In Ontario, the line between an insured health service and an elective cosmetic procedure can sometimes seem blurry. The Ontario Health Insurance Plan (OHIP) is designed to cover medically necessary services, but what happens when a procedure has both cosmetic and potential health-related components? A recent decision by the Health Services Appeal and Review Board sheds light on this complex issue, offering important insights for patients and healthcare providers.
The case involved Joe Ishac, who sought reimbursement from OHIP for the removal of bilateral pectoral implants. While the removal was initially recommended due to complications, the Board ultimately upheld the decision that the procedure was not eligible for public funding. This post will explore the key points of this decision, explain why the reimbursement was denied, and discuss the wider implications for anyone navigating the OHIP system for similar procedures.
Mr. Ishac had previously undergone pectoral implant surgery, a procedure he paid for privately as it was considered cosmetic. Subsequently, he cited physical, mental and emotional pain from the implantation. His plastic surgeon explanted the implants. OHIP was not charged for the explanation and the surgeon was very clear that “… there was no complication to his procedure and therefore OHIP was not billed.” In the surgeon’s response to the CFMA (Commitment to the Future of Medicare Act, 2004) inquiry, it was noted that the “patient solely no longer wanted his implants as he “felt guilty” of having had an aesthetic procedure.”
Believing the removal was now a medically necessary procedure due to the complications, Mr. Ishac applied for OHIP reimbursement to cover the cost of the surgery. The General Manager of OHIP denied the request, leading Mr. Ishac to appeal the decision to the Health Services Appeal and Review Board. The core of the dispute was whether the removal of cosmetic implants, even due to complications, qualifies as an insured service.
The Board’s ruling focused on the interpretation of the Health Insurance Act and its regulations, which define what services are covered by OHIP. The decision to deny reimbursement was based on several crucial factors.
A central element of the Board’s reasoning was a specific regulation that excludes services performed at the same “situs” (location on the body) as a previously uninsured cosmetic procedure. Essentially, if a follow-up procedure is required at the same site as an initial non-OHIP-covered cosmetic surgery, that follow-up is also generally excluded from coverage.
The Board determined that removing the pectoral implants was directly related to the patient experiencing an undesirable result from the original cosmetic enhancement. Because the initial implant surgery was not insured, any subsequent procedure to reverse or correct a cosmetic procedure at the same anatomical location was also deemed ineligible for OHIP funding. This provision is in place to prevent the public healthcare system from bearing the costs associated with certain complications arising from elective cosmetic surgeries.
The case also hinged on the definition of “medically necessary.” While Mr. Ishac experienced real pain and complications, the Board distinguished between a service that is medically advisable and one that is medically necessary under the Health Insurance Act.
The Board concluded that while removing the implants was a reasonable medical recommendation to resolve his symptoms, it did not meet the stringent criteria for an insured service. The problem originated from a non-insured cosmetic choice. Therefore, addressing the consequences of that choice, even when they manifest as medical symptoms, falls outside the scope of OHIP coverage. The procedure was not aimed at treating an underlying illness or disease process separate from the implants themselves.
In its review, the Board referenced previous decisions that have consistently upheld this interpretation of the Act. The principle is that OHIP is not intended to be an insurance plan for elective cosmetic procedures or their subsequent complications. Patients who choose to undergo private cosmetic surgery are generally expected to assume the financial risks associated with those procedures, including the potential need for revision or removal.
The Board found no compelling reason to deviate from this established line of reasoning. The decision reaffirms the boundary between public healthcare and the private cosmetic surgery market.
This decision has significant implications for individuals considering or having undergone cosmetic procedures. It serves as a clear reminder of the financial responsibilities involved.
Anyone opting for a cosmetic procedure not covered by OHIP must understand that the financial commitment may extend beyond the initial surgery. The cost of managing potential complications, including corrective or removal surgeries, will likely be an out-of-pocket expense. This case highlights the importance of discussing all potential risks and long-term costs with a surgeon before proceeding with any elective cosmetic enhancement.
The ruling reinforces the specific purpose of OHIP: to fund services required to maintain health, prevent disease, and diagnose or treat an injury, illness, or disability. It does not cover services that are solely for cosmetic purposes or those required to correct a cosmetic procedure.
This distinction is vital for managing public healthcare resources effectively. By maintaining a clear line, the system ensures that funds are prioritized for services deemed essential for the health and well-being of all Ontarians.
It is important to note that not all plastic surgery is considered cosmetic. OHIP does cover reconstructive procedures that are deemed medically necessary. Examples include:
In these instances, the surgery is not for aesthetic enhancement but to restore form and function. The key difference lies in the primary reason for the procedure.
The decision in the Joe Ishac case clarifies the boundaries of OHIP coverage for procedures related to cosmetic surgery. While the outcome may be disappointing for those in similar situations, it provides a clear and consistent interpretation of Ontario’s healthcare legislation.
If you are considering any medical procedure, it is crucial to have an open conversation with your doctor about whether it qualifies as medically necessary under OHIP. Understanding the scope of public funding and the potential for private costs is an essential step in making informed decisions about your health and well-being. This case serves as a powerful illustration of where that line is drawn.
Decision Date: October 24, 2025
Jurisdiction: Health Services Appeal and Review Board
Citation: Ishac v Ontario (Health Insurance Plan), 2025 CanLII 108363 (ON HSARB)
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