Medical Inadmissibility: Understanding Excessive Demand on Health and Social Services in Canadian Immigration Law

When applying to enter or remain in Canada, immigration applicants must navigate a complex set of medical admissibility requirements. One critical ground for refusal is the potential for an applicant’s health condition to place an “excessive demand” on Canada’s publicly funded health and social services. This blog provides a detailed overview of how Immigration, Refugees and Citizenship Canada (IRCC) evaluates excessive demand, the processes involved, and key considerations for applicants facing this issue.

Legal Basis for Excessive Demand Assessment

Under subsection 38(1) of the Immigration and Refugee Protection Act (IRPA), a foreign national may be deemed inadmissible to Canada if their health condition is likely to cause excessive demand on health or social services. Specifically:

• 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 16(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

This provision aims to balance Canada’s immigration objectives with the need to protect its public health and social systems. However, certain applicants, such as those sponsored by a spouse, common-law partner, or parent, as well as Convention refugees and protected persons (along with their dependents), are exempt from this criterion under subsection 38(2) of the IRPA.

Defining Excessive Demand

Excessive demand is determined by assessing whether the anticipated costs of an applicant’s health or social services exceed a specific financial threshold or negatively impact service wait times for Canadian residents. The threshold is set at three times the average Canadian per capita cost for health and social services over a five-year period.

As of 2025, this amount is $26,220 annually, totalling $131,100 over five years. Health services include hospital care, physician services, nursing, and pharmaceutical care, while social services encompass residential care, personal support services, and rehabilitation services aimed at assisting with physical, psychological, or vocational functioning.

Changes to the Excessive Demand Framework

Since June 1, 2018, IRCC has implemented significant updates to the excessive demand policy. The cost threshold was tripled from its previous level to better align with Canadian values of inclusivity, particularly for individuals with manageable health conditions. Additionally, the definition of social services was narrowed to exclude special education, social rehabilitation, and personal support services unrelated to constant supervision or health-related care. These changes, solidified through regulatory amendments in 2022, have allowed more applicants with health conditions to qualify for admission while maintaining oversight of public resource impacts.

M Medical Categories

The M codes, assigned by Immigration, Refugees and Citizenship Canada’s (IRCC) Migration Health Branch (MHB) after an immigration medical examination (IME), categorize an applicant’s health condition and determine their medical admissibility. These codes play a pivotal role in identifying whether a condition might cause excessive demand on health or social services, as outlined under section 38(1)(c) of the Immigration and Refugee Protection Act (IRPA). Below is a detailed look at each M code and its relevance to excessive demand evaluations.

M1: No Significant Findings

• Definition: Indicates a clean bill of health with no abnormalities or conditions requiring ongoing care.
• Excessive Demand Relevance: Applicants with an M1 code are automatically admissible on medical grounds. There’s no risk of exceeding the $26,220 annual cost threshold ($131,100 over five years) or impacting wait times, as no health or social services are needed beyond routine care.
• Commentary: This is the most straightforward outcome, reflecting Canada’s openness to healthy applicants while ensuring minimal strain on public resources.

M2: Abnormal Findings, No Immediate Concern

• Definition: Identifies minor or controlled conditions (e.g., well-managed hypertension) that don’t require significant intervention.
• Excessive Demand Relevance: M2 conditions typically fall well below the excessive demand threshold and don’t add to wait lists. Costs and service demands remain negligible.
• Commentary: This code balances inclusivity with oversight, allowing applicants with minor issues to proceed without triggering deeper scrutiny. It aligns with the 2018 policy shift toward greater leniency for manageable conditions.

M3: Condition Requiring Treatment or Monitoring, No Excessive Demand

• Definition: Covers conditions needing ongoing care (e.g., mild asthma) but not exceeding the cost or wait time thresholds.
• Excessive Demand Relevance: M3 explicitly denotes that while services are required, they stay under $26,220 annually and don’t strain system capacity. It’s a key threshold for admissibility.
• Commentary: M3 reflects a practical compromise—acknowledging health needs without penalizing applicants whose conditions fit within Canada’s resource limits. It’s a common outcome for chronic but affordable conditions post-2018 reforms.

M4: Potential Public Health Risk

• Definition: Flags contagious diseases (e.g., active tuberculosis) that could endanger public health, regardless of cost.
• Excessive Demand Relevance: While M4 focuses on public health rather than excessive demand, treatment costs or isolation needs could indirectly overlap with demand concerns if extensive resources are required.
• Commentary: This category prioritizes safety over economics, but its overlap with M5 considerations highlights the complexity of dual-purpose assessments. Successful treatment can shift an M4 to M1 or M3.

M5: Condition Likely to Cause Excessive Demand

• Definition: Identifies conditions (e.g., kidney failure requiring dialysis) where costs exceed $131,100 over five years or significantly extend wait times, increasing morbidity or mortality risks for Canadians.
• Excessive Demand Relevance: M5 is the cornerstone of excessive demand refusals. It triggers procedural fairness, giving applicants 60 days to mitigate via private funding or updated medical evidence.
• Commentary: M5 embodies the tension between individual rights and system sustainability. The 2018 threshold increase (to $26,220 annually) and narrowed social services scope have reduced M5 assignments, but conditions like rare cancers or heavy caregiving needs still qualify. The wait time clause—adding to lists and worsening outcomes—adds a qualitative layer beyond mere cost, making M5 a nuanced gatekeeper.

M6: Public Safety Risk

• Definition: Applies to conditions (e.g., untreated severe mental illness with violent tendencies) posing a danger to others.
• Excessive Demand Relevance: M6 focuses on safety, not demand, but associated treatment costs (e.g., psychiatric care) could theoretically intersect with M5 if extensive.
• Commentary: While distinct from excessive demand, M6 underscores IRCC’s holistic approach to admissibility. Its rarity in pure demand cases highlights the priority of immediate risk over long-term resource use.

General Observations

• Process Integration: M codes streamline the IME review. M1–M3 fast-track approvals, while M4–M6 prompt deeper analysis. For M5, the Medical Notification (IMM 5365B) details cost and wait time impacts, feeding into the Procedural Fairness Letter process.
• Flexibility: Applicants can shift from M5 to M3 by proving costs fall below thresholds or wait time effects are negligible (e.g., private care arrangements). This reflects Canada’s commitment to fairness, codified since the 2018 policy shift.
• Exemptions: Refugees and certain family-sponsored applicants bypass M5 concerns entirely, receiving an “excessive demand exempt” designation—a statutory nuance under IRPA subsection 38(2).

Implications for Applicants

The M codes are more than labels—they’re decision points. M5, with its dual focus on cost ($131,100 over five years) and wait time strain, is the critical hurdle for excessive demand cases. Its interplay with procedural fairness offers a lifeline, but success hinges on robust evidence. The system’s evolution—higher thresholds, fewer social services counted—has softened M5’s bite, yet it remains a formidable barrier for severe conditions in a resource-conscious framework.

The Immigration Medical Examination Process

All applicants for permanent residence, and some temporary residence categories, must undergo an immigration medical examination (IME) conducted by a panel physician authorized by IRCC. The IME includes a physical exam, chest X-rays, blood tests, urine tests, and a review of medical history. Results are submitted to IRCC’s Migration Health Branch (MHB), where medical officers assess whether an applicant’s condition meets the criteria for excessive demand or poses a danger to public health or safety.

Procedural Fairness in Excessive Demand Cases

If a medical officer determines that an applicant’s condition may result in excessive demand, the applicant is not immediately refused. Instead, IRCC follows a procedural fairness process. The medical officer prepares a Medical Notification (IMM 5365B), outlining the diagnosis, required services, and estimated costs, which is sent to the visa or immigration officer. The officer then issues a Procedural Fairness Letter to the applicant, detailing the inadmissibility concern and providing 60 days to respond with additional information or a mitigation plan. Extensions may be requested if more time is needed to gather evidence.

Responding to a Procedural Fairness Letter

Applicants have the opportunity to challenge the medical opinion or demonstrate that their condition will not impose excessive demand. Responses may include updated medical reports showing improved health, evidence of private funding or insurance to cover costs, or a mitigation plan outlining how they will avoid reliance on public services. For example, an applicant might prove they can pay for medications or treatments privately, reducing the burden on Canada’s system. If no response is provided within the allotted time, the application may be refused based on the existing evidence.

Reviewing New Information

When an applicant submits additional documentation, the visa officer forwards it to the MHB for reassessment. The medical officer reviews the new evidence and issues an updated opinion. Possible outcomes include:

• A determination that the applicant remains inadmissible, triggering further procedural fairness steps.
• A finding that the condition no longer poses excessive demand, allowing the application to proceed. If the applicant submits a declaration of ability and intent to offset costs (e.g., through private means), and the officer is satisfied, no new IME is required unless the existing medical certificate has expired.

Final Decision and Record-Keeping

The visa or immigration officer makes the final decision on admissibility, considering all evidence and the medical officer’s opinion. Detailed case notes are recorded in IRCC’s systems (e.g., GCMS), and any declarations of ability and intent are retained on file. If approved, the application moves forward; if refused, the applicant is notified of the decision and the underlying reasons.

Implications for Applicants

The excessive demand provision applies universally to non-exempt applicants, including those seeking temporary or permanent residency, unless their medical certificate is marked as “excessive demand exempt.” Conditions such as chronic illnesses requiring costly treatments or ongoing social support may trigger scrutiny. However, the 2018 policy shift has reduced refusals for conditions like HIV, where treatment costs now often fall below the updated threshold.

Key Takeaways

• Excessive demand is assessed against a $131,100 five-year threshold as of 2025.
• Exemptions apply to family-sponsored applicants, refugees, and protected persons.
• Procedural fairness ensures applicants can respond to inadmissibility findings within 60 days.
• Mitigation plans or private funding can overcome excessive demand concerns.
• Policy changes since 2018 reflect a more inclusive approach, narrowing the scope of social services considered.

If you worry you might be medically inadmissible or have received a Procedural Fairness Letter, don’t hesitate to contact us for a full analysis of your situation.