Excessive demand on health services and on social services

Part of the immigration application review and decision making process is Immigration, Refugees, and Citizenship Canada (IRCC) decision makers determining if an individual might reasonably be expected to cause excessive demand on health or social services in Canada.

On this page

• Excessive demand provisions
• Processing overview
• MHB medical assessment
• Application processing instructions
• Processing at a port of entry
• IRCC processing instructions for IN, CN and DN offices
• HMID-NF instructions
• Procedural fairness instructions (HMID-NF and MHB)

Excessive demand provisions

Subsection R1(1) of the Immigration and Refugee Protection Regulations (IRPR) defines “excessive demand” as either of the following:

• a demand on health services or social services for which the anticipated costs exceed triple the average Canadian per capita health services and social services costs over a period of 5 consecutive years immediately following the most recent medical examination required under paragraph A16(2)(b) of the Immigration and Refugee Protection Act (IRPA), or
• a demand on health services or social services that would add to existing waiting lists and would increase the rate of mortality and morbidity in Canada as a result of an inability to provide timely services to Canadian citizens or permanent residents

Health services means any health services for which the majority of the funds are contributed by governments, including the services of family physicians, medical specialists, nurses, chiropractors and physiotherapists; laboratory services; and the supply of pharmaceutical or hospital care.

Social services means any social services, such as home care, specialized residences and residential services, special education services, social and vocational rehabilitation services, personal support services and the provision of devices related to those services

1. that are intended to assist a person in functioning physically, emotionally, socially, psychologically or vocationally; and
2. for which the majority of the funding, including funding that provides direct or indirect financial support to an assisted person, is contributed by governments, either directly or through publicly funded agencies.

Processing overview

The Migration Health Branch (MHB) completes a medical assessment with a finding that the principal applicant, accompanying family member or non-accompanying family member (applicant) might reasonably be expected to cause excessive demand on health or social services.

The excessive demand medical assessment is associated with the applicant’s application(s).

If the medical officer determines that the applicant, principal applicant, accompanying family member or non-accompanying family member) is still reasonably expected to cause excessive demand, the migration officer should do both of the following:

1. Complete all application processing steps, including any outstanding admissibility or eligibility assessments, other than the assessment of medical admissibility and final decision.
2. Transfer the application to HMID-NF for continued processing and a final decision.

MHB medical assessment

When a review of immigration medical examination (IME) results shows that the foreign national (principal applicant, accompanying family member or non accompanying family member) is potentially inadmissible on health grounds, the MHB medical officer responsible for the file must complete all medical assessments, based on the definition of excessive demand found in subsection R1(1).

Recording excessive demand medical assessments in the Global Case Management System

When it is the finding of the medical officer that the foreign national might reasonably be expected to cause excessive demand, based on the definitions of excessive demand found in the IRPA and IRPR, a medical officer rationale must be entered as a note in the “Medicals – HB” screen of the Global Case Management System (GCMS).

This note must be entered by the assessing medical officer and must meet all of the following conditions:

• list the medical condition or conditions (diagnoses) identified during the IME that are related to the findings of likely inadmissibility
• provide a detailed summary, including the costs (where available), of why the foreign national might reasonably be expected to cause excessive demand on publicly funded health and social services in Canada (and, if also applicable, if the foreign national is likely to be a danger to public health or public safety), based on the definitions found in the IRPA and IRPR
• in the rationale, list the following, as defined by subsection R1(1):
  • the health and social services required by the applicant
  • the cost of these services, if applicable, and the total cost of all health and social services

Any time the medical officer finds that the foreign national is likely inadmissible on health grounds, the following information must be recorded by the medical officer in the Assessment Details applet of the “Medicals – HB > IME” screen of GCMS:

• Medical code
• Reason
• Surveillance code
• Diagnosis code

Medical code

One of the following medical codes must be entered to denote the medical officer’s assessment that the foreign national is likely inadmissible on health grounds, in whole or in part due to an excessive demand on health or social services:

• M5: The foreign national’s condition might reasonably be expected to cause excessive demand on health or social services, under the definition of excessive demand found in subsection R1(1).
• M4/5: The foreign national’s condition might reasonably be expected to cause excessive demand on health or social services, under the definition of excessive demand found in subsection R1(1), and the foreign national is likely to be a danger to public health, based on the findings of the medical assessment.
• M5/6: The foreign national’s condition might reasonably be expected to cause excessive demand on health or social services, under the definition of excessive demand found in subsection R1(1), and the foreign national is likely to be a danger to public safety, based on the findings of the medical assessment.

Reason

The medical officer must enter 1 or more of the medical assessment reasons below to denote which section of the IRPA is being applied to the medical assessment. If more than 1 reason exists, all must be entered.

In cases where the foreign national is found likely to present both an excessive demand and a danger to either public health (M4/5) or public safety (M5/6), or in cases where more than 1 type of potential excessive demand applies (M5), all applicable reasons must be entered.

• Health services, paragraph A38(1)(c): The applicant’s condition might reasonably be expected to cause excessive demand on health services to such an extent that the applicant is inadmissible under paragraph A38(1)(c).
• Social services, paragraph A38(1)(c): The applicant has a condition that might reasonably be expected to cause excessive demand on social services to such an extent that the applicant is inadmissible under paragraph A38(1)(c).
• Displacement of Canadian on waiting list: The applicant has a condition that might reasonably be expected to cause displacement of Canadians who are on a waiting list and to have negative impact on the morbidity and mortality of Canadians.
• Health condition, paragraph A38(1)(a): The applicant has a condition that is likely to be a danger to public health to such an extent that the applicant is inadmissible under paragraph A38(1)(a).
• Health condition, paragraph A38(1)(b): The applicant has a condition that is likely to be a danger to public safety to such an extent that the applicant is inadmissible under paragraph A38(1)(b).

Surveillance code

One of the following surveillance codes must be entered to record if the applicant requires medical surveillance after entering Canada and, if applicable, which type of surveillance applies:

• S1: There is no requirement for medical surveillance.
• S2.01: The applicant is inadmissible to Canada, due to active tuberculosis. This surveillance only exists for applicants who have been found likely to be both an excessive demand and a danger to public health. Therefore, this surveillance code is only included when a medical code of M4/5 has been entered (see above).
• S2.02: Medical surveillance is required if the applicant is granted entry to Canada (inactive pulmonary tuberculosis).
• S2.02U: Medical surveillance is required. Conditional entry is recommended if the applicant is granted entry to Canada (inactive complex pulmonary tuberculosis).
• S2.06: The applicant complied with a medical surveillance requirement on a previous IME. No requirement for medical surveillance.

Diagnosis code

A medical officer must enter 1 or more diagnosis codes. These codes exist as a list in GCMS. All diagnoses (and associated codes) included in the medical officer’s rationale must be populated in this section of the medical assessment.

Application processing instructions

Once the MHB has recorded that the foreign national is likely inadmissible on health grounds, this information is automatically populated in any permanent or temporary residence application records to which the medical assessment is linked in GCMS.

When the IME is completed as an upfront medical examination or is initially associated with a different application type, the migration officer may first need to import the medical results into the application record, using the instructions in Medical assessment coding.

Processing at a port of entry

Border services officers should follow the current instructions for referring processing of foreign nationals with medical conditions (section 7.8 of ENF 4 (PDF, 1.58 MB)).

If the foreign national is referred for an IME, the MHB medical officer provides the medical officer rationale and enters into GCMS their assessment of the foreign national’s admissibility on health grounds.

If the medical officer finds that the foreign national is likely inadmissible on health grounds, the border services officer should go to the Assessment Details applet of the “Medicals – HB > IME” screen in GCMS. On this screen, the completed assessment by the medical officer should include all of the following:

• Medical code
• Reason
• Surveillance code
• Diagnosis code

Finally, the border services officer reviews and ensures temporary residence and permanent residence applications are coded correctly in GCMS, according to the steps outlined in IRCC processing network instructions. The border services officer must ensure the foreign national has no inadmissibility concerns before allowing them to enter Canada.

IRCC processing instructions for IN, CN and DN offices

Once the GCMS application has been updated to reflect the MHB assessment that the foreign national might reasonably be expected to cause excessive demand (and, if applicable, also likely to be a danger to public health or public safety), the migration officer responsible for the application must complete the following steps:

1. Complete all outstanding application processing steps (eligibility, security and criminality assessments) with the exception of assessing medical admissibility and recording a final decision on the application.
2. Initiate an application file transfer and complete the file transfer to the HMID-NF.

HMID-NF instructions

Once the transfer of the application from the processing network office to HMID-NF is complete, HMID-NF must do all of the following:

• Review the application to determine which medical inadmissibility grounds exist. These should always include an excessive demand finding and, in some cases, may also include a finding of a danger to public health or public safety.
• Prepare and send a procedural fairness letter specific to the findings of the associated medical assessment.
• Review any response provided by the applicant to the procedural fairness request.

For permanent residence applications only: If the applicant is requesting an exemption from the medical inadmissibility, based on humanitarian and compassionate (H&C) grounds, or, in the absence of a specific request, if facts in the application suggest that an exemption from the medical inadmissibility is being requested by the applicant, the officer should consider H&C grounds before proceeding.

See more information about reviewing and assessing H&C considerations and about assessing H&C considerations when no exemption has been requested.

In these cases, the officer should do all of the following:

• Determine if the information provided, including any H&C considerations, if applicable (see above), overcomes medical admissibility concerns.
• If the officer is satisfied that there are sufficient H&C grounds, refer the file to the delegated decision maker (PM-05). The officer cannot grant an exemption to section A38.
• Render a final decision on the application, based on available information.

Procedural fairness instructions (HMID-NF and MHB)

Once the transfer of the application to HMID-NF is complete, procedural fairness must be initiated to give applicants the opportunity to respond to the officer’s concerns.

• HMID-NF procedural fairness instructions
• MHB procedural fairness instructions

HMID-NF procedural fairness instructions

Once the medical officer has determined that the applicant is likely inadmissible to Canada, due to excessive demand (and, if applicable, also due to a likely danger to public health or public safety), the HMID-NF officer prepares and sends a procedural fairness letter, using the appropriate procedural fairness letter template (at the bottom of this section).

For applications where an applicant requests an extension of time to submit a procedural fairness response, the officer should use their discretion in determining if extra time should be provided, based on reasons given by the applicant. A decision regarding the amount of time given for the extension should be exercised on a case by case basis.

If a procedural fairness response is not received within the time frame given (including any extensions) to the applicant, the HMID-NF officer will do all of the following:

• Change the status of the applicable GCMS medical activity from “Ready to be Assessed” to “Failed”.
• Record that an applicant has been found to be non-compliant in the “Other Requirements” section in GCMS.
• Enter all appropriate medical inadmissibility refusal information in GCMS. This should include details of excessive demand findings and, if also applicable, information related to medical inadmissibility, due to a likely danger to public health or public safety. This must also include any refusal information related to the non-compliance.
• Prepare and send a refusal letter that details all relevant refusal grounds.
• Record a final decision in GCMS.

If a procedural fairness response is received, the HMID-NF officer should do all of the following:

• Digitize the procedural fairness response and record documents in GCMS (if required). These documents should be placed in the “IMM > Correspondence > Incoming” section of GCMS.
• Prepare a detailed annex of the procedural fairness submission.
• Request that the medical officer review and assess if the information received addresses concerns from a medical perspective and await a response. This request can be made by sending an email to the responsible Regional Medical Office (RMO).
• Assess if the procedural fairness response addresses medical inadmissibility.

The procedural fairness letter response is received, and the applicant is medically admissible after a review (including H&C considerations) of the response

If a procedural fairness letter response is received, and it is the migration officer’s assessment, after consulting with the medical officer, that the information provided addresses all medical admissibility concerns, the officer should do the following:

• Enter an application note advising that medical admissibility concerns have been addressed. This note must detail how concerns were addressed.
• Update the medical admissibility status activity for the excessive demand individual from “Ready to be Assessed” to “Passed”.
• Note: Inadmissibility may only be overcome by H&C considerations for permanent residence applications. See more information about reviewing and assessing H&C considerations and about assessing H&C considerations when no exemption has been requested.
• If the applicant has requested an exemption from the medical inadmissibility, based on H&C grounds, or, in the absence of a specific request, if facts in the application suggest that an exemption from the medical inadmissibility has been requested by the applicant, and there are sufficient H&C grounds to overcome inadmissibility, apply H&C considerations to overcome medical inadmissibility by doing the following:
  • updating the medical activity status for the applicant from “Ready to be Assessed” to “Failed”
  • creating a new activity line in the “Other Reqs > H&C” section of the GCMS application for the applicant who has been assessed as being otherwise inadmissible
  • selecting “Type H&C – Medical”
  • changing the status of this activity from “Not Started” to “Passed” or “Passed H&C”
  • Note: An officer with the GCMS responsibility of “Manager” may need to complete this step. In these cases, the officer should ask their manager to complete this step.
• Record the final decision on the application in GCMS.
• Complete final processing steps, including the issuance of any documents.

The procedural fairness letter response is received, and the applicant remains medically inadmissible after a review of the response

If a procedural fairness response is received, but the submitted documents do not address inadmissibility findings, even with the application of H&C considerations to overcome medical inadmissibility, the officer should do the following:

• Enter an application note advising that medical admissibility concerns have not been addressed.
• Update the medical admissibility status activity for the excessive demand individual from “Ready to be Assessed” to “Failed”.
• and (if inadmissibility is not overcome on H&C grounds)
• Note: H&C grounds may only be considered for permanent residence applications. See more information about reviewing and assessing H&C considerations and about assessing H&C considerations when no exemption has been requested.
• If the applicant has requested an exemption from the medical inadmissibility, based on H&C grounds, or, in the absence of a specific request, if facts in the application suggest that an exemption from the medical inadmissibility has been requested by the applicant, and there are insufficient H&C grounds to overcome inadmissibility:
  • update the medical activity status for the applicant from “Ready to be Assessed” to “Failed” or “Failed H&C”
  • create a new activity line in the “Other Reqs > H&C” section of the GCMS application for the applicant who has been assessed as being otherwise inadmissible
  • select “Type H&C – Medical”
  • change the status of this activity from “Not Started” to “Failed”
  • Note: The officer with the GCMS responsibility of “Manager” may need to complete this step. In these cases, the officer should ask their manager to complete this step.
• Record the final decision on the application in GCMS.
• Complete outstanding processing steps.
• Enter the appropriate medical inadmissibility refusal information in GCMS.
• Prepare and send a refusal letter that details all relevant refusal grounds. This letter must specify all reasons that the applicant has been found inadmissible, including, if required (see above), an acknowledgement that application of H&C considerations did not overcome inadmissibility.

MHB procedural fairness instructions

Once a procedural fairness response is received from the applicant, the HMID-NF contacts the responsible regional medical office by email to request a review of the submission. Once this request is received, the medical officer should do the following:

• Review all the medical documents submitted in response to the procedural fairness letter.
• If applicable, review the medical applicability of the submitted mitigation plan in the context of the Canadian health care system.
• Prepare a medical officer consideration letter. This should reflect the impact that information included in the procedural fairness response may have on the medical assessment, including
  • changes to medical diagnoses, prognoses or services required
  • other information that may impact the medical admissibility decision of the assessing officer
• Record the medical officer consideration letter within the IME notes section of GCMS.
• Send a copy of the medical officer consideration letter to the HMID-NF by responding to the email sent by the HMID-NF that advised a response to procedural fairness was received.