The Manitoba Court of Appeal ruled in favor of twin sisters Kelsey and Kelly Fehr, overturning the province’s repeated denials of out-of-province health coverage for follow-up surgeries to treat their severe lipedema.
The decision, 2026 MBCA 52, found that Manitoba Health applied the wrong legal test when rejecting the sisters’ claims for coverage of additional procedures at Stanford University Medical Center in California. The ruling sets a clearer standard for how provincial health authorities must evaluate similar claims moving forward.
Eight years of denials
Kelsey and Kelly Fehr, both 38 and residents of Winnipeg, have lived with a debilitating form of lipedema. The genetic disease causes abnormal buildup of dense, fibrotic fatty tissue in the limbs.
In 2020, Manitoba Health approved coverage for an initial surgery at Stanford, which removed 12 to 14 liters of diseased tissue from each sister’s thighs. The procedure provided significant pain relief and improved their mobility. After being advised that four to five surgeries would be needed, Manitoba Health reversed its position in June 2022, calling the treatment an “emerging” procedure and denying further support.
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The Fehrs appealed the decision, but the Manitoba Health Appeal Board dismissed their case in May 2023. A Court of King’s Bench judge upheld that dismissal in December 2024. The Court of Appeal disagreed with both lower rulings, calling the province’s approach legally flawed.
A two-step test collapsed into one
The court identified the core issue: Manitoba Health misapplied the legal test for excluding coverage under section 2(18)(b) of the Excluded Services Regulation. The provision requires authorities to consider two distinct questions when evaluating whether a treatment qualifies as an “emerging” procedure ineligible for coverage. First, is the treatment emerging? Second, has its efficacy been established?
The appeal board stopped at the first question. It determined the surgery was not the standard of care in Manitoba and treated that as the final answer. The board never addressed whether the treatment’s efficacy had been proven, which the ruling called a critical oversight. The court noted this was particularly problematic because the sisters had already undergone a successful procedure at Stanford.
The difference between efficacy and effectiveness matters because it shapes how provinces decide which treatments deserve public funding. Efficacy asks whether a treatment can work under ideal conditions, like those in a controlled clinical trial. Effectiveness measures whether it works in real-world settings. The regulation only requires proof of efficacy, but Manitoba Health demanded evidence of effectiveness, setting a higher bar than the law requires.
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The court also criticized the province for relying on a two-page internal memo from Deputy Minister of Health Karen Herd to justify its decision. The Health Services Insurance Act requires broad decisions about medical coverage to be made through open regulation, not behind closed doors. The ruling emphasized that the appeal board must act as an independent check on Manitoba Health, not simply endorse its decisions.
The case returns to a newly constituted panel of the Manitoba Health Appeal Board for reconsideration. The sisters have been advised they likely need five more surgeries.
The decision comes as provinces increase scrutiny of out-of-province and out-of-country medical treatments. While cost control remains a concern, the court made clear that bureaucratic shortcuts cannot override the law. For patients with rare or complex conditions, access to care often depends on whether provincial health plans will recognize treatments performed elsewhere. The Fehr case does not guarantee coverage for every out-of-province procedure, but it establishes a precedent that could make it harder for provinces to deny claims without proper legal justification.
