I APPEAi PART C Decision under Appeal In a reconsideration decision dated 20 April 2012, the Ministry denied the Appellant's request for a crisis supplement to purchase medications because it determined the Appellant's situation did not meet the eligibility criteria for a crisis supplement, that is, the expense was not unexpected and that a crisis supplement may not be provided for the purpose of obtaining health care goods or services as set out in the Employment and Assistance for Persons with Disabilities Regulation, Section 57. PART D Relevant Legislation Employment and Assistance for Persons with Disabilities Act (EAPWDA), Section 5 Employment and Assistance for Persons with Disabilities Regulation (EAPWDR), Section 57 EAA T003(10/06/01)
I APPEAi PART E -Summa of Facts The Appellant submitted a letter from his doctor dated May 16, 2012 that explained that the HGH therapy has been working well in managing the Appellant's Crohn's Disease. The doctor endorses the Appellant's application for coverage of this therapy. The Appellant also submitted his 2011 and 201 O Canada Revenue Assessments which showed his income at $21,514 and $18,572, respectively, to establish his inability to pay the cost of HGH. The Ministry had no objection to these documents. After review, the Panel finds the letter and the assessments are in support of evidence that was before the Ministry at the time to the reconsideration decision and admits the documents under Employment and Assistance Act, Section 22(4)(b). Evidence before the Ministry at the time of the reconsideration decision included: • A letter dated March 20, 2012 from the Appellant, • A medical prescription for human growth hormone (HGH), dated February 20, 2012. In the notice of appeal, the Appellant states he is asking for coverage of a long term medication, not a crisis supplement. He declares that the Ministry's decision not to cover the cost of the medication is wrong. He summarizes that he requires long term medications to live with his Crohn's Disease and that the Ministry currently covers his other medications and HGH is a long term medication that he requires. In the letter dated March 20, 2012, the Appellant describes how Crohn's disease has severely affected his life. He states that he, in conjunction with his doctor, tried a new medication "HGH" a year and a half ago and that is has improved his overall health. He says he takes less pain medicine, had zero emergency room visits and no hospital stays. He states he believes the Ministry has a duty to cover this drug for him because it is prescribed by a medical practitioner and is being used to treat a chronic and ongoing bowel disease. He concludes that he would pay for the HGH himself but the cost is way out of his financial realm. Within the reconsideration decision the Ministry stated the Appellant has been a recipient of income assistance (IA) since September 13, 1994 and on March 27, 2003 he was designated as a Person with Disabilities (PWD). Currently the Appellant has a Medical Services Only (MSO) designation with the Ministry. The Ministry states that a prescribed medication is part of daily living costs, not an unexpected cost and is considered a health care good, as such cannot be provided for with a crisis supplement. The Ministry notes the Appellant with a MSO designation is not eligible for the general supplements listed under EAPWDR, Schedule C. At the hearing, the Appellant explained that the Ministry pays all his medications and medical costs. He says HGH, although expensive, offsets the cost of hospital stays, pain medications and other alternate medications because it keeps him healthier. He says Chrohn's Disease is difficult to understand because it behaves differently for everyone who has it and it is extremely difficult to manage. EMT 003( 10/06/01)
I APPEAL He reiterated that he does not want a supplement of any kind, he is looking to the Ministry to fund HGH as part of his overall ongoing medical costs. He says a Ministry representative had told him to request a crisis supplement when he had gone in to explain his difficulty of paying for HGH. At the hearing the Ministry clarified that as an MSO client, the Appellant is not eligible for the general supplements under Schedule C. She also stated that HGH is not covered under the medical services plan and the only way such treatments may be possibly be funded is under "special authority" . The Panel finds from the evidence presented that: • The Appellant is a recipient of medical costs coverage with a MSO designation. • The Appellant has a chronic condition, Chrohn's disease for which he takes ongoing medications. • HGH is not covered by the medical services plan. EAAT 003(10/06/01)
IA PPE, PART F Reasons for Panel Decision The issue in this case is the reasonableness of the Ministry's decision to deny the Appellant's request for a crisis supplement to purchase medications because it determined the Appellant's situation did not meet the eligibility criteria for a crisis supplement, that is, the expense was not unexpected and that a crisis supplement may not be provided for the purpose of obtaining health care goods or services as set out in the Employment and Assistance for Persons with Disabilities Regulation, Section 57. The criteria for a crisis supplement are set out in the EAPWDR, Section 57 as follows: 57 (1) The minister may provide a crisis supplement to or for a family unit that is eligible for disability assistance or hardship assistance if (a) the family unit or a person in the family unit requires the supplement to meet an unexpected expense or obtain an item unexpectedly needed and is unable to meet the expense or obtain the item because there are no resources available to the family unit, and (b) the minister considers that failure to meet the expense or obtain the item will result in (i) imminent danger to the physical health of any person in the family unit, (2) A crisis supplement may be provided only for the calendar month in which the application or request for the supplement is made. (3) A crisis supplement may not be provided for the purpose of obtaining (a) a supplement described in Schedule C, or (b) any other health care goods or services. The Ministry argues that the intent of a crisis supplement is not to supplement expected daily living costs such as medication, it is provided to those who experience unexpected costs. Furthermore a crisis supplement may not be provided for any health care good or service. The Appellant argues he needs the medication to maintain his health and it is outside his financial means to pay for it. The medication for which the crisis supplement has been requested is a planned and prescribed treatment for a chronic disease and as such cannot be considered an unexpected expense. The Panel finds the Ministry reasonably determined that the request did not meet the criteria for a crisis supplement because it is not an unexpected expense. A medical prescription falls under the aeneral definition of "any other health care qoods or services" EAAT 003(10/06/01)
I APPEAL as described in the applicable legislation for crisis supplements. The legislation specifies health care goods or services may not be provided by a crisis supplement. As such, the Panel finds the Ministry reasonably determined it could not provide a crisis supplement to the Appellant for the medication. The Panel finds the Ministry decision was a reasonable application of the applicable enactment in the circumstances of the Appellant and confirms the decision. EAAT 003( 10/06/01)
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