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One of the benefits of retirement for those who have planned prudently is the freedom and ability to travel extensively. As with most worthwhile activities, travel offers both benefits and risks. The primary risk is one known to every traveler, but is one which is too often neglected or overlooked - the risk of being stricken with a serous illness in another country.

Although we have seen a growing political debate in Canada over the state of public health care and its future direction, most people make their plans for foreign travel assuming that their public health insurance is completely "portable". Others may obtain supplemental private health insurance, without carefully reading and understanding the coverages and the exclusions from coverage in a particular insurance contract.

The discussion of this subject must begin with an understanding that (using Ontario as the example) OHIP does not offer adequate protection for the cost of medical services, particularly in the United States.

An important precondition to any OHIP coverage for medical services rendered abroad is that one must satisfy the 183 day residency requirement. That is, a person must be physically present in Ontario for at least 183 days in each year, and have his or her primary residence in Ontario, in order to maintain eligibility to access OHIP coverage. This requirement is subject to a grace period of 30 days, to allow for unplanned necessary time outside of Ontario for those who have consumed all or nearly all of the 183 day allowance.

The OHIP coverages which are available for medical treatment outside Canada, and the limits or caps on reimbursement, are set out in the regulations passed under the Health Insurance Act. Those regulations may be summarized as follows:

Coverage for either hospital or out-patient treatment is available only for emergencies. That is, illnesses which are acute and unexpected. If the illness is not in the nature of an emergency, or if it pre-dated the departure from Canada, it is not covered.

A wide range of services are excluded from coverage, those being various therapies, drug treatment outside of a hospital, and laboratory services.

Where the treatment is covered, and the "emergency" test is met, OHIP will reimburse in accordance with certain limits.

For hospital care, reimbursement is limited to a maximum of $200 per day, or $400 per day for certain types of care such as coronary or intensive care. The limits on reimbursement often represent a small fraction of the daily rates charged in American hospitals, which also charge for many treatments and services beyond the daily bed rate.

With respect to prescription drugs, there is no coverage for drugs purchased outside Ontario by seniors covered by the Ontario Drug Benefits Plan. It should be noted that seniors can purchase a supplementary 100 day supply of a medication before departing Ontario.

Clearly therefore, every prudent traveler should purchase supplementary health insurance, so as to avoid the risk of being crippled financially by the need for foreign medical care.

It is by no means unheard of for an emergency stay in an American hospital of something in the order of one week to run up costs of $20,000 to $25,000, of which perhaps one-tenth might be covered by OHIP.

Although securing private insurance can represent a critical financial decision, the purchase is often made without any scrutiny of the specific coverages offered, and more importantly, the stated exclusions from the coverages. The same consumer who will engage in extensive research and comparison shopping for an appliance or an automobile, will typically purchase medical insurance without having the faintest idea what coverages and exclusions the policy contains.

As with the purchase of any important service, it is critical that the individual read the policy, ask questions about provisions which are not clear, and comparison shop. The adage that you get what you pay for is probably never truer than in the purchase of private health insurance. Because of the magnitude of the risk, the focus should be on quality, and not on price.

It is also critical that the application for coverage be completed with care. The insurer treats the statements made on an application as representations it relies upon to issue the policy. For example, if one were to fail to truthfully answer questions on an application concerning a pre-existing cardiac condition, a subsequent claim for coverage for emergency cardiac care might well be denied.

In summary, don't leave home without supplementary health coverage, and make sure that what you purchase is suited to your particular health needs.


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