P ART C -D ecision un der App ea l T he decisi on und er app eal is the rec o nsider atio n d ecisio Soci a l I n no v ation (the minist ry) da ted 06 December coverage for pa rtial dentu r e s. The mini stry dete rm i ned a ssis tan ce , is not eligib le to rec e ive coverage for basi E mploy ment a nd Assistance Re g u lation and sectio n The ministry deter mined t h at wh il e t he appel lan t is eligib 69 of the Re g u lation an d sectio n 5 of Sch edule C, th not partial dent u r e s. T he ministry al s o determi ned th d e nta l service s under se ct io n 70 of th e Reg ulation a not in cluded i n the se rvices that can be p rovide d as an emerg The ministry fu rt h er d eter mined that t he ap pel lant was not eligib a li fe-threatening health need under se ct i on 7 6 of t h p rovisi on appl ie s onl y to m e dical su ppl ies, me di ca l tra de vic e s. PART D -Relevant Le gislation E m p loyment an d Assistance R egulat io n (E A R), s ectio s ectio ns 4, 5 a nd 6. EAAT003(10/06/01) APPEA L # I n of the M in istry of Social Dev elopment an d 2 013 th a t den i ed the appell ant's request for that t h e app e ll ant, w hile a re c i pient of incom e c dental supple ment s under section 68 of the 4 of S c h edule C of th e Reg ulation. le t o rece iv e denture servi ces under sectio n e serv ices listed o nly refer to compl ete dentures, at wh il e t he a p pell a nt is eli g ible for emerg ency nd sec t ion 6 of Schedu le C, pa rt ial den tur es are ency den t a l service . le fo r c o verage fo r p ar ti a l dent ures as e Regulation, as the r e medy pro vided under thi s nspo rtation and medical e q ui pment and ns 67 , 68, 69, 70 a nd 76, and Sc h edul e C
P A R T E S u m m a r y o f F a c t s T h e e v i d e n c e b e f o r e t h e m i n i s t r y a t r e c o n s i d e r a t i o n • F r o m t h e m i n i s t r y ' s f i l e s : t h e a p p e l l a n t i s a r e • A t r e a t m e n t p l a n ( u n d a t e d ) f r o m a d e n t u r i s t f a n d r e l a t e d e x a m a n d l a b c o s t s , fo r a t o t a l c o p a r t i a l d e n t u r e s a r e n o t c o v e r e d u n d e r e m e r g • A t t a c h e d t o t h e t r e a t m e n t p l a n i s a t o o t h c h a r 2 1 , 2 4 , 2 5 a n d 2 8 m i s s i n g . T h e c h a rt n o t e s t h t e e t h r e m a i n i n g . • 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 t h a t d e n i a l o f t h e p a r t i a l d e n t u r e " e f f e c t s m y a m e n t a l h e a l t h . " A t t a c h e d i s a n a r t i c l e ( p r e s u m t e e t h l o s s . A l s o a t t a c h e d i s a s u b m i s s i o n b y t " I h a v e a n e x t e n d e d w o r k b a c k g r o u n d i n b a s e t h a t a l l o w s m e t o w o r k w i t h t h e p u b l p u b l i c s e t t i n g s , a n d d e a l w i t h c l i e n t s f a c e m e m o r e p r e s e n t a b l e t o f u t u r e e m p l o y e r s t o b e c o m e i n d e p e n d e n t f r o m S o c i a l A s s i s S i n c e h a v i n g m y u p p e r t e e t h r e m o v e d i t h I d o n o t h a v e t h e f r o n t t e e t h t o b i t e i n t o w g r i n d m y f o o d . I h a v e l o w v i t a m i n B 1 2 l e v a m r e q u i r e d t o e a t m a k e s i t h a r d t o m a n a r e g a r d i n g f u t u r e d a m a g e c a u s e d b y m i s s S i n c e t h e l o s s o f m y t e e t h , m y m e n t a l h e a b e c o m e h a r d e r f o r m e t o f a c e t h e p u b l i c , p a c k a r e h a r d f o r m e t o d o , i n f e a r t h a t s o t h i n k t h e w o r s t o f m e . I h a v e o v e r h e a r d p t e e t h a r e m i s s i n g b e c a u s e o f d r u g u s e , I h a b u s e p r o b l e m a n d [ t h i s ] i s n o t t h e c a u s e f e e l l i k e I j u s t s h o u l d n o t h a v e c o m e o u t o I n h e r N o t i c e o f A p p e a l , d a t e d 2 3 D e c e m b e r 2 0 1 3 , t h n e c e s s a r y f o r m e t o m a i n t a i n p r o p e r h e a l t h , a n d f u r t A t t h e h e a r i n g t h e a p p e l l a n t s u b m i t t e d a l e t t e r f r o m h " [ T h e a p p e l l a n t ] i s s u f f e r i n g f r o m d i f f i c u l t y e x t r a c t i o n s . S h e i s i n n e e d o f d e n t u r e s a n a n i n o r d i n a t e a m o u n t o f t i m e t o c h e w h e r r e s u l t o f f o o d t h a t h a s n ' t b e e n c h e w e d p r o p l a c e s a s a r e s u l t o f t h e a b o v e . I n v i e w o f t h e a b o v e i t w o u l d b e a p p r e c i a t c o n s i d e r a t i o n . . . " T h e a n n e l l a n t s t a t e d t h a t t h e l a c k o f a d e n t u r e p l a t e E M T 0 0 3 ( 1 0 / 0 6 / 0 1 )I A P P E A L # i n c l u d e d t h e f o l l o w i n g : c i p i e n t o f i n c o m e a s s i s t a n c e . o r a ' T o o t h B o r n e P a rt i a l M a x " [ p a rt i a l d e n t u r e ] , s t o f $ 1 5 4 4 . 0 0 . T h e t r e a t m e n t p l a n n o t e s t h a t e n c y s e r v i c e s w i t h t h e m i n i s t r y . t s h o w i n g t e e t h i n t h e u p p e r a r c h 1 8 , 1 3 , 1 2 , 1 1 , a t t e e t h 2 3 a n d 2 7 w i l l b e e x t r a c t e d , l e a v i n g 6 d a t e d 0 5 D e c e m b e r 2 0 1 3 . T h e a p p e l l a n t w r i t e s b i l i t y t o b e h i r e d " a n d " e f f e c t s m y p h y s i c a l & a b l y f r o m t h e I n t e r n e t ) d i s c u s s i n g t h e i m p a c t o f h e a p p e l l a n t , w h i c h r e a d s i n p a r t : c l e r i c a l a n d a d m i n i s t r a t i v e w o r k , I a l s o h a v e a s k i l l i c i n a v a s t r a n g e o f j o b s t h a t w o u l d p l a c e m e i n t o f a c e . H a v i n g a p a rt i a l d e n t u r e p l a t e w i l l m a k e . B e i n g a b l e t o o b t a i n a n d h o l d a j o b w i l l a l l o w m e t a n c e . a s b e c o m e h a r d e r f o r m e t o e a t p r o p e r f o o d s , a s i t h , a n d a l s o m i s s i n g b a c k t e e t h t h a t a l l o w m e t o e l s . N o t b e i n g a b l e t o e a t t h e p r o p e r f o o d s t h a t I g e t h i s c o n d i t i o n . . . . [ R e f e r e n c e t o a t t a c h e d a r t i c l e i n g t e e t h . ] l t h h i s t o r y o f d e p r e s s i o n h a s s u f f e r e d . I t h a s s i m p l e [ t a s k s ] l i k e j u s t d r o p p i n g o f f t h i s a p p e a l m e o n e w i l l n o t i c e t h a t m y t e e t h a r e m i s s i n g , a n d e o p l e t a l k i n g a n d m a k i n g a c c u s a t i o n s t h a t m y a v e n e v e r i n t h e p a s t o r p r e s e n t h a d a d r u g o f m y t o o t h l o s s . E v e r y t i m e I h e a r t h i s I c r y a n d f m y h o u s e . " e a p p e l l a n t w r i t e s : " T h e p a r t i a l d e n t a l p l a t e i s h e r h e l p m e o b t a i n f u l l t i m e e m p l o y m e n t . " e r p h y s i c i a n , u n d a t e d . T h e l e t t e r r e a d s : i n c h e w i n g a s a r e s u l t o f d e n t a l c a r i e s a n d d i n v i e w o f o n g o i n g p a i n a n d s i n c e i t t a k e s h e r f o o d . S h e i s a l s o d e v e l o p i n g a b d o m i n a l p a i n a s a p e r l y . P a t i e n t i s a l s o d i f f i c u l t e a t i n g i n p u b l i c e d i f p a t i e n t ' s c o n d i t i o n i s t a k e n i n t o i s n o w c a u s i n a o t h e r m e d i c a l o r o b l e m s , s u c h a s
a b d o m i n a l p a i n b e c a u s e s h e c a n ' t c h e w h e r f o o d p r c o n t r i b u t e s t o h e r v i t a m i n B 1 2 d e f i c i e n c y . S h e i s e x S h e s a i d t h a t s h e i s s c h e d u l e d t o h a v e a n o t h e r t w o w i t h o u t a d e n t u r e p l a t e h e r r e m a i n i n g t e e t h a r e s t a r m o r e d i f f i c u l t t o b i t e o r c h e w f o o d . T h e a p p e l l a n t e x p l a i n e d t h a t h e r d e n t a l c o n d i t i o n a f s u p e r v i s o r y e x p e r i e n c e , e m p l o y e r s a r e r e l u c t a n t t o T h e m i n i s t r y s t o o d b y i t s p o s i t i o n a t r e c o n s i d e r a t i o n T h e p a n e l f i n d s t h a t t h e p h y s i c i a n ' s l e t t e r s u b m i t t e d t e s t i m o n y , a r e i n s u p p o r t o f t h e e v i d e n c e b e f o r e t h e i n f o r m a t i o n p r o v i d e d i n h e r R e q u e s t f o r R e c o n s i d e r a l e t t e r a n d t h e a p p e l l a n t ' s o r a l t e s t i m o n y a s e v i d e n c e A s s i s t a n c e A c t . E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )A P P E A L # , I o p e r l y . N o t b e i n g a b l e t o e a t e n o u g h r e d m e a t p e r i e n c i n g o n g o i n g p a i n a n d f e e l s d e p r e s s e d . t e e t h r e m o v e d i n t h e n e x t c o u p l e o f w e e k s , a s t i n g t o d r i f t , l o o s e n a n d f a i l . T h i s m a k e s i t e v e n f e c t s h e r a b i l i t y t o b e h i r e d . A s s h e h a s h a d c o n s i d e r h e r f o r l e s s r e s p o n s i b l e p o s i t i o n s . . b y t h e a p p e l l a n t a t t h e h e a r i n g , a n d h e r o r a l m i n i s t r y a t r e c o n s i d e r a t i o n , e l a b o r a t i n g u p o n t i o n . T h e p a n e l t h e r e f o r e a d m i t s t h e p h y s i c i a n ' s u n d e r s e c t i o n 2 2 ( 4 ) o f t h e E m p l o y m e n t a n d
PART F Reasons for Panel Decision ---------'-'-- ---------The issu e in th i s appeal is whether the mini stry decisio dentures is r ea s o n a bl y supported by the evide nce or the c i rcum s ta n c e s of the appellant. S pe c i fic a lly, the determinatio ns are re asona b le : • that the appellant, while a r e ci pient of income assistance, is not e bas i c d e ntal supplements un der section 68 o EAR. • t hat while t he appellant is eligible to receive denture serv s ection 5 of Sc h edule C, the services l ist ed only den tures. • that while the appellant is eligible for em ergency and section 6 of Schedule C, partial dentur es p ro vid e d a s an em erg ency de nta l service. • that the ap pell ant w as not eli g i b l e for coverage nee d under secti on 76 o f t he Re gulati on, as the reme only to medical supp lie s , medical tr ans portat i Th e relevant legislation is set o u t in the E AR: Section 6 8 , b y cross refere nce to secti on 67(1), limits C, sect i o n 4) to recipie nts of i ncom e assist ance if a n b a rriers t o emplo ym ent and to certain o the r categ or i Section 69 auth orize s the pro v is ion o f D e ntur e S u pp r e cipie nts o f incom e assist an c e . From Schedul e C: Definit io ns 1 In t his Sch edule: "dentu re ser vices" means services and ite ( a ) if p ro vided by a d e ntis t (i) are set out under fee n Allowances -Denti s t that is effectiv t he deputy minister , and (ii) are provided at the rate set out for the service or item in that Schedule, and (b) if provi d ed by a denturist (i) are set out under fee n Allowances -Dentur ist the deputy minister, and (ii) are provided at the rate set out for the service or item in that Sc (Under the Schedule of Fee Allowances -Denturist, fee number 31310 to 31331 refer only to complete and immediate complete maxillary and/or mandibular dentures.) Denture supplements EMT 003(1 0/06/01) I APP EAL# ------� n to de n y th e a ppellant's req uest for partial i s a re asona ble application of the le gislati on in i ssue i s whether t he following m i nistry ligible to r eceive cov e rage for f t h e EA R a nd s ection 4 o f Sc he d u l e C of the ices un der se ct i on 69 of the EAR and refer to complete dentures, not partial den t a l ser vices u nder section 70 of t he EAR are n ot included in the services that can be for pa r t ial dentur es as a l ife-thr e at e n ing he al th d y provided un d e r th i s provisi on ap pl ies o n and medical equipm e nt and devices. the pr ov i si on of d ental supple men ts ( Sc he d u l e y pers on i n t he f a mily unit has persist e nt mult ip l e es o f p e r sons. le m e nts set out in Schedule C, sect i o n 5 t o al l m s tha t umb ers 51101 to 51302 in the Schedule of Fee e April 1, 201 0 and is o n file with the office of umb ers 31310 to 31331 in the S chedule of Fee that is effective Apri l 1, 2010 and is on file with the office of hedu le;
I APPEAL# 5 The health supplements that may be provided under section 69 [denture supplements] of this regulation are denture services. Similarly, section 70 authorizes the provision of Emergency Dental and Denture Supplements set out in Schedule C, section 6 to all recipients of income assistance. From Schedule C: Definitions 1 In this Schedule: "emergency dental service" means a dental service necessary for the immediate relief of pain that, (a) if provided by a dentist, (i) is set out in the Schedule of Fee Allowances -Emergency Dental -Dentist, that is effective April 1, 201 0 and is on file with the office of the deputy minister, and (ii) is provided at the rate set out in that Schedule, and (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances -Emergency Dental -Denturist, that is effective April 1, 2010 and is on file with the office of the deputy minister, and (ii) is provided at the rate set out in that Schedule; Emergency dental supplements 6 The health supplements that may be paid for under section 70 [emergency dental and denture supplements] of this regulation are emergency dental services. (Under the Schedule of Fee Allowances -Emergency Dental-Denturist, the services provided are direct reline for complete or partial denture, repair without impression and adjustment to denture.) The EAR also provides the following: Health supplement for persons facing direct and imminent life threatening health need 76 The minister may provide to a family unit any health supplement set out in sections 2 (1) (a) and (f) [general health supplements] and 3 [medical equipment and devices] of Schedule C, if the health supplement is provided to or for a person in the family unit who is otherwise not eligible for the health supplement under this regulation, and if the minister is satisfied that (a) the person faces a direct and imminent life threatening need and there are no resources available to the person's family unit with which to meet that need, (b) the health supplement is necessary to meet that need, (c) the person's family unit is receiving premium assistance under the Medicare Protection Act, and (d) the requirements specified in the following provisions of Schedule C, as applicable, are met: (i) paragraph (a) or (f) of section (2) (1); (ii) sections 3 to 3.12, other than paragraph (a) of section 3 (1). The position of the ministry is that the provision of health supplements is strictly limited by the eligibility criteria set out in the relevant sections of the EAR and the applicable sections of Schedule C. Services provided bv dentists and/or denturists are covered under sections 68, 69 and 70 of the EAAT003(10/06101)
APPEAL# I EAR, and sections 4, 5 and 6 of Schedule C. The appellant is not eligible for the requested partial denture under the legislation either because she does not meet the eligibility criteria for dental services under section 68 of the EAR, and theref o re the benefits under section 4 of Schedule C are not available to her, or because a partial denture is not eligible item under section 5 or 6 of Schedule C. Section 76 of the EAR (Health supplement for persons facing direct and imminent life threatening health need) does not apply, as this remedy relates only to the provision of health supplements listed in sections 2 and 3 of Schedule C. The appellant's position is that, as a recipient of income assistance, the ministry should take into account her overall health situation and what is required to help her get back to work. She needs a denture plate to regain her mental and physical health, as well as to help save her remaining teeth. With good health and being more presentable she is confident that, with her experience and skills, she could soon find employment. Without a denture plate, her health will likely continue to deteriorate and she would be unlikely to find work, remaining on income assistance. Panel findings Appendix B, Relevant Legislation, of the reconsideration decision sets out legislation regarding health supplements from the Employment and Assistance for Persons with Disabilities Regulation, not from the EAR. At the hearing, the ministry representative and the appellant confirmed that the appellant is a recipient of "regular" income assistance. The panel requested the appellant to review section 68 (with the cross reference to section 67) of the EAR, a copy of which was at hand, and she acknowledged that she did not fit into any of the categories of persons eligible for dental supplements under that section (e.g. as a person with persistent multiple barriers to employment). On this basis, and after a thorough review of section 68 of the EAR, the panel finds that the ministry reasonably determined that the appellant was not eligible to receive coverage under section 68 of the EAR and section 4 of Schedule C. While as a recipient of income assistance the appellant is eligible to receive coverage under sections 5 and 6 of the Schedule C, a partial denture is not listed as an eligible service under the Schedule of Fee Allowances -Denturist or the Schedule of Fee Allowances -Emergency Dental-Denturist. The panel notes that the legislation provides no discretion for the minister, in unusual or exceptional circumstances or taking into account medical or employment considerations, to provide coverage for services not otherwise authorized. The panel therefore finds that the ministry reasonably determined that the appellant was not eligible to receive coverage under sections 69 and 70 of the EAR and sections 5 and 6 of Schedule C. As a partial denture is not an item listed in sections 2 or 3 of Schedule C, the panel finds that the ministry reasonably determined that section 76 of the EAR did not apply. Based on the foregoing, the panel finds that the ministry's decision to deny the appellant's request for coverage for partial denture was a reasonable application of the legislation in the circumstances of the appellant. The panel therefore confirms the ministry's decision. EAAT003(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.