To be fair, our public health care system does excel at immediate emergency care, basic hospital stays, and standard physician visits. However, increasingly, many of us are finding that it has critical vulnerabilities. This is especially true when it comes to surgical wait times and the approval of new medications, treatments and therapies.
Accordingly, if someone’s provincial health care coverage falls short, patients face a grim ultimatum: wait while their health deteriorates, or pay out-of-pocket for private or out-of-country treatment. Increasingly, an unimaginable situation is becoming increasingly common: spending $200,000 now for out-of-country treatment, so that you could appeal a decision by your provincial government later. For most families, absorbing such a critical financial blow is not an option. For many families a financial burden in the hundreds is a problem, let alone the idea of dealing with a six-figure cost coupled with a battle with government bureaucracy, government red tape. For most Canadians acting without having a cash safety net can mean instant financial ruin.
If you want an example of what I am talking about, let’s look at the case of Vienna Pedatella. In 2021, this 13-year-old Albertan was diagnosed with idiopathic scoliosis, a condition causing an S-shaped curvature of the spine. Despite having some treatment - wearing a brace for 23 hours a day, undergoing physical therapy, and strength training - her condition continued to progress.
When she finally went to see a specialist at BC Children’s Hospital, she was informed that she had missed the window for a treatment known as tethering. At that point, the only Canadian option which remained was a full spinal fusion: a procedure which would connect 14 levels of vertebrae with metal rods, screws, and bone grafts. If she had gone down this path her mobility would have been permanently restricted; and even worse, the wait list was over two years long.
Faced with severe daily pain and the danger of her curved spine compressing internal organs, Vienna's family sought alternative options in the United States. They located a specialist in New Jersey capable of performing Anterior Scoliosis Correction (ASC), a mobility-preserving procedure. Her parents applied to Alberta's Out-of-Country Health Services Program for funding, but the request was denied. To preserve their daughter's health and mobility, her parents "bit the bullet" and paid the $199,074 surgical bill out of their own pockets. Furthermore, the parents are now engrossed in a lengthy court battle; trying to recoup nearly $200,000 from the government of Alberta.
With all that being said, there might have been a different option. It is called critical illness insurance. Now let me explain what Critical Illness Insurance (CII) is. When an insured is diagnosed with a covered illness, Critical Illness Insurance provides a lump-sum, tax-free payout. Unlike disability and many other health care insurance options, CII provides an immediate and unrestricted source of funds that can be deployed as the insured sees fit: including funding out-of-country procedures, purchasing non-covered drugs, or providing household stability.
Now let me be clear, Idiopathic Scoliosis and Kyphoscoliosis are not usually on the list of covered illnesses. However, the severity of Vienna’s condition could have triggered secondary complications that match an insurer’s benchmark definitions.
In this case, two definitions could have been triggered. Kyphoscoliosis, in its most extreme form, can restrict the chest cavity so much that it might lead to end-stage respiratory or cardiovascular failure requiring mechanical support or an organ waitlist. This could lead to major organ failure which is usually on the list of covered illnesses.
The second definition which might have been triggered by some policies is Paralysis and/or Loss of Independent Existence. Or put differently, in some extreme cases, the spinal curvature or surgical complications can lead to permanent loss of movement or the inability to independently perform basic activities of daily living (e.g., bathing, dressing, transferring).
While scoliosis itself requires careful underwriting, a parent holding a comprehensive critical illness policy on a child or a broad policy covering critical surgical complications would receive an immediate lump sum. That tax-free capital allows families to bypass domestic wait lists, fund cutting-edge surgeries abroad, and recover physically without being forced to spend $200,000 upfront while waiting years to appeal a provincial decision.
If you felt that Vienna’s situation was a stretch, Alex Shved’s situation is not. Diagnosed with Stage 4 melanoma, his cancer has metastasized to his bones and lungs. Given that he is a father of two young girls and that he is only 37 years old, I imagine that all he wants to do is recover. This oncologist recommended that he receive a cutting edge treatment called Tumor-Infiltrating Lymphocyte (TIL) therapy. To make a long story short, the treatment extracts the patient's immune cells, multiplies them into the billions and then reinfuses those immune cells so that they can kill off cancer cells.
While Health Canada has approved a version of TIL therapy (Lifileucel), the treatment is still undergoing reviews at the provincial level to determine whether funding, public funding, should be used to pay for this new treatment option.
To be clear, Mr. Shved’s oncologist has done the right thing: he has requested out-of-country funding for him to receive some TIL therapy at the Moffitt Cancer Center in Florida. The problem is simple: Ontario’s Ministry of Health (OMH) rejected the request. OMH has said that they cannot provide "interim drug funding" because the TIL therapy is undergoing public funding review.
The problem for Mr. Shved is simple: the treatment costs about $1 million.
Thus, the dilemma is spelled out: a patient has to play a high-stakes battle of legal appeals, judicial reviews, and freedom-of-information requests while fighting terminal cancer. A patient will become more sick because the government of Ontario is not willing to provide treatment now, but might well do so later.
Which gets me to my point. Unlike complex spinal conditions, if someone has Stage 4 Melanoma in Canada, and they have a Critical Illness Insurance Policy, it is almost guaranteed that that policy will pay out. After all, Stage 4 Melanoma is a standard condition on every Critical Illness Insurance policy in Canada. In fact, Cancer diagnoses account for a majority of critical illness claims with most insurance carriers in Canada. Accordingly, having a critical illness policy in Canada ensures that if you need something more than traditional treatments like chemotherapy and surgery, you have the capital to access advanced breakthrough therapies that are frequently bogged down in years of regulatory review.
Had Alex possessed a substantial Critical Illness policy upon his initial cancer diagnosis, he would have received a tax-free lump-sum payout immediately. Rather than losing precious months filing appeals against the Ontario Drug Benefit board or waiting on political interventions, he could have used his payout right away to access TIL therapy internationally (such as in Turkey or Israel, where it is available at a fraction of the U.S. cost).
With that being said, Vienna’s and Alex’s stories provide a clarifying lesson: sometimes, in Canada, when serious medical crises occur, families need a plan to navigate the long wait times and unmanageable bills. Critical Illness Insurance, in my opinion, is an important part of that plan.
Or put differently, Critical Illness Insurance isn't about doubting Canada's remarkable healthcare system. Rather, Critical Illness Insurance is a tool that gives your family options, capital, and freedom when time is running out. By buying a lump-sum policy before health issues arise, you ensure that if a medical crisis strikes, you can focus 100% of your energy on getting healthy, rather than fighting a bureaucracy or draining your life savings.
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