Physician

A physician is a licensed medical doctor who diagnoses, treats, and helps prevent illness, injury, and disease. Physicians play a central role in healthcare by providing medical assessments, prescribing medications, ordering diagnostic tests, and coordinating patient care with specialists or allied health professionals. In Canada, physicians are regulated by provincial colleges of physicians and surgeons to ensure professional standards and ethical medical practice.

How It Works

Under the Canada Health Act, provincial and territorial public health insurance plans must cover all medically necessary hospital, physician, and certain surgical-dental services, which are called insured health services. Insured physician services are medically required services provided by emergency, specialty, or family doctors, and the specific services included are generally determined by the provincial or territorial health care insurance plan in consultation with the medical profession. Extra-billing, which means charging an insured person an amount for an insured physician service on top of what the provincial or territorial plan pays, is not allowed under the Canada Health Act. With the exception of Ontario, physicians can choose to give up their right to bill the public health insurance plan and take up private practice, a status referred to with terms such as non-participation or non-enrolment. On the private side, insurance policies often require that diagnoses, prescriptions, and treatment plans be provided by a physician to qualify for reimbursement.

Example:

Suppose you experience severe stomach pain in Canada and visit a physician who orders an ultrasound and prescribes medication. The physician visit itself is an insured service covered by your provincial health plan, while a private health or travel insurance plan may reimburse benefits such as the prescription, as long as they meet the plan's eligibility rules and are supported by physician documentation.

What to Watch For:

Make sure the provider you see is recognized as a physician under your plan's definition. Services provided by naturopaths or alternative practitioners are typically classified separately under paramedical benefits rather than as physician services. Because insurance policies often require that diagnoses, prescriptions, and treatment plans come from a physician to qualify for reimbursement, retaining proper physician documentation helps support your claims.