The Ontario Health Insurance Plan covers medically necessary services, but the framework for what counts as “medically necessary” within the statutory meaning is narrower than what patients often expect. The distinction is particularly important where a procedure has both cosmetic and health-related dimensions, or where a follow-up procedure is sought to address the consequences of an earlier cosmetic procedure. The framework draws a sharp line between insured services and elective cosmetic procedures, and the line is maintained by specific regulatory provisions and a body of administrative decisions that have developed over time.
Ishac v Ontario (Health Insurance Plan), 2025 CanLII 108363 (ON HSARB), released by the Health Services Appeal and Review Board on October 24, 2025, is a recent administrative articulation of the framework. The appellant had previously undergone bilateral pectoral implant surgery, a cosmetic procedure he paid for privately. Subsequently he reported physical, mental, and emotional symptoms that he attributed to the implants and that led to the surgeon explanting them. The appellant then sought OHIP reimbursement for the removal procedure. The General Manager of OHIP denied the request, and the appellant appealed to the Health Services Appeal and Review Board. The Board upheld the denial, applying the framework articulated in the Health Insurance Act, RSO 1990, c H.6, and the related regulations.
The case is doctrinally important for several reasons. It is a recent administrative articulation of the “situs” provision, which excludes from OHIP coverage services performed at the same anatomical location as a previously uninsured cosmetic procedure. It illustrates the distinction between “medically necessary” services within the statutory meaning and services that are “medically advisable” in the broader clinical sense. It reaffirms the framework for the boundary between public healthcare coverage and private cosmetic surgery. And it provides a useful reference for patients and clinicians navigating the OHIP system in cases involving cosmetic procedure complications.
This piece is a brief departure from the usual subject matter of the case comment series, which focuses primarily on medical malpractice trial decisions and professional regulation cases. The OHIP coverage framework is a distinct area of administrative practice rather than civil litigation, and the doctrinal framework that governs it is statutory rather than common law. However, the framework matters to patients and clinicians who interact with OHIP for coverage questions, and Ishac v Ontario (Health Insurance Plan) is a useful reference for those navigating similar situations.
The legal framework — OHIP coverage and the Health Insurance Act
A brief overview of the legal framework is useful for the analysis.
The Health Insurance Act. The Health Insurance Act, RSO 1990, c H.6 is the foundational provincial legislation governing OHIP coverage. The Act establishes the framework for what services are insured and under what circumstances. The framework distinguishes between insured services (covered by OHIP), non-insured services (not covered), and services that may be insured in some circumstances but not others.
The Schedule of Benefits. The specific catalogue of insured services is set out in the Schedule of Benefits for Physician Services under the Health Insurance Act. The Schedule sets out the specific services that are insured along with the fee codes, eligibility criteria, and any limitations. The Schedule is updated periodically and is the primary technical reference for coverage decisions.
The General Regulation. General Regulation 552 under the Health Insurance Act sets out additional rules including the framework for what constitutes a medically necessary service, the framework for cosmetic procedures, the framework for out-of-province coverage, and a range of other coverage rules. The “situs” provision discussed in Ishac derives from the General Regulation.
The “medically necessary” framework. The Health Insurance Act covers services that are medically necessary. The framework treats “medically necessary” as a defined statutory concept rather than as a broad clinical judgment. The framework distinguishes between:
- Medically necessary services: services required to diagnose or treat an illness, injury, or disability, or to maintain health, prevent disease, or restore function. The framework applies a structured definition.
- Medically advisable services: services that a physician may reasonably recommend in the clinical circumstances but that do not meet the statutory definition of medically necessary. These services may be appropriate clinical care but they are not insured.
- Cosmetic services: services that primarily aim at improving appearance rather than addressing an illness, injury, or disability. These services are typically not insured.
The distinctions can be difficult in practice because the categories can overlap in specific cases. The framework relies on the analysis of each specific procedure in its specific clinical context.
The “situs” provision. General Regulation 552 includes a provision that excludes from OHIP coverage services performed at the same anatomical site as a previously uninsured cosmetic procedure. The framework reflects the policy that the public healthcare system should not bear the costs of complications arising from elective cosmetic procedures that the patient chose to undertake privately. The framework operates by anatomical location rather than by procedure type: a follow-up procedure at the same site as the original cosmetic procedure is excluded regardless of the specific clinical reason.
The Commitment to the Future of Medicare Act framework. The Commitment to the Future of Medicare Act, 2004, SO 2004, c 5 (the CFMA) establishes additional protections for the public healthcare system, including provisions that limit physicians’ ability to charge OHIP-insured patients for OHIP-insured services. The CFMA inquiry framework allows the Ministry of Health to investigate whether a physician’s billing practices comply with the framework. The CFMA inquiry process is administrative and is distinct from the OHIP coverage appeal framework.
The Health Services Appeal and Review Board. The HSARB is the independent administrative tribunal that hears appeals of OHIP coverage decisions among other matters. The Board operates under the Ministry of Health and Long-Term Care Appeal and Review Boards Act, 1998. The Board applies the statutory framework and the existing body of administrative decisions. Appeals from HSARB decisions can be taken to the Divisional Court on questions of law.
The clinical context — pectoral implants and explantation
A brief clinical overview is useful for the analysis.
Pectoral implants. Pectoral implants are silicone or other prosthetic devices placed under the pectoral muscle to augment the appearance of the chest. The procedure is most often performed for cosmetic reasons in male patients seeking to enhance chest definition. It can also be performed for reconstructive reasons in specific clinical contexts (for example, in patients with significant chest wall asymmetry due to congenital conditions, post-traumatic deformity, or following oncological resection). The framework for OHIP coverage depends on the underlying indication.
Complications of implant surgery. Implant procedures can have a range of complications including:
- Surgical complications: bleeding, infection, capsular contracture, implant migration or rupture
- Functional symptoms: pain, restricted movement, sensory changes
- Aesthetic dissatisfaction: appearance not meeting patient’s preferences
- Psychological symptoms: regret about the procedure, body image concerns
The framework for OHIP coverage of follow-up care depends in part on the nature of the complication and on the relationship between the complication and the original procedure.
Explantation. Explantation is the surgical removal of implants. The procedure can be performed for several reasons including identified medical complications (rupture, infection, capsular contracture), persistent functional symptoms, or patient preference. The clinical and coverage analysis can differ based on the documented reason for the explantation.
The facts
The appellant. Mr. Joe Ishac had previously undergone bilateral pectoral implant surgery. The procedure was performed for cosmetic reasons and was paid for privately. No OHIP claim was made for the original procedure.
The subsequent symptoms. Following the implant surgery, the appellant reported physical, mental, and emotional symptoms that he attributed to the implants. The specific clinical content of these symptoms is summarized in the Board’s reasons but is not extensively reproduced.
The explantation. The same plastic surgeon who had placed the implants performed the explantation procedure. In responding to a CFMA inquiry initiated by the Ministry of Health, the surgeon was explicit that there was no surgical complication to the procedure and that OHIP was not billed for the explantation. The surgeon also documented that the appellant’s primary motivation for explantation was no longer wanting the implants and a sense of regret about having had a cosmetic procedure.
The OHIP reimbursement application. Mr. Ishac subsequently applied for OHIP reimbursement of the cost of the explantation procedure. The application proceeded on the basis that the complications he had experienced made the explantation medically necessary.
The General Manager’s decision. The General Manager of OHIP denied the reimbursement application.
The appeal. Mr. Ishac appealed the General Manager’s decision to the Health Services Appeal and Review Board.
The Board’s analysis
The Board upheld the General Manager’s denial. The reasoning proceeded along several principal axes.
The situs provision. The Board found that the situs provision in General Regulation 552 applied. The original pectoral implant surgery was a cosmetic procedure that was not insured. The explantation procedure was performed at the same anatomical site. The framework therefore excluded the explantation from OHIP coverage.
The Board’s reasoning emphasized the policy underlying the situs provision. The public healthcare system is not designed to bear the financial consequences of complications arising from elective cosmetic procedures that the patient chose to undertake privately. Where the patient has assumed the cost and the risks of the cosmetic procedure, the framework treats the subsequent costs of addressing the consequences as the patient’s continuing responsibility.
The medically necessary analysis. The Board distinguished between services that are medically necessary within the statutory meaning and services that are medically advisable in the broader clinical sense. The Board found that while the explantation was a reasonable medical recommendation given the appellant’s reported symptoms, it did not meet the statutory definition of medically necessary because the underlying cause of the symptoms was the appellant’s own non-insured cosmetic choice.
The framework distinguishes between treating an illness or disease process and addressing the consequences of a patient’s elective choice. The explantation was not aimed at treating an underlying illness or disease process separate from the implants themselves; it was aimed at reversing the consequences of the original cosmetic procedure. The framework treats the reversal of cosmetic choices as outside the scope of OHIP coverage.
The precedent consistency analysis. The Board referenced previous administrative decisions that have consistently upheld the interpretation of the Health Insurance Act and the General Regulation applied in this case. The framework is well-established in the body of HSARB decisions and has not been disturbed by judicial review. The Board found no compelling reason to deviate from the established framework.
The conclusion. The Board concluded that the explantation procedure was not eligible for OHIP coverage. The appellant’s appeal was dismissed.
The doctrinal anchors
Several doctrinal anchors emerge from the case.
The Health Insurance Act framework. OHIP coverage operates under the Health Insurance Act, RSO 1990, c H.6 and the related regulations. The framework treats “medically necessary” as a defined statutory concept rather than as a broad clinical judgment. The framework distinguishes between insured services, non-insured services, and services that may be insured in some circumstances but not others. Ishac v Ontario (Health Insurance Plan) applies the framework in the cosmetic procedure context.
The “situs” provision. General Regulation 552 excludes from OHIP coverage services performed at the same anatomical site as a previously uninsured cosmetic procedure. The framework operates by anatomical location rather than by procedure type. Ishac v Ontario (Health Insurance Plan) is a recent administrative authority on the application of the situs provision to a follow-up procedure aimed at reversing a cosmetic enhancement.
The “medically necessary” vs “medically advisable” distinction. The framework distinguishes between services that meet the statutory definition of medically necessary and services that may be reasonable clinical recommendations but do not meet the statutory definition. Reasonable clinical advice does not automatically translate into OHIP coverage. The framework relies on the analysis of each specific procedure in its specific clinical context.
The cosmetic vs reconstructive surgery framework. OHIP covers reconstructive procedures that are medically necessary (breast reconstruction following mastectomy; congenital anomaly correction; reconstruction following traumatic injury or burns). OHIP does not cover cosmetic procedures (those primarily aimed at improving appearance rather than addressing an illness, injury, or disability). The framework requires analysis of the primary indication for the procedure in its specific context.
The CFMA inquiry framework. The Commitment to the Future of Medicare Act, 2004 establishes a framework for the Ministry of Health to inquire into physician billing practices. The CFMA inquiry response forms part of the evidentiary record in OHIP coverage disputes. Ishac v Ontario (Health Insurance Plan) illustrates the use of the surgeon’s CFMA response as evidence of the indication for the procedure.
The HSARB appellate framework. The Health Services Appeal and Review Board hears appeals of OHIP coverage decisions among other matters. The framework operates as an independent administrative tribunal with specialized expertise in health insurance matters. Appeals from HSARB decisions can be taken to the Divisional Court on questions of law.
The “consequences of cosmetic choice” assumption-of-risk framework. Where a patient chooses to undergo a cosmetic procedure privately, the framework treats the subsequent costs of addressing the consequences as the patient’s continuing responsibility. The framework reflects the broader policy of preserving public healthcare resources for services that meet the statutory definition of medically necessary.
The “originating non-insured procedure determines coverage of related care” framework. The framework looks to the originating procedure to determine the coverage status of related follow-up care. Where the originating procedure was not insured (because it was cosmetic), the related follow-up care at the same site is also typically not insured. The framework does not require analysis of whether the follow-up care would have been insured if performed independently.
The administrative tribunal decision framework. Administrative tribunal decisions like HSARB decisions are part of the body of authority that informs the OHIP coverage framework. The decisions are appealable to the courts on questions of law but operate as the primary venue for coverage disputes. The framework operates with specialized expertise and structured procedural rules.
Why this case matters
For patients considering cosmetic procedures. The case is a useful reference for understanding the financial framework that applies to cosmetic procedures and their potential complications.
Some practical observations:
Cosmetic procedures and their consequences are typically out-of-pocket. Where a patient chooses to undergo a cosmetic procedure privately, the framework typically treats the subsequent costs of addressing complications, revisions, or reversals as the patient’s continuing responsibility. The financial commitment to a cosmetic procedure may extend beyond the initial surgery.
The “situs” provision is specific and broadly applied. Where a follow-up procedure is performed at the same anatomical site as a previously uninsured cosmetic procedure, the framework typically excludes the follow-up from OHIP coverage regardless of the specific clinical reason. The framework operates by anatomical location rather than by clinical indication.
The “medically necessary” framework is narrower than expected. The statutory definition of “medically necessary” is narrower than the broad clinical sense of what may be reasonable medical advice. A procedure that is medically advisable in the clinical sense may not be medically necessary under the framework.
Reconstructive surgery is treated differently. Where the surgery is for true reconstructive purposes (post-mastectomy, congenital anomaly, traumatic injury), the framework typically supports OHIP coverage. The key distinction is whether the primary purpose is reconstructive (covered) or cosmetic (not covered).
Discussion with the surgeon and OHIP information is important before the procedure. Where there is uncertainty about whether a procedure or its follow-up care will be covered, the framework supports advance consultation with the surgeon and (where appropriate) inquiry with OHIP about coverage. Pre-procedure clarity supports informed decision-making.
For more on OHIP coverage and complaints about medical care more generally, see A Patient’s Guide to Making Complaints About Health Care in Ontario.
For clinicians performing cosmetic procedures. A few practical observations:
Document the indication clearly. Where a procedure is performed for cosmetic reasons, the framework supports clear contemporaneous documentation of the indication. The documentation forms part of the record for any subsequent coverage inquiries or CFMA inquiries.
The CFMA inquiry framework can engage with billing patterns. The Ministry of Health has the authority to inquire into physician billing practices under the CFMA. Cooperation with CFMA inquiries and accurate response forms part of the broader regulatory framework.
Pre-procedure financial discussion matters. Where a procedure is cosmetic and not OHIP-covered, the framework supports clear pre-procedure discussion with the patient about the financial responsibilities, including the potential for out-of-pocket costs of addressing complications, revisions, or reversals. The discussion supports informed consent and reduces post-procedure disputes.
Distinguish cosmetic from reconstructive carefully. Where the indication for a procedure is mixed (cosmetic and reconstructive), the framework supports careful documentation of the primary indication. The OHIP coverage analysis can turn on the documented primary indication.
A note on this case and the broader work
This case is a brief departure from the typical subject matter of these case comments, which focus primarily on medical malpractice civil litigation and professional regulatory decisions. The OHIP coverage framework is an administrative practice area rather than a civil litigation area. The framework operates through specialized administrative tribunals (the HSARB and others) rather than the civil courts, and the doctrinal framework is statutory rather than common law.
The reason for including the case in the broader collection is that the framework matters to patients and clinicians who interact with OHIP for coverage questions, and the framework can interact with the broader framework for medical care in ways that are relevant to the work generally. For example:
- Patients with serious health conditions sometimes navigate complex coverage analyses involving both OHIP-insured services and non-insured components
- The framework for “medically necessary” under the Health Insurance Act is sometimes cited in adjacent contexts (such as in arguments about the standard of care for the timing of treatment)
- The framework for HSARB appeals interacts with the broader administrative law framework that includes the Patient Ombudsman, the regulatory colleges, and the Office of the Chief Coroner
The case is offered as a useful reference for those navigating the OHIP coverage framework in cases involving cosmetic procedures or their complications, rather than as a primary practice area for the firm. Where a coverage dispute is part of a broader medical malpractice or professional regulatory matter, the analysis may be addressed in that broader context.
Decision Date: October 24, 2025
Jurisdiction: Health Services Appeal and Review Board (Ontario)
Citation: Ishac v Ontario (Health Insurance Plan), 2025 CanLII 108363 (ON HSARB)
Outcome: Appeal dismissed. The Board upheld the General Manager of OHIP’s decision denying reimbursement for the cost of bilateral pectoral implant explantation. The Board applied the situs provision in General Regulation 552 under the Health Insurance Act, which excludes from OHIP coverage services performed at the same anatomical site as a previously uninsured cosmetic procedure. The Board found that the original pectoral implant surgery was a cosmetic procedure that was not insured and that the subsequent explantation procedure was performed at the same anatomical site. The Board further found that while the explantation was a reasonable medical recommendation given the appellant’s reported symptoms, it did not meet the statutory definition of medically necessary because the underlying cause of the symptoms was the appellant’s own non-insured cosmetic choice. The framework treats the reversal of cosmetic choices as outside the scope of OHIP coverage. The decision is consistent with previous HSARB decisions on similar coverage disputes.
Key authorities: Health Insurance Act, RSO 1990, c H.6; General Regulation 552 under the Health Insurance Act (situs provision); Schedule of Benefits for Physician Services under the Health Insurance Act; Commitment to the Future of Medicare Act, 2004, SO 2004, c 5 (CFMA inquiry framework); Ministry of Health and Long-Term Care Appeal and Review Boards Act, 1998, SO 1998, c 18, Sched H (HSARB establishment).
Ishac v Ontario (Health Insurance Plan): The Situs Provision and OHIP Coverage for Cosmetic Procedure Complications
HSARB upholds OHIP coverage denial for pectoral implant removal, applying the situs provision that excludes follow-up procedures at the site of cosmetic surgery.
The Ontario Health Insurance Plan covers medically necessary services, but the framework for what counts as “medically necessary” within the statutory meaning is narrower than what patients often expect. The distinction is particularly important where a procedure has both cosmetic and health-related dimensions, or where a follow-up procedure is sought to address the consequences of an earlier cosmetic procedure. The framework draws a sharp line between insured services and elective cosmetic procedures, and the line is maintained by specific regulatory provisions and a body of administrative decisions that have developed over time.
Ishac v Ontario (Health Insurance Plan), 2025 CanLII 108363 (ON HSARB), released by the Health Services Appeal and Review Board on October 24, 2025, is a recent administrative articulation of the framework. The appellant had previously undergone bilateral pectoral implant surgery, a cosmetic procedure he paid for privately. Subsequently he reported physical, mental, and emotional symptoms that he attributed to the implants and that led to the surgeon explanting them. The appellant then sought OHIP reimbursement for the removal procedure. The General Manager of OHIP denied the request, and the appellant appealed to the Health Services Appeal and Review Board. The Board upheld the denial, applying the framework articulated in the Health Insurance Act, RSO 1990, c H.6, and the related regulations.
The case is doctrinally important for several reasons. It is a recent administrative articulation of the “situs” provision, which excludes from OHIP coverage services performed at the same anatomical location as a previously uninsured cosmetic procedure. It illustrates the distinction between “medically necessary” services within the statutory meaning and services that are “medically advisable” in the broader clinical sense. It reaffirms the framework for the boundary between public healthcare coverage and private cosmetic surgery. And it provides a useful reference for patients and clinicians navigating the OHIP system in cases involving cosmetic procedure complications.
This piece is a brief departure from the usual subject matter of the case comment series, which focuses primarily on medical malpractice trial decisions and professional regulation cases. The OHIP coverage framework is a distinct area of administrative practice rather than civil litigation, and the doctrinal framework that governs it is statutory rather than common law. However, the framework matters to patients and clinicians who interact with OHIP for coverage questions, and Ishac v Ontario (Health Insurance Plan) is a useful reference for those navigating similar situations.
The legal framework — OHIP coverage and the Health Insurance Act
A brief overview of the legal framework is useful for the analysis.
The Health Insurance Act. The Health Insurance Act, RSO 1990, c H.6 is the foundational provincial legislation governing OHIP coverage. The Act establishes the framework for what services are insured and under what circumstances. The framework distinguishes between insured services (covered by OHIP), non-insured services (not covered), and services that may be insured in some circumstances but not others.
The Schedule of Benefits. The specific catalogue of insured services is set out in the Schedule of Benefits for Physician Services under the Health Insurance Act. The Schedule sets out the specific services that are insured along with the fee codes, eligibility criteria, and any limitations. The Schedule is updated periodically and is the primary technical reference for coverage decisions.
The General Regulation. General Regulation 552 under the Health Insurance Act sets out additional rules including the framework for what constitutes a medically necessary service, the framework for cosmetic procedures, the framework for out-of-province coverage, and a range of other coverage rules. The “situs” provision discussed in Ishac derives from the General Regulation.
The “medically necessary” framework. The Health Insurance Act covers services that are medically necessary. The framework treats “medically necessary” as a defined statutory concept rather than as a broad clinical judgment. The framework distinguishes between:
The distinctions can be difficult in practice because the categories can overlap in specific cases. The framework relies on the analysis of each specific procedure in its specific clinical context.
The “situs” provision. General Regulation 552 includes a provision that excludes from OHIP coverage services performed at the same anatomical site as a previously uninsured cosmetic procedure. The framework reflects the policy that the public healthcare system should not bear the costs of complications arising from elective cosmetic procedures that the patient chose to undertake privately. The framework operates by anatomical location rather than by procedure type: a follow-up procedure at the same site as the original cosmetic procedure is excluded regardless of the specific clinical reason.
The Commitment to the Future of Medicare Act framework. The Commitment to the Future of Medicare Act, 2004, SO 2004, c 5 (the CFMA) establishes additional protections for the public healthcare system, including provisions that limit physicians’ ability to charge OHIP-insured patients for OHIP-insured services. The CFMA inquiry framework allows the Ministry of Health to investigate whether a physician’s billing practices comply with the framework. The CFMA inquiry process is administrative and is distinct from the OHIP coverage appeal framework.
The Health Services Appeal and Review Board. The HSARB is the independent administrative tribunal that hears appeals of OHIP coverage decisions among other matters. The Board operates under the Ministry of Health and Long-Term Care Appeal and Review Boards Act, 1998. The Board applies the statutory framework and the existing body of administrative decisions. Appeals from HSARB decisions can be taken to the Divisional Court on questions of law.
The clinical context — pectoral implants and explantation
A brief clinical overview is useful for the analysis.
Pectoral implants. Pectoral implants are silicone or other prosthetic devices placed under the pectoral muscle to augment the appearance of the chest. The procedure is most often performed for cosmetic reasons in male patients seeking to enhance chest definition. It can also be performed for reconstructive reasons in specific clinical contexts (for example, in patients with significant chest wall asymmetry due to congenital conditions, post-traumatic deformity, or following oncological resection). The framework for OHIP coverage depends on the underlying indication.
Complications of implant surgery. Implant procedures can have a range of complications including:
The framework for OHIP coverage of follow-up care depends in part on the nature of the complication and on the relationship between the complication and the original procedure.
Explantation. Explantation is the surgical removal of implants. The procedure can be performed for several reasons including identified medical complications (rupture, infection, capsular contracture), persistent functional symptoms, or patient preference. The clinical and coverage analysis can differ based on the documented reason for the explantation.
The facts
The appellant. Mr. Joe Ishac had previously undergone bilateral pectoral implant surgery. The procedure was performed for cosmetic reasons and was paid for privately. No OHIP claim was made for the original procedure.
The subsequent symptoms. Following the implant surgery, the appellant reported physical, mental, and emotional symptoms that he attributed to the implants. The specific clinical content of these symptoms is summarized in the Board’s reasons but is not extensively reproduced.
The explantation. The same plastic surgeon who had placed the implants performed the explantation procedure. In responding to a CFMA inquiry initiated by the Ministry of Health, the surgeon was explicit that there was no surgical complication to the procedure and that OHIP was not billed for the explantation. The surgeon also documented that the appellant’s primary motivation for explantation was no longer wanting the implants and a sense of regret about having had a cosmetic procedure.
The OHIP reimbursement application. Mr. Ishac subsequently applied for OHIP reimbursement of the cost of the explantation procedure. The application proceeded on the basis that the complications he had experienced made the explantation medically necessary.
The General Manager’s decision. The General Manager of OHIP denied the reimbursement application.
The appeal. Mr. Ishac appealed the General Manager’s decision to the Health Services Appeal and Review Board.
The Board’s analysis
The Board upheld the General Manager’s denial. The reasoning proceeded along several principal axes.
The situs provision. The Board found that the situs provision in General Regulation 552 applied. The original pectoral implant surgery was a cosmetic procedure that was not insured. The explantation procedure was performed at the same anatomical site. The framework therefore excluded the explantation from OHIP coverage.
The Board’s reasoning emphasized the policy underlying the situs provision. The public healthcare system is not designed to bear the financial consequences of complications arising from elective cosmetic procedures that the patient chose to undertake privately. Where the patient has assumed the cost and the risks of the cosmetic procedure, the framework treats the subsequent costs of addressing the consequences as the patient’s continuing responsibility.
The medically necessary analysis. The Board distinguished between services that are medically necessary within the statutory meaning and services that are medically advisable in the broader clinical sense. The Board found that while the explantation was a reasonable medical recommendation given the appellant’s reported symptoms, it did not meet the statutory definition of medically necessary because the underlying cause of the symptoms was the appellant’s own non-insured cosmetic choice.
The framework distinguishes between treating an illness or disease process and addressing the consequences of a patient’s elective choice. The explantation was not aimed at treating an underlying illness or disease process separate from the implants themselves; it was aimed at reversing the consequences of the original cosmetic procedure. The framework treats the reversal of cosmetic choices as outside the scope of OHIP coverage.
The precedent consistency analysis. The Board referenced previous administrative decisions that have consistently upheld the interpretation of the Health Insurance Act and the General Regulation applied in this case. The framework is well-established in the body of HSARB decisions and has not been disturbed by judicial review. The Board found no compelling reason to deviate from the established framework.
The conclusion. The Board concluded that the explantation procedure was not eligible for OHIP coverage. The appellant’s appeal was dismissed.
The doctrinal anchors
Several doctrinal anchors emerge from the case.
The Health Insurance Act framework. OHIP coverage operates under the Health Insurance Act, RSO 1990, c H.6 and the related regulations. The framework treats “medically necessary” as a defined statutory concept rather than as a broad clinical judgment. The framework distinguishes between insured services, non-insured services, and services that may be insured in some circumstances but not others. Ishac v Ontario (Health Insurance Plan) applies the framework in the cosmetic procedure context.
The “situs” provision. General Regulation 552 excludes from OHIP coverage services performed at the same anatomical site as a previously uninsured cosmetic procedure. The framework operates by anatomical location rather than by procedure type. Ishac v Ontario (Health Insurance Plan) is a recent administrative authority on the application of the situs provision to a follow-up procedure aimed at reversing a cosmetic enhancement.
The “medically necessary” vs “medically advisable” distinction. The framework distinguishes between services that meet the statutory definition of medically necessary and services that may be reasonable clinical recommendations but do not meet the statutory definition. Reasonable clinical advice does not automatically translate into OHIP coverage. The framework relies on the analysis of each specific procedure in its specific clinical context.
The cosmetic vs reconstructive surgery framework. OHIP covers reconstructive procedures that are medically necessary (breast reconstruction following mastectomy; congenital anomaly correction; reconstruction following traumatic injury or burns). OHIP does not cover cosmetic procedures (those primarily aimed at improving appearance rather than addressing an illness, injury, or disability). The framework requires analysis of the primary indication for the procedure in its specific context.
The CFMA inquiry framework. The Commitment to the Future of Medicare Act, 2004 establishes a framework for the Ministry of Health to inquire into physician billing practices. The CFMA inquiry response forms part of the evidentiary record in OHIP coverage disputes. Ishac v Ontario (Health Insurance Plan) illustrates the use of the surgeon’s CFMA response as evidence of the indication for the procedure.
The HSARB appellate framework. The Health Services Appeal and Review Board hears appeals of OHIP coverage decisions among other matters. The framework operates as an independent administrative tribunal with specialized expertise in health insurance matters. Appeals from HSARB decisions can be taken to the Divisional Court on questions of law.
The “consequences of cosmetic choice” assumption-of-risk framework. Where a patient chooses to undergo a cosmetic procedure privately, the framework treats the subsequent costs of addressing the consequences as the patient’s continuing responsibility. The framework reflects the broader policy of preserving public healthcare resources for services that meet the statutory definition of medically necessary.
The “originating non-insured procedure determines coverage of related care” framework. The framework looks to the originating procedure to determine the coverage status of related follow-up care. Where the originating procedure was not insured (because it was cosmetic), the related follow-up care at the same site is also typically not insured. The framework does not require analysis of whether the follow-up care would have been insured if performed independently.
The administrative tribunal decision framework. Administrative tribunal decisions like HSARB decisions are part of the body of authority that informs the OHIP coverage framework. The decisions are appealable to the courts on questions of law but operate as the primary venue for coverage disputes. The framework operates with specialized expertise and structured procedural rules.
Why this case matters
For patients considering cosmetic procedures. The case is a useful reference for understanding the financial framework that applies to cosmetic procedures and their potential complications.
Some practical observations:
Cosmetic procedures and their consequences are typically out-of-pocket. Where a patient chooses to undergo a cosmetic procedure privately, the framework typically treats the subsequent costs of addressing complications, revisions, or reversals as the patient’s continuing responsibility. The financial commitment to a cosmetic procedure may extend beyond the initial surgery.
The “situs” provision is specific and broadly applied. Where a follow-up procedure is performed at the same anatomical site as a previously uninsured cosmetic procedure, the framework typically excludes the follow-up from OHIP coverage regardless of the specific clinical reason. The framework operates by anatomical location rather than by clinical indication.
The “medically necessary” framework is narrower than expected. The statutory definition of “medically necessary” is narrower than the broad clinical sense of what may be reasonable medical advice. A procedure that is medically advisable in the clinical sense may not be medically necessary under the framework.
Reconstructive surgery is treated differently. Where the surgery is for true reconstructive purposes (post-mastectomy, congenital anomaly, traumatic injury), the framework typically supports OHIP coverage. The key distinction is whether the primary purpose is reconstructive (covered) or cosmetic (not covered).
Discussion with the surgeon and OHIP information is important before the procedure. Where there is uncertainty about whether a procedure or its follow-up care will be covered, the framework supports advance consultation with the surgeon and (where appropriate) inquiry with OHIP about coverage. Pre-procedure clarity supports informed decision-making.
For more on OHIP coverage and complaints about medical care more generally, see A Patient’s Guide to Making Complaints About Health Care in Ontario.
For clinicians performing cosmetic procedures. A few practical observations:
Document the indication clearly. Where a procedure is performed for cosmetic reasons, the framework supports clear contemporaneous documentation of the indication. The documentation forms part of the record for any subsequent coverage inquiries or CFMA inquiries.
The CFMA inquiry framework can engage with billing patterns. The Ministry of Health has the authority to inquire into physician billing practices under the CFMA. Cooperation with CFMA inquiries and accurate response forms part of the broader regulatory framework.
Pre-procedure financial discussion matters. Where a procedure is cosmetic and not OHIP-covered, the framework supports clear pre-procedure discussion with the patient about the financial responsibilities, including the potential for out-of-pocket costs of addressing complications, revisions, or reversals. The discussion supports informed consent and reduces post-procedure disputes.
Distinguish cosmetic from reconstructive carefully. Where the indication for a procedure is mixed (cosmetic and reconstructive), the framework supports careful documentation of the primary indication. The OHIP coverage analysis can turn on the documented primary indication.
A note on this case and the broader work
This case is a brief departure from the typical subject matter of these case comments, which focus primarily on medical malpractice civil litigation and professional regulatory decisions. The OHIP coverage framework is an administrative practice area rather than a civil litigation area. The framework operates through specialized administrative tribunals (the HSARB and others) rather than the civil courts, and the doctrinal framework is statutory rather than common law.
The reason for including the case in the broader collection is that the framework matters to patients and clinicians who interact with OHIP for coverage questions, and the framework can interact with the broader framework for medical care in ways that are relevant to the work generally. For example:
The case is offered as a useful reference for those navigating the OHIP coverage framework in cases involving cosmetic procedures or their complications, rather than as a primary practice area for the firm. Where a coverage dispute is part of a broader medical malpractice or professional regulatory matter, the analysis may be addressed in that broader context.
Decision Date: October 24, 2025
Jurisdiction: Health Services Appeal and Review Board (Ontario)
Citation: Ishac v Ontario (Health Insurance Plan), 2025 CanLII 108363 (ON HSARB)
Outcome: Appeal dismissed. The Board upheld the General Manager of OHIP’s decision denying reimbursement for the cost of bilateral pectoral implant explantation. The Board applied the situs provision in General Regulation 552 under the Health Insurance Act, which excludes from OHIP coverage services performed at the same anatomical site as a previously uninsured cosmetic procedure. The Board found that the original pectoral implant surgery was a cosmetic procedure that was not insured and that the subsequent explantation procedure was performed at the same anatomical site. The Board further found that while the explantation was a reasonable medical recommendation given the appellant’s reported symptoms, it did not meet the statutory definition of medically necessary because the underlying cause of the symptoms was the appellant’s own non-insured cosmetic choice. The framework treats the reversal of cosmetic choices as outside the scope of OHIP coverage. The decision is consistent with previous HSARB decisions on similar coverage disputes.
Key authorities: Health Insurance Act, RSO 1990, c H.6; General Regulation 552 under the Health Insurance Act (situs provision); Schedule of Benefits for Physician Services under the Health Insurance Act; Commitment to the Future of Medicare Act, 2004, SO 2004, c 5 (CFMA inquiry framework); Ministry of Health and Long-Term Care Appeal and Review Boards Act, 1998, SO 1998, c 18, Sched H (HSARB establishment).
Paul Cahill
Partner, Davidson Cahill Morrison LLP | LSO Certified Specialist in Civil Litigation
Paul represents victims of medical malpractice across Ontario, with trial experience including a $11.5M jury verdict in a birth injury case. He is recognized in Best Lawyers in Canada and serves as trial counsel to other lawyers on complex medical negligence matters.
About PaulMore on medical malpractice in Ontario.
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