals with no symptoms to detect unsuspected disease—often related to coronary disease or cancer. Most screening services are not considered “medically necessary,” and therefore do not constitute insured services under the HIA.

  5. Non-Residents

    Under the HIA, only persons who are “ordinarily resident in Ontario,” and those deemed residents under the Regulations,¹⁶ are entitled to become insured persons and receive insured services without charge. Accordingly, medical services provided to non-residents in Ontario are not insured services.

Legal Citations (Footnotes)

  1. Health Insurance Act, R.S.O. 1990, c. H.6, s. 10.
  2. Health Insurance Act, s. 11.
  3. Health Insurance Act, s. 11.2(1).
  4. Health Insurance Act, s. 14(1).
  5. Health Care Accessibility Act, R.S.O. 1990, c. H.3, ss. 1(2), (3).
  6. Health Insurance Act, R.R.O. 1990, Reg. 552, ss. 11(1)(b), (c).
  7. Health Insurance Act, Reg. 552, s. 7(3).
  8. Health Insurance Act, s. 14(1).
  9. Compulsory Automobile Insurance Act, R.S.O. 1990, c. C.25, ss. 1(1), 2(1).
  10. Insurance Act, O. Reg. 403/96, Statutory Accident Benefits Schedule, ss. 14(1), (2).
  11. Health Insurance Act, s. 11.2(2).
  12. Workplace Safety and Insurance Act, 1997, S.O. 1997, c. 16, Schedule A, s. 33(1).
  13. Workplace Safety and Insurance Act, 1997, ss. 32(a), (b).
  14. Health Insurance Act, ss. 36.1(1), 36.2(1).
  15. Health Insurance Act, Reg. 552, ss. 8, 8.2.
  16. Health Insurance Act, Reg. 552, s. 1.1.