P A R T C D e c i s i o n u n d e r A p p e a l T h e d e c i s i o n u n d e r a p p e a l i s t h e F e b r u a r y 2 7 , 2 0 1 4 D e v e l o p m e n t a n d S o c i a l I n n o v a t i o n ( t h e " m i n i s t r y " ) , a p p e l l a n t w a s n o t e l i g i b l e f o r f u l l c o v e r a g e o f t h e f e e e x a m i n a t i o n a n d a c o m p l e t e m a x i l l a r y u p p e r d e n t u r a n d S e c t i o n s 6 2 a n d 6 3 o f t h e E m p l o y m e n t a n d A s ( t h e " E A P W D R " ) . I n p a r t i c u l a r , t h e m i n i s t r y f o u n d t h r a t e s s e t o u t i n t h e S c h e d u l e o f F e e A l l o w a n c e s D e P A R T D R e l e v a n t L e g i s l a t i o n E A P W D R S c h e d u l e C , S e c t i o n s 1 a n d 4 E A P W D R S e c t i o n s 6 2 a n d 6 3 S c h e d u l e o f F e e A l l o w a n c e s D e n t u r i s t E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )I A P P E A L # r e c o n s i d e r a t i o n d e c i s i o n o f t h e M i n i s t r y o f S o c i a l i n w h i c h t h e m i n i s t r y d e t e r m i n e d t h a t t h e s c h a r g e d b y h i s d e n t u r i s t f o r h i s r e c a l l e a s p r o v i d e d i n S c h e d u l e C , S e c t i o n s 1 a n d 4 ( 2 ) s i s t a n c e f o r P e r s o n s w i t h D i s a b i l i t i e s R e g u l a t i o n a t t h e d e n t u r i s t c h a r g e d f e e s i n e x c e s s o f t h e n t u r i s t .
P A R T E S u m m a r y o f F a c t s T h e a p p e l l a n t i s d e s i g n a t e d a s a p e r s o n w i t h d i s a b i a n d h a s b e e n s i n c e 2 0 0 6 . T h e a p p e l l a n t a t t e n d e d e x a m i n a t i o n a n d a c o m p l e t e m a x i l l a r y u p p e r d e n t u r $ 1 0 3 0 . 0 0 ( $ 3 0 . 0 0 f o r t h e r e c a l l e x a m $ 1 0 0 0 . 0 0 f o r t p a i d b y t h e m i n i s t r y w a s $ 6 0 0 . 2 5 ( $ 1 9 f o r t h e e x a m b e p a i d b y t h e a p p e l l a n t . O n D e c e m b e r 1 9 , 2 0 1 3 t h e a p p e l l a n t w a s a d v i s e d b c o v e r a g e f r o m t h e m i n i s t r y f o r t h e d i f f e r e n c e b e t w e e a m o u n t p a i d b y t h e m i n i s t r y f o r t h e d e n t u r e s e r v i c e s T h e a p p e l l a n t r e q u e s t e d a r e c o n s i d e r a t i o n o f t h a t d T h e i n f o r m a t i o n b e f o r e t h e m i n i s t r y a t t h e t i m e o f r e • A l e t t e r f r o m t h e a p p e l l a n t ' s d e n t i s t , d a t e d N o " e d e n t u l o u s i n t h e u p p e r a r c h " , a n d i n d i c a t i n g p r o p e r f u n c t i o n . • A H e a l t h S u p p l e m e n t I n f o S h e e t 1 O D e n t a l , 2 0 1 3 , a d v i s i n g t h e a p p e l l a n t t o c o n t a c t t h e d e w a n t i n g t o r e q u e s t r e c o n s i d e r a t i o n , t o s u b m i t a d d r e s s i n g w h a t w a s d e n i e d a n d w h y i t w a s w a s , " $ 1 0 3 0 i s t h e d e n t u r i s t s f e e g u i d e . T h e b a l a n c e o w i n g i s $ 4 2 9 . 7 5 . " • A r e c e i p t f r o m t h e a p p e l l a n t ' s d e n t u r i s t , u n d a D e c e m b e r 6 , 2 0 1 3 , i n d i c a t i n g t h a t t h e a p p e l l a p a i d b y m i n i s t r y ) , a n d a c o m p l e t e m a x i l l a r y d e l e a v i n g a b a l a n c e o w i n g o f $ 4 2 9 . 7 5 . • T h e a p p e l l a n t ' s R e q u e s t f o r R e c o n s i d e r a t i o n a p p e l l a n t . I n S e c t i o n 3 o f t h e R F R t h e a p p e l l a o n d i s a b i l i t y a s s i s t a n c e i n o r d e r t o a f f o r d t h e p h e m u s t h a v e t h e d e n t u r e s i n o r d e r t o m e e t h a p p e l l a n t s t a t e s t h a t w i t h o u t d e n t u r e s , h i s a b i t o s e e k e m p l o y m e n t . H e c o n c l u d e s t h a t h i s d n e e d e d . • A r e c o r d o f t h e a p p e l l a n t ' s C A R E S n e t B e n e f i t E l i g i b i l i t y p o r t i o n o f t h e r e c o r d i n d i c a t e s t h a t t h s e r v i c e s u p t o $ 1 0 0 0 e v e r y t w o y e a r s . I t s t a t D e c e m b e r 2 0 1 4 , t h e a p p e l l a n t u s e d $ 6 0 0 . 2 5 T h e r e c o r d i n d i c a t e s t h a t t h e n e x t d a t e t h a t t h J a n u a r y 1 , 2 0 1 5 . T h e B e n e f i t E l i g i b i l i t y p o r t i o e l i a i b l e f o r o n e c o m p l e t e d e n t u r e s e r v i c e e v e r E M T 0 0 3 ( 1 0 / 0 6 / 0 1 )I A P P F A � # l i t i e s , a n d i s a r e c i p i e n t o f d i s a b i l i t y a s s i s t a n c e h i s d e n t u r i s t o n N o v e m b e r 2 7 , 2 0 1 3 f o r a r e c a l l e . T h e t o t a l c o s t o f t h e d e n t u r e s e r v i c e s w a s a n d h e C o m p l e t e M a x i l l a r y D e n t u r e ) a n d t h e a m o u n t a n d $ 5 8 1 . 2 5 f o r t h e D e n t u r e ) , l e a v i n g $ 4 2 9 . 7 5 t o y t h e m i n i s t r y t h a t h e w a s n o t e l i g i b l e t o r e c e i v e n t h e a m o u n t c h a r g e d b y h i s d e n t u r i s t a n d t h e . e c i s i o n . c o n s i d e r a t i o n i n c l u d e d t h e f o l l o w i n g : v e m b e r 2 5 , 2 0 1 3 , d e s c r i b i n g t h e a p p e l l a n t a s t h e n e e d f o r a c o m p l e t e u p p e r d e n t u r e f o r D e n t u r e s o f O r t h o d o n t i c , d a t e d D e c e m b e r 4 , n t a l o f f i c e r e g a r d i n g e l i g i b i l i t y a n d i f d e n i e d a n d a r e m i t t a n c e f o r m o r l e t t e r f r o m t h e d e n t i s t d e n i e d . H a n d w r i t t e n o n t h e b o t t o m o f t h e f o r m m i n i s t r y c o v e r s a p o r t i o n o f t h i s ( $ 6 0 0 . 2 5 ) , s o t h e t e d , b u t d a t e s t a m p e d ' R e c e i v e d ' b y t h e m i n i s t r y n t h a d r e c e i v e d a r e c a l l e x a m i n a t i o n f o r $ 3 0 ( $ 1 9 n t u r e f o r $ 1 0 0 0 ( $ 5 8 1 . 2 5 p a i d b y m i n i s t r y ) , ( R F R ) , d a t e d F e b r u a r y 8 , 2 0 1 4 a n d s i g n e d b y t h e n t w r i t e s t h a t h e d o e s n o t r e c e i v e e n o u g h m o n e y a y m e n t r e q u i r e d f o r h i s d e n t u r e s . H e a d d s t h a t i s d i e t a ry r e q u i r e m e n t s o f h e p a t i t i s C . T h e l i t y t o s p e a k c l e a r l y i s a f f e c t e d , w h i c h i s n e e d e d e n t u r e s w e r e b r o k e n a n d a r e p l a c e m e n t s e t i s E l i g i b i l i t y , a s o f F e b r u a r y 2 7 , 2 0 1 4 . T h e P l a n e a p p e l l a n t i s e l i g i b l e f o r b a s i c a n d m a j o r e s t h a t d u r i n g t h e p e r i o d o f J a n u a r y 1 , 2 0 1 3 t o o f t h e $ 1 0 0 0 b e n e f i t a n d h a s $ 3 9 9 . 7 5 r e m a i n i n g . e a p p e l l a n t w i l l b e e l i g i b l e f o r f u l l b e n e f i t i s n o f t h e r e c o r d i n d i c a t e s t h a t t h e a p p e l l a n t i s v f i v e v e a r s . I t s t a t e s t h a t d u r i n a t h e P e r i o d o f
November 27 , 2013 to November 26, 2018, the appel further remaining until Novem b e r 27, 2018. • A summar y of the appellant's C A RES net Cl aim of the eligible am o u n ts for the appellant's examination ($19) a den t urist, as p e r the a mounts allow a b l e b y the ministry fee schedule. The app ellant submitted a signed Notice of Appeal on the f irst req uest he h a s made t o t he ministry for dent replacement set of dentures after f ive years. H e adds th denied, c oncluding t hat h e has never nee ded help in the past, but now he does not have the money av ailabl e to pay the diff er ence. T he app e llant ' s oral evi dence on appe al inc luded th • The appellan t c o n t a cted the min istry's 1-888 a p pointmen t wi th t h e den t urist in Nov embe r 20 a vailable to h im for dent ure s eve r y five years. at th is t ime . • T he den t urist ha s made th e ap pellant's dentur not be r elea sed until th e payment fo r t h e full a dds that h e had a sked t h e dentur is t ab o ut a had p revi ous dis abil ity a ss is tanc e cl ients d efa re l ease the dentur es if t h e f u ll b ala nce i s p a id. • Wh en the d en tures w ere bein g mad e, t h e dentur of t he co sts wo uld not be covered b y the ministry. tele p h one n umb er ag ain t o c o nf irm and was told avail able to him for d entures ev ery fi ve years. • Th e a p pella nt e xp lai ned th at he is n ot feel ing to ea t the t ype s of hea lthy f ood recommended to him • Th e a p pella nt s tated that he doe s n o t hav e any ava to cover the cost of his dentures and would gladly accept any sort of help t provide and has offered to repay $20 off his monthly cheques to pay off the amount owing. • T he appellant stated th at his annual tr avel al lo but he had expenses that this allowance is intended to cover and also has a c member, out of province, that he inten d s to travel to see. The ministry reli ed prim arily on i t s reconsideration decision and confirmed that the $100 limit is correct, however the maximum amount paid for each specific item (recall visit or upper dentures) are negotiated through the ministry and the dental association. situation is not uncommon and dental p ractitioners often charg allocated amount as set out in the legislation, and unfortunately the balance is the responsibility of the patient. The ministry also noted that the denturist likely contacted the ministry for preapproval of this service and was aware of the ministry's Schedule of Fee Allowances limits. EAA T003(10/06/01) I A PPEAL # lant has used this benefi t and has n o D et ails, i ndicating that the minist ry paid 100 % nd dentures ($58 1. 25) t o the M ar c h 1 9, 2014, in which he states tha t this is ur es and that a person is allowed to rec eive a at h e does not understand why h e h a s b een e fo llowing i nformation: tel ephon e numb e r p r i or to a ttend ing his 13 and was t o ld that he had $1000 c overage He added t hat h e i s u nsure w h o h e s p oke wi th e s and the y a r e ready to be picked u p, but will a m ount owing has bee n made. The appel lant rr a n g ing a payment pla n, but the dentur ist has ult on th eir pa ym ents a nd is o n l y wi lli n g to i st to l d the appe l lant that he though t a p ort io n Th e appe l la nt con ta c ted the 1-88 8 a s econd time that th ere was $100 0 coverag e wel l bec ause witho ut h i s d en tures , he i s un a b le f o r h epat itis C. il able mo n e y o r r e sourc e s ava il able t o h i m he mini stry c an wance w i ll be issued at the end of the month, ri tica l ly ill family 0 coverage The ministry adds that this e fee s for services in excess of the
PART F -Reas ons for Panel De cision The d ec i s ion un der a ppe al is the Febru ary 27, 20 1 4 de t e rm ine d that th e appell an t w as n ot elig i b le for ful h is reca l l examinati on and a com plete m a xilla ry uppe a nd 4(2) and Sections 62 an d 63 of th e EAP WDR. c harged fe es in excess of t h e rate s se t out in the S The r elev ant l egis lat ion is as follows : E APWDR Secti on 63 :--Den t al S up plem en t 63 ( 1) S ubject to subsection s (2) a n d (3), the minister may provi supp l em en t s] o f Sch edul e C that i s pr ovi d ed to or for a fami pe r s on in th e f amily unit w h o is eligible for he alth s upple me (a) sec tion 6 2 (1 ) ( a), { b) (i ii), {d) or (e) [gene r a l health (b) s ection 62 ( 1 ) (b) ( i) , (d. 1), (d. 3 ) or (f) , i f (i) th e pe rson is under ag e 65 an d the family Protecti o n Act, or (ii) the pe rson is aged 65 o r more a nd any person in the f al lowa nce or the fede ra l guarant eed income (B .C. R eg. 67/2010) { B.C. R eg.114/201 0) (c ) se ction 62 (1) ( b ) (ii), or ( d .2), (B.C. Reg . 6 7 /2010) (c.1) sec tion 62 (1) (c), o r (d) secti o n 6 2 (1) (g). (2) A pers on el igi ble to rec eiv e a health supplement un der section 62 (1 (a) w hile a ny pe rson in the f amily unit i s (i) u nder age 65 and receiving a pen si o n or ot (ii) ag e d 65 or more and recei vin g t he f e deral spous supp l eme nt , a nd ( b) f o r a maximum of on e year f r o m the dat e o n which th only. (B.C. Reg. 67 /2010) {B.C. Reg. 114/2010 ) (3 ) A person eligibl e to r eceive a health supplement u nd er s ection (a) while any person in the family unit is receiving the federal spouse's allowance or the federal guaranteed income supplement, and (b) for a maximum of one yea r from the date on which the family unit only. (B.C. Reg. 67 /2010) (B.C. Reg. 114/2010) (4) A per son who was eligible to receive a health supplement under subsection (1) (b) but ceases to be eligible for medical s ervices only may continue to receive t he su ppl e ment family unit ceased to be eligible for medical services only. Schedule C -Dental supplements Section 1 "basic dental service" means a d ental service that EAAT 003(10/06/01) I �� P EAL# r e cons iderati o n de cision i n wh i c h the m i n i stry l coverage of the fee s charged by h is dent uris t for r denture as provided in Sc hedu le C, Sections 1 In pa r ti c ular , t h e m i nistry fou nd tha t the den turi st ched ule of Fe e Al lowa nces-Dentur ist . de a ny healt h supp lement s et ou t in secti o n 4 [den t al ly unit if the h ealth su pple ment is provided to or for a n t s under ( B.C. R e g. 67 /201 0) (B.C . Reg . 114 / 2 010 ) s upp lem ents], unit is recei ving premiu m a ssis tan ce under the Medic are amily unit is rece ivi n g the f e der a l spouse ' s su pple men t, ( B .C . Re g. 114/2010 ) ) (b) (i i) or (d.2) ma y r e c e ive the supplem ent he r pay m ent u n d er t h e Canada P e n s ion Pl an, or e's al lowa nc e or the federa l guarant e ed i ncome e fa mi l y unit ceas ed to be e lig ible fo r me dic al s erv ices 62 (1) (c) may receive the supplement ceased t o be eligible f or me dical services fo r a maximum of one year from the date on which the
(a) if p rovided by a dentist, (i) is s et o u t in t h e S c hedule of Fee Allo wances D e n office o f the d e puty m inister, and (B.C. R eg. 314/200 (ii) is p rovide d at the rate set out fo r the se r vice in that S ( b ) if pro vided b y a denturist , (i) is set o u t in t h e Sch edule o f Fe e A llow an ces D enturist of fic e o f the deputy min ist er, and (B.C. Reg . 314 /2006} (ii) is prov ided at the rate s et o u t f or the service in t hat ( c) if prov ided by a de ntal hygi enis t , (i) is se t out in the Sch edule o f Fe e All ow a n ces -De ntal the office of the dep uty minis ter, and (ii) is p rovided at t h e rate se t o u t for the service in t ha (B.C . Re g. 65/20 10) 4 (1) In t his s ection, "p eriod" m eans (a) in re spe ct of a depe n d ent chil d, a 2 ye ar period be January 1 i n a n odd n umbered y ear, a n d (b ) in r e spe ct of a person n ot re fe rred to in parag raph ea ch sub seque n tJ anuary 1 in an odd num bere d ye ar. (1.1} T h e hea lth suppleme n t s tha t m ay be pa i d u n der s ectio n servic es to a maximum of (a) $1400 ea ch period if p rovi ded to a depe n d ent chi ld, (b) $1 000 each pe r io d, if provid ed to a person not referr ( c) R e p e aled (B.C. Reg . 16 3/2005) (2) Den t ures ma y be p rovid ed as a ba sic d ental service on l y to (a) w ho h as nev er wo r n d e nt ures , or (b) wh ose d entures are more t han 5 y ear s ol d . (3) T he limits under s ubs ectio n (1.1) may b e e xcee de d b y an am t he amo un t r e maining to the per s on under t ho se l i mits at th e ( a) a pe r son req uire s a full upp er den ture, a f u ll low er pre vious 6 m onths t o relieve pai n , (b) a person requires a pa r ti al d enture to replac e at le one of which was ex t r a cted in th e previ o u s 6 months to (c) a person who has be en a recipient of disability assist dependant of t h at pers on requi res replac ement den tures. (4) Subsection (2) (b) does not apply with respect to a person de partial denture. (5) The dental supplements that may be provided to a person described in subsection (3) (b), or to a person described in subsect ion (3) (c) who requires a partial de nture, are limi t ed to services under (a) fee numbers 52101 to 52402 in the Schedule of Fee All definition "bas i c dental service" in section 1 of this Schedule, or (B.C. Reg. 94/2005) (b) fee numbers 41610, 41612, 41620 and 4 1 6 22 in the paragraph (b) o f the definition "basic dental servi ce" in secti (6) The dental supp leme nts that may be p rovid ed to a perso n described i replacement of a full upper, a full lower denture or both are limited to services under (a) fee numbers 51101 to 51102 in the Schedule of Fee Allowances -Dentist referr definition "basic dental service" in section 1 of this Schedule, or (B.C. Reg. 94/2005) (b) fee n umbers 3 1 3 1 0, 31320 o r 31 3 30 in the Sche d u (b) of the definition "basic dental service" in section 1 of this Schedule. (B.C. Reg. 94/2005) EAAT 003(1 0/06/01) I AP PEAL # tis t th at is effec tive Apr il 1 , 2010 a n d is o n file with the 6) (B.C. Reg. 65/2010 ) c he d u le, that is effective A pril 1, 2010 a n d is on f ile wi th t h e (B. C. Reg. 65/2010 ) Sched ul e, and (B.C. R eg. 88 /20 05) Hyg ienis t t hat is effe ctive Ap ril 1 , 201 0 and is o n fi le with t Schedule; gin nin g on J anuary 1, 20 09 , and on e ac h subse q u ent (a ) , a 2 year perio d b eginn ing o n J anu ary 1, 2003 a n d on (B. C. Reg. 65/2010} 6 3 [dental supple ments] of t hi s regulatio n a re b asic de nta l ( B .C. Re g . 6 5/20 1 0 ) ed to in parag raph (a ), (B .C. Reg. 163/2005) a p erson ount nece ssa r y to pro vide dentures , taki n g into a ccou n t t ime t he d entures are to be provi ded, i f denture or b oth bec ause of extract ions mad e in t he ast 3 co n t iguo us m issing teeth on th e sa me arch, at l e ast reliev e pain, or ance or income assis tanc e for at least 2 year s o r a (B.C. Reg. 94/2005) scribed in subs e ction (3) (a) who ha s previ o u sl y h ad a owances -Denti st referred to in p aragraph (a) o f the Schedule o f Fe e All owanc es-Den turist refe rred to in on 1 of this Schedule. (B.C. Reg. 94/2005) n subsection (3) (c) who requires the ed to in paragraph (a) of the le of Fee Allowances-Denturist referred to i n paragraph
I APPEAL# (7) A reline or a reb ase of dentures may be provided as a basic dental service only to a person who has not had a reline or rebase of dentures for at least 2 years. * * * Whether the appellant is eligible for dental supplements (Section 63 and Schedule C. Section 4 of EAPWDR) The ministry is satisfied that the information provided by the appellant has established that he is in receipt of disability assistance has met the statutory criteria for EAPWDR (Section 63 and Schedule C, Section 4). Whether the appellant is eligible for fees in excess of allowable ministrv rates. (Schedule of Fee Allowances-Denturist) The appellant argued that when he contacted the ministry's 1-888 telephone line, on two occasions, he was informed that he was eligible for $1000 toward the coverage of dentures, every five years. The ministry's position was that the appellant's denturist charged rates in excess of the rates set out in the Schedule of Fee Allowances-Denturist and there is no exception in policy for coverage of fees in excess of the rates set out in the Schedule of Fee Allowances and they are not authorized to provide coverage for fees in excess of these rates. The ministry also argues that the denturist was aware of the maximum fees that would be covered by the ministry and did share this information with the appellant at the time the dentures were being made. The panel accepts that the appellant did contact the ministry prior to attending his denturist appointment and was provided information regarding his denture coverage, however it is unclear if the information provided to him explained the application of the maximum rates paid for each service as set out in the Schedule of Fee Allowances, leading the appellant to misunderstand that there was $1000 available for replacement of a complete maxillary denture. The panel finds that under Schedule C, section 1, the ministry is not authorized to provide coverage for fees in excess of the rates and the appellant did receive the maximum allowable payment for the recall examination and complete maxillary upper denture he received from the denturist, therefore, the ministry's decision to deny the appellant coverage of the excess fees charged by the denturist was reasonable. Conclusion For the reasons detailed above, the panel finds that the ministry decision was a reasonable application of the legislation in the circumstances of the appellant. Accordingly, the ministry decision is confirmed. EMT 003(10/06/01)
You are being directed to the most recent version of the statute which may not be the version considered at the time of the judgment.