Man approved for hip replacement

Authority Vancouver Island Health Authority
Details

Manuel came to our Office in the summer of 2010 because he was being charged by the Vancouver Island Health Authority (VIHA) for a non-standard hip replacement. Manuel had a hip replacement in 2004 that was fully funded by the Ministry of Health. His other hip was severely arthritic and also needed to be replaced. Manuel said he contacted the Ministry of Health and was told the ministry no longer covers the type of non-standard hip replacement he was seeking.

Manuel’s surgeon had told the health authority that the non-standard hip replacement was medically necessary due to Manuel’s age, weight, activity level and previous non-standard hip replacement. Manuel said he received a letter from VIHA stating the non-standard procedure was not fully funded and that he would have to pay $2,118 in direct charges. Manuel is on disability assistance and receives a monthly income of under $800. Manuel thought it was unfair that VIHA would not cover the entire cost.

We investigated to determine if VIHA’s reasons were adequate and appropriate. We learned that health authorities are permitted to charge patients for optional or alternative medical devices that are not medically required. When the patient prefers such an alternative device without recommendation by the attending physician as “medically required,” the patient may be charged for the difference in cost between the alternative and standard device.

Under ministry policy, health authorities must provide alternative prosthetic devices at no cost to the patient if the attending surgeon has provided written confirmation that the alternative device is medically required for the patient and that the standard procedure and device are not medically appropriate.

As a result of our investigation, VIHA reviewed Manuel’s file and confirmed that the surgeon had completed a form confirming that the non-standard prosthesis was medically required. However, the surgeon had also submitted a form earlier indicating that Manuel understood that the non-standard prosthesis was requested as his preference and that he was aware that there were cost-sharing implications. After discussing the situation with us, and speaking with Manuel’s surgeon directly, VIHA agreed to provide the non-standard prosthesis to Manuel at no cost to him. VIHA also clarified the forms with the physician and notified Manuel of their decision.

Category Health
Type Case Summary
Fiscal Year 2010
Location Vancouver Island / Sunshine Coast