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What Counts As Medically Necessary in the Canadian Health Act


It’s common to refer to the Canadian healthcare system as a government-funded system, but it’s actually a mix of public and private participation. There is no specific definition of medical necessity in Canada’s Health Act; therefore, “medically required” services are paid for by the federal government. It is the responsibility of provincial and territory health insurance plans to determine which services are medically required. As a result, hospital and medical service coverage varies greatly amongst provinces in Canada. Public health insurance does not cover outpatient prescription medicines.

The insurance coverage for uncommon disease diagnostics and treatments is likewise limited. Employer-sponsored health insurance policies are pricey, yet they don’t give enough protection. A lack of insurance coverage for those who are unemployed, self-employed or informally employed, as well as those with rare diseases that necessitate expensive treatments and drugs, can lead to financial hardship. This paper discusses what counts as medically necessary in the Canadian health act in relation to Gustaf’s and Jonas’s cases of short stature.

It is general knowledge that a medically essential service is one that is required by a patient in order to avert harm to their health. That Canadian citizens have access to any medical or hospital care deemed medically necessary contrasts with the more limited coverage and qualifying criteria of public programs in the United States. National pride and a concrete symbol of Canada’s greater collaborative attitude can be found in these Canadian program elements. Canada’s citizens have always supported the national health insurance program, and they look to the federal government to safeguard the program’s standards whenever they appear to be challenged, as was the case in the 1980s with the rise in extra billing.[1]

Although some Canadians are already questioning if Canada’s publicly funded health insurance coverage is too generous in terms of covered services, that is, too comprehensive, in the current fiscal context of restraint According to one poll, public support for the Canada Health Act’s comprehensiveness principle dropped from 88 percent in 1992 to 73 percent in 1999. Medically required services need to be defined by national organizations such as the Health Action Lobby, which has campaigned for their inclusion in provincial public health insurance schemes to meet the federal criteria of comprehensiveness.

This is how comprehensiveness is defined in the Canada Health Act1:

A province’s health insurance plan must cover all insured health services provided by hospitals, doctors, and dentists, as well as similar or additional services provided by other health practitioners permitted by provincial law.

Hospital, physician, and in-patient surgery dental services are all examples of insured health services. Hospital services are defined as those that are medically necessary for in-patients or out-patients in a hospital. Listed and specified services provided by the hospital include those provided by physicians, who provide any medically necessary services. There is a policy conundrum because the statute does not define medical necessity or provide any criteria for establishing its existence. It is unclear how provincial governments should utilize this legislation as a foundation for making service coverage decisions if there is no policy-based principle tied to the concept.

It is my contention that the concept of medical necessity, both in Canada and the United States, has evolved over time to meet the differing policy objectives of various parties. In my definition of meanings, I am referring to how the concept of medical necessity is perceived or socially constructed. I agree that the problem description of a health policy issue is not provided, but rather is formed in the imaginations of individuals or groups as an essential component of political scheming. Multiple interpretations can be gained via the use of vague concepts to describe a situation, which in turn provides intellectual support for various policy perspectives.

In the Gustal and Jona case, providing growth hormone to Gustal is far more critical. This is owing to the fact that Gustal’s small height is the result of a sickness or disease that causes growth hormone deficit, while the Jona problem is a genetic ailment passed down from parents. In Jona’s case, his parents are both naturally short, and he acquired this trait from them. There is no one-size-fits-all response to growth hormone injections. Even yet, this treatment is most beneficial in persons with a deficiency in growth hormone, as opposed to those whose short height is due to anything else. Growth hormone has been approved for the treatment of idiopathic low stature by the FDA.

The definition of medical necessity in Canada’s health act is not specified in law or government policy. To be considered medically necessary, a healthcare service or supply must meet generally accepted medical standards and be required for the treatment of a patient’s condition, illness, injury, or symptoms. To avoid unfavorable health repercussions, a medically necessary service must be requested by a patient. Every hospital or doctor’s office in Canada is covered by the country’s universal health care system. Health care services deemed to be “medically necessary” receive government funding in Canada. A medical necessity determination is made by the health insurance plans in each territory or province, depending on your location.

The Canadian Health Act’s universality principle mandates that all citizens of Canada’s provinces and territories be entitled to participate in publicly sponsored health plans in their respective regions. Achieving government obligations under the Canada Health Transfer requires that the supporting measures and requirements be completed. Public power should control and implement plans based on a non-benefit assumption. Exhaustibility: Plans should cover generally protected well-being administrations provided by medical clinics, doctors, or dental specialists (for careful dental systems that necessitate an emergency clinic setting.) in general. Those who are usually protected should be eligible for guaranteed health care under the same set of rules. Individuals should be able to keep their health insurance coverage even if they move from one part of the country to another, or if they are temporarily absent from their native province or territory or from Canada as a whole. Unhindered or blocked access to assured well-being services should not be hindered or blocked, either directly or indirectly, by the use of client fees or any other reasonable means.

All standard and regional state-run administrations are involved in a wide range of health and well-being initiatives. They are also in charge of health monitoring and epidemic response. When it comes to implementing and managing public health programs across Canada, the Public Health Agency of Canada (PHAC) is responsible, however, the responsibility for most everyday general health exercises is still held by local and regional governments. Physical and mental: Structures, equipment, data innovation (IT), and the well-being workforce are all examples of non-monetary contributions to Canada’s well-being framework. The ability of any health framework to provide timely access to quality health administrations depends not only on the availability of physical and human resources but also on finding the right balance between these resources. In light of Canadians’ ever-evolving innovation, medical care methods, and well-being demands, F/P/T states should constantly adjust their assistance.1


This paper concludes with a case study of two persons who are both under 5 feet tall. By providing supporting evidence, the study examines the cases of Gustal’s condition, which can be described as a disorder or disease. When it comes to boosting a person’s height and weight, growth hormone is the most effective treatment. The case study argues that the fundamental reason of low height in an individual should be taken into account when determining where hormone of growth intervention is appropriate. People who have a short height due to a condition can benefit from using growth hormone injections. The final section outlines the criteria used by the Health Act of Canada to decide what is considered medically necessary. An accurate diagnosis of any illness or problem in the body is necessary for a person’s well-being. A country’s population must be protected by providing the medical essentials required in the health sector, including funds, basic services, and the availability of both human and physical resources in hospitals. The availability of top-notch medical care in hospitals is essential for combating sickness and other problems that plague people and, as a result, preventing social catastrophes that endanger lives.


Skelton, Charles Weijer & Anthony. 2019. Bioethics in Canada: 2nd Edition. Canada: Oxford University Press.

[1] Skelton, Charles Weijer & Anthony. 2019. Bioethics in Canada.


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