Suzanne Craig

The General Manager of OHIP brought a motion to dismiss a physician's appeal regarding the denial of sixteen claims for fee code W010.

The claims were denied because they were not submitted with the correct enrollment information within the prescribed six-month timeframe.

The Physician Payment Review Board found that the claims were refused under s. 18(3) of the Health Insurance Act for failing to meet prescribed requirements, rather than under s. 18(2).

Consequently, the Board concluded it lacked jurisdiction to hear the appeal, as decisions under s. 18(3) can only be challenged by way of judicial review to the Divisional Court.

The motion was granted and the appeal dismissed without costs.

The General Manager of OHIP requested a reconsideration of a Board decision that found the Board had jurisdiction to hear Dr. Rao's appeal regarding denied claims.

The General Manager argued the Board made a material error of law by failing to determine if it had jurisdiction under s. 18(3) of the Health Insurance Act.

The Board denied the request for reconsideration, finding no material error of law, as the previous decision correctly identified that the basis for the General Manager's refusal of the claims was unclear and required a hearing on the merits to determine if it fell under s. 18(2) or s. 18(3).