OHIP decides whether you are eligible for OHIP and whether the Plan covers the health services you are claiming. OHIP will send you a letter giving you the reasons for its decision.
You should review the reasons that OHIP gives for its decision, including the relevant sections of the Health Insurance Act. If you think that OHIPís decision is wrong, you may appeal the decision to the Health Services Appeal and Review Board.
The Health Services Appeal and Review Board (the Board) is an independent, adjudicative Board. It is not part of OHIP or any other part of the Ontario Ministry of Health and Long-Term Care.
The Lieutenant Governor-in-Council, on the recommendation of the Minister of Health and Long-Term Care, appoints the members of the Board. The members include health care providers, lawyers, social workers, business people and others. The Boardís members are appointed to serve on a part-time basis.
The Board can change OHIPís decision if it is satisfied that OHIP made a mistake in interpreting the Health Insurance Act in your case. The Board cannot change or ignore the Act and it cannot take into account compassionate reasons or any other reasons that are not in the Act.
If you decide to appeal, you must write a letter informing both OHIP and the Health Services Appeal and Review Board that you wish to appeal. You must do this within 15 days of receiving OHIPís decision. You should include in your letter information about why you believe OHIPís decision was wrong, and include a copy of OHIPís decision.
The Boardís address is:
OHIPís address is:
If you want to appeal OHIPís decision but you need more time, you must write to the Board and ask for an extension of the 15-day time limit for making an appeal. You must tell the Board the reasons why you are asking for an extension of the time limit.
The Board will write to you to acknowledge that it has received your request for an appeal. Its letter will include a FORM 1 for you to complete and return to the Board. This form will refer to you as "the appellant" and to OHIP as "the respondent". The form will specify what other information the Board needs from you and from OHIP in order to hear your appeal. In addition to the completed form, you will also need to send the Board the following information: copies of all the documents, medical records and any other information that you want the Board to consider in making a decision about your appeal. The Board will not proceed with your appeal until it receives all of the requested information.
Please be sure to send the Board only copies of any documents. Do not send any original documents to the Board. Keep copies of all of the information that you send to the Board.
You should be aware that, in hearing your appeal, the Board will only have the documents, medical records and information that you send to it. It does not have access to your medical records or to your OHIP files.
You do not need a lawyer to appeal OHIPís decision. However, if you decide that you would like to have someone speak on your behalf, you will need to send the Board your written authorization for another person such as a family member, friend, lawyer, or other person to be your representative at the hearing. Your written authorization should include the name, address and telephone number of that person.
Please note that if you decide to have another person represent you, the Board will send all future correspondence about your appeal to your representative and not to you. It will be up to your representative to keep you informed.
The Board holds three types of hearings: oral, electronic, and written hearings.
At an Oral Hearing, you and OHIPís representative will appear before the Board in person.
At an Electronic Hearing, the Board will conduct the hearing by telephone. All or some of the Parties participate throughout the hearing by telephone.
In a Written Hearing, the Board will consider only the written submissions and documents that you and OHIP file with it.
In the Form 1 that the Board sends to you, the Board will ask you whether you have a preference for a certain type of hearing. Your request is an important consideration. However, it is up to the Board to decide which type of hearing it will hold to hear your appeal.
It is very important for you to send your completed form and submissions to the Board by the date that the Board sets. The Board will not be able to proceed with your request for an appeal until it receives all of this material. If the Board does not receive your material by the due date, it may decide that you have chosen not to proceed with your appeal and it will not hold a hearing.
Once it receives your information, the Board will send copies to OHIP for its comments.
The Board holds public hearings. This means that members of the public can have access to the information about your appeal that you and OHIP provide to the Board. If there are reasons why you would like your information to be kept private, you may write to the Board to ask it to order that your information not be made public. After it hears from you, the Board will decide whether the public may have access to your information.
At the hearing, there will be at least three members of the Board, you and any witnesses, a court reporter who will record the proceedings, and OHIPís representative. Other OHIP staff may also attend, either to present information concerning OHIPís decision or to listen to the hearing.
Members of the public are entitled to attend the Boardís hearings. If you feel that there are circumstances about your case that you do not want made public, you may request the Board to hold your appeal hearing in private. After hearing from you, the Board will decide whether the public may attend the hearing.
Before your appeal hearing takes place, OHIP must send you copies of all of the information that it provides to the Board about the decision that you are appealing.
Once the Board decides that it has all of the written information that it needs, it will set a hearing date. The Board will write to you and OHIP to let you know the date, time and place for your appeal hearing. It will also tell you the type of hearing (oral, electronic or written) that it will hold. It takes about three months from the time you write to the Board to request an appeal until the Board schedules your appeal hearing.
Please note that if you are unable to proceed on the day that the Board sets for the hearing, you should immediately telephone the Boardís Deputy Registrar at 416-327-8512.
Attending Public Proceedings
Proceedings before the Appeal Board are open to the public unless the Appeal Board orders otherwise in a particular case pursuant to an application under Rule 14 of the Appeal Board's Rules of Practice and Procedure (the "Rules). Members of the media are welcome to attend public hearings and observe the proceedings.
No Recording of Public Proceedings
Although observers are welcome to attend and take notes of public proceedings, the Appeal Board does not permit photographic, audio or video recording of any of its proceedings, other than by court reporters in the course of preparing the official transcript of the proceeding.
Interviews with the Appeal Board
Any requests for interviews or other information pertaining to the Appeal Board or a proceeding should be directed to the Registrar of the Health Services Appeal and Review Board.
ATTENDING YOUR APPEAL HEARING
What Can I Do to Prepare for My Appeal Hearing?
Review carefully all of the information or evidence from OHIP so that you are clear about why OHIP made the decision and you can argue your point more effectively.
Review the Health Insurance Act and its Regulations (available by calling Publications Ontario at 1 800 668 9938). This will give you information on what OHIP took into account in making the decision and what the Board will consider when it hears your appeal.
Make arrangements for any witnesses who support your case to attend the hearing.
At the hearing, the Board will refer to you (the appellant) and OHIP (the respondent) as "the parties".
You can expect the hearing to take about one and half-hours of time. If you are attending an oral hearing, you and any witnesses should plan to arrive at least 15 minutes before the time that your appeal hearing is scheduled to start.
In making its decision, the Board will apply the Health Insurance Act and Regulations. It will consider the written documents that you and OHIP have provided and the arguments that you and OHIP present during the hearing.
PLEASE NOTE: The Board MUST apply the provisions of the Health Insurance Act and its Regulations. In making its decision, it does NOT have the authority to change the law or to take into account any other considerations.
At the hearing, the Board will hear both from you and from a representative from OHIP. You will need to tell the Board why you believe that OHIPís decision was wrong, based on the provisions of the Health Insurance Act and Regulations.
You can expect that an oral or electronic hearing will follow these steps:
The Board will ask you to present your evidence. This means that you will have an opportunity to tell the Board the facts of your case, discuss any documents that you have sent to the Board, give evidence yourself, and ask your witnesses to provide information. You will also explain to the Board why you believe that the OHIP decision that you are appealing was wrong, based on the provisions of the Health Insurance Act and Regulations.
When you have finished presenting your case, the Board will ask OHIPís representative if he or she has any questions for you or your witnesses.
The Board will ask OHIPís representative to present OHIPís evidence and to explain why OHIPís decision was correct, based on the provisions of the Health Insurance Act and its Regulations. When OHIP has finished presenting its case, you will have an opportunity to ask any questions of OHIP.
When OHIPís representative has finished his or her presentation, you will have the opportunity to clarify any issues that the OHIP representativeís presentation raised and to make some closing remarks. After the Board has heard from you and OHIP, the Board will thank you and end the appeal hearing. After your appeal hearing, the Board will meet in private to discuss the information that you and OHIP presented and will make a decision. The Board will send you its decision, in writing, together with the reasons for its decision.
If you have any questions, would like more information about the Board and the appeal process, or want a copy of Information on Appealing a Decision by OHIP-Attending Your Appeal Hearing or the Boardís Rules of Practices and Procedures, please contact the Boardís Deputy Registrar at 416-327-8512 or email@example.com.
To get a copy of the Health Insurance Act and its Regulations, call Publications Ontario at 1-800-668-9938 or go to the Legal section.
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