Segal v. Ontario Health Insurance Plan, (1994) 77 O.A.C. 31 (DC)

• Judge: Hartt, Saunders and Moldaver, JJ.
• Court: Ontario Court of Justice General Division (Canada)
• Case Date: November 10, 1994
• Jurisdiction: Ontario
• Citations: (1994), 77 O.A.C. 31 (DC)

Segal v. Health Ins. Plan (1994), 77 O.A.C. 31 (DC)

MLB headnote and full text

Ellen Segal (appellant) v. The General Manager, The Ontario Health Insurance Plan (respondent)

(File No. 347/94)

Indexed As: Segal v. Ontario Health Insurance Plan

Ontario Court of Justice

General Division

Divisional Court

Hartt, Saunders and Moldaver, JJ.

November 10, 1994.

Summary:

Segal applied to be reimbursed for hospital services performed outside Ontario. The Health Services Appeal Board dismissed her appeal from the decision of the General Manager of the Ontario Health Insurance Plan. Segal appealed.

The Ontario Divisional Court allowed the appeal and remitted the matter to a differ­ently constituted Board for reconsideration.

Government Programs - Topic 1921

Medicare - Entitlement - The General Manager of the Ontario Health Insurance Plan adopted a policy of paying 75% of a claim that met the conditions of s. 57 of regulation 452 of the Ontario Health In­surance Regulations, and the remaining 25% if, either the services were rendered in an emerg­ency or, the conditions of Appendix C to the Schedule of Benefits were met - Appendix C was incorporated by the General Manager as a basis for exercising his discretion - The Ontario Divisional Court held that the Health Services Appeal Board was bound to determine the reason­ableness of a policy adopted by the Gen­eral Man­ager - The Board need not re­consider the pol­icy in each case but must determine whether the application of the policy was reasonable in the cir­cumstances before it - See para­graphs 4 to 6.

Cases Noticed:

Mawani Estate v. Ontario Health Insur­ance Plan (1993), 62 O.A.C. 389 (Div. Ct.), refd to. [para. 8].

Statutes Noticed:

Health Insurance Act, R.S.O. 1990, c. H-6, sect. 18 [para. 7]; sect. 20(1)(b) [para. 1]; sect. 21(1) [para. 5].

Health Insurance Act Regulations (Ont.), R.R.O. 1980, Reg. 452, sect. 57, sect. 59 [para. 2].

Counsel:

Robin Lynn Martin, for the appellant;

Louise Hurteau, for the respondent.

This appeal was heard before Hartt, Saunders and Moldaver, JJ., of the Ontario Court of Justice, General Division, Divi­sional Court. The decision was endorsed on the appeal record and released on November 10, 1994.