Ontario loses battle to refuse to pay for penis-sparing vaginoplasty for non-binary resident
Ontario's top court has ruled the province must cover the cost of an out-of-country, penis-sparing vaginoplasty for a 'transgender and non-binary resident' who wishes to have both female and male genitalia.
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In a unanimous decision released this week, a three-judge panel of the Ontario Court of Appeal confirmed a lower court's ruling ordering the Ontario Health Insurance Plan to pay for the patient, identified as K.S. in court records, to undergo the novel phallus-sparing surgery at a Texas clinic.
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'K.S. is pleased with the Court of Appeal's decision, which is now the third unanimous ruling confirming that her gender affirming surgery is covered under Ontario's Health Insurance Act and its regulation,' K.S.'s lawyer, John McIntyre, said in an email to National Post.
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The legal battle between K.S., whose sex at birth was male, dates to 2022, when the Ontario Health Insurance Plan (OHIP) refused a funding request for surgery to construct a vagina while sparing the penis, a procedure this is not available in Ontario, or anywhere else in Canada.
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OHIP argued that, because the vaginoplasty would not be accompanied by a penectomy, the procedure isn't one specifically listed in OHIP's Schedule of Benefits and therefore shouldn't be publicly funded. OHIP also argued that the requested surgery is considered experimental in Ontario and, thus, also ineligible for coverage.
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K.S. appealed to the Health Services Appeal and Review Board, which overturned OHIP's refusal, arguing that 'vaginoplasty' should be covered, whether a penectomy, a separate procedure included on the list of publicly funded sex-reassignment surgeries, is performed or not.
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OHIP appealed that decision to the Divisional Court but lost again after the panel dismissed the province's appeal and declared the surgery, which leaves intact a functioning penis, an insured service.
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The province's latest appeal was heard on Nov. 26. The three-judge appeal court panel rejected OHIP's arguments that the proposed surgery isn't an insured service because it won't be accompanied by removal of the penis — a penectomy 'neither recommended by K.S.'s health professionals nor desired by K.S.,' according to the court's written decision.
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K.S., who is in her early 30s, 'has experienced significant gender dysphoria since her teenage years, as well as physical, mental and economic hardships to transition her gender expression to align with her gender identity,' the court said.
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K.S.'s doctor submitted a request to OHIP for prior funding approval for the surgical creation of a vaginal cavity and external vulva. The request made it clear that K.S. wasn't seeking a penectomy.
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In a letter accompanying the request, her doctor said that because K.S. is 'not completely on the 'feminine' end of the spectrum' it was important for her to have a vagina while maintaining her penis, adding that the Crane Center for Transgender Surgery in Austin, Tx.,'has an excellent reputation' for gender-affirming surgery, 'and especially with these more complicated procedures.'
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Toronto Star
4 hours ago
- Toronto Star
‘There is something wrong': Patients say they are paying out of pocket for cataract surgeries at private clinics
It all started at the optometrist. Stephen Purdey was at a regular checkup to update his prescription last summer when his optometrist flagged something in his eye. The optometrist thought it was cataracts, but recommended Purdey visit an ophthalmologist to confirm. So Purdey visited a private clinic in Toronto in March for a consultation after months on the wait-list to see a specialist, and that is where he said he started to feel 'vulnerable and susceptible.' 'Because of the combination of wanting to do the best thing for yourself,' said Purdey, who is in his 70s. 'Plus not necessarily understanding everything that the doctors are telling you, you really are as a patient vulnerable to suggestions.' ARTICLE CONTINUES BELOW 'And that's what happened to me.' The ophthalmologist he was referred to, according to Purdey, acknowledged that the patient could get his procedure done for free under OHIP. Cataract surgery is considered a 'medically necessary surgery' by the province, so even if a person opts to go to a private clinic they shouldn't be billed for the basic OHIP-covered procedure. Patients who spoke to the Star said they went in for cataract surgery at private clinics and felt they had to pay between a couple of hundred and thousands of dollars out of pocket, whether to bypass reportedly long wait times or receive better treatment, including upgraded lenses. Their stories come at a time when the provincial government continues to expand the number of privately run surgical and diagnostic centres performing cataract procedures, a move first announced two years ago. They also raise questions about whether there are sufficient guardrails in place to make sure patients don't feel pressured to pay out of pocket for upgrades they may not need. In Purdey's case, he said his ophthalmologist offered him other options, such as laser-based eye measurements, instead of a free ultrasound measurement, and 'better quality' corrective lenses — treatments that would cost money but, to Purdey, sounded appealing. 'Right away you have the impression that lasers are better than ultrasound,' he said of the measurement procedure. 'And they said, 'Yeah, that's true.'' ARTICLE CONTINUES BELOW ARTICLE CONTINUES BELOW Laser-based measurements have been found to be more accurate than an ultrasound, although the American Academy of Ophthalmology notes that there does not appear to be a difference between using a laser or ultrasound during the cataract surgery itself. Purdey was convinced, however, so he agreed to spend $650 on the laser measurements and an astigmatism test and said he'd consider paying another $200 to $1,600 for the so-called better lenses, then went home. 'Out of control' The four patients who spoke to the Star for this story are older adults who were worried that they might forever damage their vision if they didn't get surgery for their cataracts. Some of these same patients also said they didn't think they were given all the information they needed to make a decision about whether to pay for so-called better measurements and lenses. 'It is really out of control,' said Natalie Mehra, executive director of the Ontario Health Coalition (OHC), an advocacy group focused on protecting public health care. 'Essentially it's like there isn't public medicare when it comes to eye surgery in Ontario,' says Natalie Mehra, executive director of the Ontario Health Coalition, an advocacy group focused on protecting public health care. 'It's gone.' Richard Lautens Toronto Star Things have gotten so bad from the perspective of the OHC that the group is filing formal complaints with the provincial and federal governments next week, Mehra said. ARTICLE CONTINUES BELOW ARTICLE CONTINUES BELOW She said some private clinics around the province bill OHIP for medically necessary cataract surgeries, as they are allowed to, but also charge patients 'mandatory' user fees for things like eye measurements or the surgery itself in a practice known as extra-billing — which is illegal under Ontario law and a breach of the Canada Health Act. Extra-billing also includes charging patients for speedier care. Mehra noted that the onus to report extra-billing to the province is on patients, many of whom do not realize that such 'mandatory' user fees aren't allowed. After investigating, if the province finds that extra-billing took place, it is required to report this annually to the federal government. Ottawa, in turn, will then claw back a certain amount of funding for the province's medicare program under the Canada Health Act. And, on top of the extra-billing, private clinics are charging patients add-ons under the guise that they are medically necessary for cataracts, Mehra said. Last year, Mehra said the coalition received more than 200 complaints over alleged extra-billing for cataract surgeries, one of the top two concerns the group heard from Ontarians. The other was about patients being kicked out of hospital before they are ready to be discharged. And Mehra said she believes there are probably thousands more who just don't know that they're being charged for what should be a free procedure. For its part, the provincial Ministry of Health said that 32,000 people had publicly funded cataract surgery at community surgical and diagnostic centres in 2024. 'We will continue to deliver more connected, convenient care in every corner of the province, always ensuring that people are accessing the care they need with their OHIP card, never their credit card,' ministry spokesperson Ema Popovic said in an emailed statement. ARTICLE CONTINUES BELOW ARTICLE CONTINUES BELOW Still, Mehra said the complaints heard by the OHC run counter to the intentions of the province's medicare system — something patients also echoed in interviews with the Star. 'Essentially it's like there isn't public medicare when it comes to eye surgery in Ontario,' Mehra said. 'It's gone.' Hazy advice Up until her death in April from complications following cardiac surgery, something about a procedure Judith Deutsch had on her cataract back in 2022 didn't sit right with her, said husband Jim Deutsch. Judith Deutsch, pictured here in March, didn't 'feel good' about her experience seeking care for her cataracts three years ago up until her death in April, husband Jim said. Family photo Three years earlier, the Toronto couple had decided to go to a private clinic after they were told the wait time for cataract surgery covered by OHIP 'was going to be too long' by a doctor at a separate clinic. They considered the situation to be an 'emergency' — she incurred a concussion and a gash on her face because she couldn't see well — so the couple was willing to pay out of pocket to get care faster. 'It was going to cost a lot of money,' Jim told the Star. 'But she kept falling and just wanted to get it done as quickly as possible.' Jim said he doesn't believe that he and his wife were scammed — they were aware of the private option and had the means to afford it. But he said the couple still didn't 'feel good' about paying to 'jump the queue' for Judith's surgery. ARTICLE CONTINUES BELOW ARTICLE CONTINUES BELOW The OHC's Mehra said that long wait times are commonly mentioned by doctors at private clinics to encourage patients to pay out of pocket for their surgeries. 'They say the wait times in the public hospital are two years, which they are not,' Mehra said. 'Most people are getting it in 90 days, so they lie to patients and convince them to pay.' According to the province's surgery wait-time website at the time of publication, the average wait time between a referral and the first clinician appointment for the lowest priority patients is 100 days. Meanwhile, the average wait time between a clinical decision for a surgery and the operation itself is 103 days. It's not just wait times; doctors also upsell patients with 'medically unnecessary stuff,' Mehra said. She said the OHC has heard from past cataract patients that they were encouraged to buy corrective lenses that address non-cataract issues like astigmatism. Judith was one of these patients, with Jim saying his wife ended up paying more than $5,000 for her surgery, including specialty lenses that she thought were connected to her cataracts and would lead to better outcomes for her vision, but later learned were for other eye conditions. Although the couple willingly paid more to get faster care, they say they weren't aware the specialty lenses weren't necessary. ARTICLE CONTINUES BELOW ARTICLE CONTINUES BELOW Mehra said she has also heard of patients being charged for post-operative medicine — something Paula from Barrie told the Star separately. Paula told the Star she had to pay $230 for eye drops after her 2023 surgery at a private clinic, on top of the $5,000 she paid for special lenses and to get faster care. (She said her ophthalmologist told her the wait would be over a year if she did not pay $2,500.) 'That's not right,' Paula said of the eye drop charges. 'They should be covered.' The Star agreed to use only Paula's first name since she has glaucoma and worries that speaking publicly could interfere with her ability to receive care. While Paula knew going into her surgery that she wanted to get upgraded lenses and extra measurements, she said the ophthalmologist didn't ask her if she wanted the upgraded measurements. 'They should have asked me,' she said. 'If there were two options, they should have given me the option of 1 or 2.' ARTICLE CONTINUES BELOW ARTICLE CONTINUES BELOW Patients blame issues with medicare system Jim Deutsch thinks that his wife's experience seeking care for her cataracts stems from a failure of Canada's medicare program. Business She paid $8,000 for cataract surgery at a private clinic on a doctor's referral. She says no one told her OHIP had a free option The office of Ontario's Patient Ombudsman received some 4,429 complaints in the 2023-24 fiscal year — the most since it opened in 2016. Business She paid $8,000 for cataract surgery at a private clinic on a doctor's referral. She says no one told her OHIP had a free option The office of Ontario's Patient Ombudsman received some 4,429 complaints in the 2023-24 fiscal year — the most since it opened in 2016. 'Medicare ended up being something that was quite different from what (Tommy Douglas) originally imagined,' said Deutsch, a psychiatrist who moved to Canada from the U.S. decades ago to work in the country's public system. 'Along the way we've ended up with this situation of scarcity and profit and allowing there to be private clinics that will offer something more speedily.' Paula, too, believes the current system isn't fair — even if she said she would pay out of pocket again to get her surgery done faster. 'There is something wrong with the whole system,' she said, describing it as 'two-tier medicine.' The OHC pins the blame on the Ford government, specifically the passage of Bill 60: Your Health Act in 2023. ARTICLE CONTINUES BELOW ARTICLE CONTINUES BELOW The legislation allows more private clinics to provide certain publicly funded procedures, including cataract surgery. The provincial government said the Act was intended to reduce long wait times, while critics, including the OHC, said it would draw resources away from public hospitals. 'No one is able to regulate and control the private market for health care,' Mehra said. 'The most sensible thing we can do is bring (cataract surgeries) back into public hospitals.' The Ministry of Health's Popovic stood by Bill 60 in her statement to the Star. 'To be very clear, Ontario has provisions through legislation that prohibit a patient from being charged for an OHIP-covered service, legislation that was strengthened by our government through Bill 60,' she said. Popovic added that anyone who believes they have been charged for an OHIP-covered service can contact the Commitment to the Future of Medicare Act program to ask for a review, and that those who have been found to have been billed will be reimbursed. 'Narrowly missed getting trapped' After coming home from the private eye clinic, Purdey changed his mind; he wasn't going to pay for the laser measurements or other add-ons. 'I was told that the laser measurement stuff was better,' he said, 'but they didn't really tell me how much better it was.' He called up the clinic to ask for the OHIP-funded procedures and in late May he had the first round of publicly funded surgery on one of his eyes. 'I'm quite satisfied,' Purdey said the day after his surgery. 'I feel like I narrowly missed getting trapped into spending a whole lot of money.'
CBC
28-04-2025
- CBC
Doctor operating safer supply clinics billed OHIP $2.5M last year
A doctor running a network of addiction clinics across Ontario, including an Ottawa location that offers safer opioid supply, is billing public insurance about $2.5 million per year. Dr. Suman Koka is the sole officer and director of Northwood Recovery, which has locations in North York, Hamilton and Manitoulin Island. It operates under the name Recovery North in Sudbury, Timmins and Sault Ste. Marie. Northwood Recovery opened its first Ottawa location in Hintonburg last year, but quietly moved it to Chinatown this March. Neighbours in both Hintonburg and Chinatown have criticized Koka for prescribing opioid medications to fentanyl users. They say his patients are trading the prescription drugs on the street to get harder substances, attracting dealers and crime to the area. City councillors representing both neighbourhoods have urged Northwood Recovery to change its operations or shut down. In an interview last month, Koka confirmed that the Ottawa clinic offers safer supply, a harm reduction approach intended to help users replace street drugs like fentanyl with safer prescription narcotics. Among other treatments, Koka prescribes hydromorphone, which is also known by the trade name Dilaudid. He confirmed that he primarily meets with patients at the Ottawa clinic remotely through telemedicine. CBC submitted a freedom of information request to the Ontario Ministry of Health seeking records of Koka's total billing to the Ontario Health Insurance Plan (OHIP). It reveals that he billed just over $2.3 million in 2023 and nearly $2.5 million in 2024. Those totals do not represent Koka's profit or take-home pay, since at least some of the money would be used to cover overhead costs at his clinics, which could include rent, supplies and administrative staff. But the totals are far in excess of typical billing. The average gross clinical payment for Ontario physicians was $388,557 in 2022-23, according to the Canadian Institute for Health Information. Payments for the top quintile — the top 20 per cent of physicians by billing — were $568,432 on average. CBC also submitted a request for Koka's billing for telemedicine specifically. He billed $524,302 for virtual care services in 2024, including video and telephone consultations. The figures were current as of January 22 of this year. The documents include a note that physicians still have a three-month period to submit additional claims for processing. Koka had previously appeared on a Toronto Star database of highly paid doctors published in 2019. According to the Sudbury Star, which cited the Toronto Star's reporting, Koka billed $1.5 million in 2018-19, putting him in the top one per cent of doctors ranked by OHIP billing. Koka did not respond to a request this week with detailed questions about his 2023 and 2024 billing. He did not explain how he is able to personally see enough patients to bill millions of dollars per year, or whether he is delegating some of the care. But in a March interview, CBC asked him whether he was still one of Ontario's highest paid doctors. "I'm not sure about that, but I'll tell you I'm probably one of the hardest working doctors in Ontario," he said at the time. Previously cautioned for telemedicine practices Doug Angus, a professor emeritus at the University of Ottawa's Telford School of Management, said Koka would have to see a very high volume of patients to generate that kind of money. Angus, who specializes in health economics, said Koka's reliance on virtual care could allow him to cycle through patients quickly. "That's changed the game completely," he said. "There's a lot of general practitioners who would love to have that kind of situation, but there's no way they can generate that kind of gross income with face-to-face visits." He said that the ministry has tried to rein in high billers, but it's difficult to monitor. He said they haven't yet addressed the question of how many patients a doctor can effectively see. Koka's membership page on the College of Physicians and Surgeons website shows he has 15 practice locations, as well as hospital privileges at the Health Sciences North regional hospital in Sudbury. His medical professional corporation has 13 different addresses. The college cautioned him in 2019, after a patient complained that Koka didn't meet with him at all. Instead, a physician assistant at his office prescribed methadone after a virtual appointment. The college found no sign that the physician assistant had proper training — and noted that delegating care is only appropriate in the context of an existing doctor-patient relationship, which did not exist in that case. Somerset Coun. Ariel Troster met with Koka last month, along with area MPP Catherine McKenney. In a post to her website, Troster said she insisted on wraparound supports for patients and better security protocols during the meeting. She said the clinic has hired a security guard and a nurse and committed to removing people from the program if they divert their medications. In his March interview with CBC, Koka said Northwood Recovery takes drug diversion very seriously. He said patients found to be trading or selling their medications are discharged from the program. According to Koka, even suspicion can lead the clinic to put patients under a stricter regime where they must take doses on site. He said telemedicine has increased the number of people he is able to see, allowing more people to access addiction treatment. "Whether it's through video conference or whether through in person, the interaction is the same," he said.
Toronto Sun
25-04-2025
- Toronto Sun
MANDEL: Ontario must cover U.S. surgery for trans patient who wants a vagina — and to keep her penis
Medical doctor writing on patient personal health care record discharge form, or prescription paperwork in hospital office, clinic centre for healthcare and life insurance concept. Photo by iStock / GETTY IMAGES Behold your tax dollars at work. OHIP has been ordered, for the third time, to pay for an out-of-country surgery for an Ontario trans, nonbinary patient who wants to keep the P while she gets the V. This advertisement has not loaded yet, but your article continues below. THIS CONTENT IS RESERVED FOR SUBSCRIBERS ONLY Subscribe now to read the latest news in your city and across Canada. Unlimited online access to articles from across Canada with one account. Get exclusive access to the Toronto Sun ePaper, an electronic replica of the print edition that you can share, download and comment on. Enjoy insights and behind-the-scenes analysis from our award-winning journalists. Support local journalists and the next generation of journalists. Daily puzzles including the New York Times Crossword. SUBSCRIBE TO UNLOCK MORE ARTICLES Subscribe now to read the latest news in your city and across Canada. Unlimited online access to articles from across Canada with one account. Get exclusive access to the Toronto Sun ePaper, an electronic replica of the print edition that you can share, download and comment on. Enjoy insights and behind-the-scenes analysis from our award-winning journalists. Support local journalists and the next generation of journalists. Daily puzzles including the New York Times Crossword. REGISTER / SIGN IN TO UNLOCK MORE ARTICLES Create an account or sign in to continue with your reading experience. Access articles from across Canada with one account. Share your thoughts and join the conversation in the comments. Enjoy additional articles per month. Get email updates from your favourite authors. THIS ARTICLE IS FREE TO READ REGISTER TO UNLOCK. Create an account or sign in to continue with your reading experience. Access articles from across Canada with one account Share your thoughts and join the conversation in the comments Enjoy additional articles per month Get email updates from your favourite authors Don't have an account? Create Account The provincial insurer argued that vaginoplasty is a listed, insured gender-affirming service — but only if it came along with the usual removal of the person's existing penis. But K.S., who doesn't identify as exclusively male or female, wanted to have both. Called penile-preserving vaginoplasty, the procedure creates a fully functional vagina without surgically removing the penis. According to the decision, K.S., who's sex assigned at birth was male, is female dominant and 'suffered physical, mental, and economic hardships to transition her gender expression to align with her gender identity.' In May 2022, her doctor submitted the required request for prior funding approval to OHIP for a vaginoplasty — but without the usually accompanying removal of her penis. '(K.S.) identifies as transfeminine but not completely on the 'feminine' end of the spectrum and for this reason it's important for her to have a vagina while maintaining her penis,' the doctor explained. Your noon-hour look at what's happening in Toronto and beyond. By signing up you consent to receive the above newsletter from Postmedia Network Inc. Please try again This advertisement has not loaded yet, but your article continues below. Since that wasn't offered anywhere in Ontario, K.S. was asking for OHIP to fund the novel 'bottom surgery' at the Crane Center for Transgender Surgery in Austin, Texas. When OHIP denied coverage, insisting the vaginoplasty wasn't covered without a penectomy, K.S. successfully appealed to t he Health Services Appeal and Review Board where she testified that removing her penis carried risks of incontinence, sexual dysfunction and removal of her nonbinary identity. OHIP's expert, Dr. Yonah Krakowski, told the board that current opinion agreed that penile preservation vaginoplasty was experimental. ' There is no peer-reviewed literature to support its indications, or the surgical techniques used in the process. Further, there is no longer term data reporting psychological or physical outcomes,' said Krakowski, Division Head of Trans Surgery at Women's College Hospital. This advertisement has not loaded yet, but your article continues below. Still, the board agreed vaginoplasty without penectomy is a specifically listed service in OHIP's schedule of benefits and must be approved for public coverage. OHIP then took the matter to the Divisional Court, which also ruled in K.S.'s favour. Vaginoplasty and penectomy are listed as separate, approved surgeries under OHIP, the court found. And forcing someone to ' remove their penis to receive state funding for a vaginoplasty would be inconsistent with the values of equality and security of the person. ' Now, Ontario's highest court has also come down against OHIP's refusal. 'The vaginoplasty recommended for K.S. is an insured service because vaginoplasty is specifically included in the Schedule of Benefits' listing of specific sex-reassignment surgical procedures that are insured services, and because K.S. meets the stringent requirements for prior authorization of that surgery,' wrote Justice Benjamin Zarnett on behalf of the three-judge panel. This advertisement has not loaded yet, but your article continues below. Those requirements include assessments which confirm the patient has a diagnosis of gender dysphoria, underwent 12 continuous months of hormone therapy, lived for 12 continuous months in a gender role congruent with their gender identity, and is recommended for the surgery. Read More 'K.S. is pleased with the Court of Appeal's decision, which is now the third unanimous ruling confirming that her gender affirming surgery is covered under Ontario's Health Insurance Act and its regulations,' her lawyer John McIntyre wrote in an email to the Toronto Sun. According to the Canadian Civil Liberties Association, an intervenor in the case, 'the Court of Appeal for Ontario is a victory for equitable and non-discriminatory healthcare funding for trans, non-binary and gender diverse people in Ontario.' OHIP was also ordered to pay K.S.'s legal costs of $23,500 — on top of the $20,000 in costs they had to pay for their appeal to the Divisional Court. But really, that's out of our pockets, of course, including the thousands of (American) dollars it will cost for this out-of-country niche and experimental surgery. mmandel@ RECOMMENDED VIDEO World Columnists Toronto & GTA Canada Columnists
