Highlights of Noteworthy Decisions

Decision 1721 14
S. Martel
  • Board Directives and Guidelines (health care) (out of province)
  • Out of province (health care)

The worker suffered a low back injury in 1996, for which he was granted a 19% NEL award in 2009, increased to 24% in 2013. The worker underwent back surgery in the United States in 2010. The worker appealed a decision of the Appeals Resolution Officer denying reimbursement for the cost of the surgery.

The worker did not obtain approval from the Board prior to undergoing the surgery. Tribunal decisions have found that workers are not entitled to reimbursement in the case of failure to obtain prior approval for elective surgery.
The worker suggested that Ontario doctors were reluctant to perform the surgery due to the worker's age (about 68 at the time of the surgery). However, there was no support for that suggestion from the medical reports.
In addition to the requirement in Board policy of prior approval for elective surgery outside Ontario, the policy also requires that the health care not be available or offered in Ontario or that the out-of-province treatment is required because of risks associated with delay in waiting a longer period of time for treatment in Ontario. That was not the situation in this case.
The worker did not meet the requirements of Board policy for elective surgery outside Ontario. The appeal was dismissed.