APPEAL I PART C -Decision under Appeal The decision under appeal is the reconsideration decision of the Ministry of Social Development and Social Innovation (the ministry) dated 04 March 2014 that determined that the appellant is ineligible for reimbursement for laxatives as a medical supply. The ministry held that, in accordance with the ministry's online resources, a request for general health supplements must be pre-approved by the ministry and the ministry does not accept payment responsibility, except in cases of a life-threatening emergency, for medical supplies purchased prior to approval. PART D -Relevant Legislation Employment and Assistance for Persons with Disabilities Regulation (EAPWDR), Schedule C, section 2. EAAT 003(10/06/01)
P A R T E S u m m a r v 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 • A 2 7 p a g e p a t i e n t m e d i c a l e x p e n s e r e p o r t f r o f r o m 1 8 A u g u s t 2 0 1 0 t o 2 7 J a n 2 0 1 4 . B o w e l c w r i t t e n n o t e i n d i c a t e s t h a t t h e s e t o t a l $ 5 4 8 . 8 1 • F r o m t h e m i n i s t r y ' s f i l e s , a s s e t o u t i n t h e m i n t h e H e a l t h A s s i s t a n c e B r a n c h c o n f i r m e d t h a t c a r e p r o d u c t s i n O c t o b e r 2 0 1 O b e c a u s e h e w a u t h o r i t y . S i n c e A u g u s t 2 0 1 3 h e h a s b e e n l i v i • F r o m t h e m i n i s t r y ' s f i l e s , a s s e t o u t i n t h e r e c o q u a d r i p l e g i c m a n i n h i s 4 0 ' s i n r e c e i p t o f d i s a a n d c o v e r a g e o f h i s s t a y a t a p r i v a t e l y o w n e d a u t h o r i t y . T h e H e a l t h A s s i s t a n c e B r a n c h h a s w i t h l a x a t i v e s a s o f t h e f a l l o f 2 0 1 3 . • T e l e p h o n e l o g b y t h e R e c o n s i d e r a t i o n O f f i c e r a t t h e a p p e l l a n t ' s c a r e f a c i l i t y , w h o p r o v i d e d t h f r o m a r e h a b i l i t a t i o n h o s p i t a l a n d w a s a d m i t t e c a r e f a c i l i t y p r o v i d e s 2 4 / 7 n u r s i n g , 3 m e a l s / d a i n c o n t i n e n c e p r o d u c t s , O T , d i e t i c i a n s a n d r e c p r e s c r i p t i o n m e d i c a t i o n s o r o v e r t h e c o u n t e r m p r o v i d e d . • 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 w r i t e s t h a t t h e i n f o r m a t i o n t h a t t h e m a l o n g t e r m c a r e f a c i l i t y i n A u g u s t 2 0 1 0 , n o t A o f t h e 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 e r e q u e 2 0 1 0 , a f t e r h e h a d b e e n m o v e d f r o m a n e x t e n c a r e s u p p l i e s w e r e n o l o n g e r c o v e r e d b y t h e h i s r e q u e s t i n g r e i m b u r s e m e n t f o r i s o n l y f o r t h e H e a l t h A s s i s t a n c e B r a n c h . T h e y a r e m a r k e d o t o t a l o f $ 5 4 8 . 8 1 T h e a p p e l l a n t ' s N o t i c e o f A p p e a l i s d a t e d 1 4 M a r c h 2 w r i t e s t h a t h e m e e t s a l l t h e c r i t e r i a t o h a v e t h e b o w e l T h i s i s c o n f i r m e d b e c a u s e h e w a s a p p r o v e d f o r t h e s e r e s u l t o f a n a p p l i c a t i o n s u b m i t t e d b y t h e r e h a b i l i t a t i o n s i n c e A u g u s t 2 0 1 0 , e v e n t h o u g h p r e v i o u s a p p l i c a t i o n T h e a p p e l l a n t e x p l a i n s t h a t h e s p e n t 1 O m o n t h s a t a r e t u r n e d t o h i s h o m e t o w n w h e r e h e w a s t e m p o r a r i l y b o t h t h e s e f a c i l i t i e s , h i s b o w e l c a r e s u p p l i e s w e r e i n c t e r m c a r e f a c i l i t v . H e w a s n o t a w a r e t h a t h i s b o w e l c a E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )A P P E A L I i n c l u d e d t h e f o l l o w i n g : m t h e a p p e l l a n t ' s p h a r m a c y , l i s t i n g h i s e x p e n s e s a r e p r o d u c t s a r e n o t e d w i t h a n " x " a n d a h a n d . i s t r y s e c t i o n o f t h e 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 e a p p e l l a n t w a s d e n i e d c o v e r a g e f o r b o w e l a s i n a n e x t e n d e d c a r e f a c i l i t y f u n d e d b y a h e a l t h n g i n a l o n g t e r m c a r e f a c i l i t y . n s i d e r a t i o n d e c i s i o n : t h e a p p e l l a n t i s a b i l i t y a s s i s t a n c e o f $ 9 5 / m o n t h c o m f o r t a l l o w a n c e c a r e f a c i l i t y w h e r e h i s b e d i s f u n d e d b y a h e a l t h a p p r o v e d a n d h a s b e e n p r o v i d i n g t h e a p p e l l a n t d a t e d 0 6 M a r c h 2 0 1 4 . S h e s p o k e w i t h a p e r s o n e f o l l o w i n g i n f o r m a t i o n : a ) t h e a p p e l l a n t c a m e d t o t h e c a r e f a c i l i t y o n 1 7 A u g u s t 2 0 1 O ; b ) t h e y , n u t r i t i o n a l s u p p l e m e n t s , w o u n d c a r e , r e a t i o n a l a c t i v i t i e s ; c ) t h e f a c i l i t y d o e s n o t p r o v i d e e d i c a t i o n s ; n o s t o o l s o f t e n e r s a n d l a x a t i v e s a r e d a t e d 1 7 F e b r u a r y 2 0 1 4 . U n d e r r e a s o n s , t h e i n i s t r y h a s o n f i l e i s i n c o r r e c t . H e w a s m o v e d t o u g u s t 2 0 1 3 a s i n d i c a t e d o n t h e m i n i s t r y s e c t i o n s t f o r c o v e r a g e w a s o r i g i n a l l y m a d e i n O c t o b e r d e d c a r e f a c i l i t y a n d d i s c o v e r e d t h a t t h e b o w e l e a l t h a u t h o r i t y . H e n o t e s t h a t t h e a m o u n t t h a t h e i t e m s t h a t h a v e s i n c e b e e n a p p r o v e d b y t h e n t h e p h a r m a c y ' s m e d i c a l e x p e n s e r e p o r t , w i t h a 0 1 4 . I n a n a t t a c h e d s u b m i s s i o n , t h e a p p e l l a n t c a r e p r o d u c t s c o v e r e d u n d e r t h e E A P W D R . p r o d u c t s e f f e c t i v e 1 2 S e p t e m b e r 2 0 1 3 a s a h o s p i t a l . H i s m e d i c a l s i t u a t i o n h a s n o t c h a n g e d s w e r e d e n i e d . r e h a b i l i t a t i o n h o s p i t a l a n d t h e n i n M a y 2 0 1 O p u t i n a h e a l t h a u t h o r i t y e x t e n d e d c a r e f a c i l i t y . A t l u d e d . I n A u g u s t 2 0 1 O h e w a s m o v e d t o t h e l o n g r e s u n n l i e s w e r e n o t c o v e r e d u n t i l h e r e c e i v e d
I APPEAL an invoice from the pharmacy. The long term care facility said that they would not supply them, the health authority said it was up to the ministry and the ministry said it was the health authority's responsibility, He was forced to borrow some money from his mother, which she could not afford, in order to pay some of the pharmacy bill, otherwise they would no longer supply anything not covered by Pharmacare. When the supplies are not available and used correctly, he has spent in excess of 3 hours sitting on the toilet. On a number of times he has gone 5 days without a bowel movement. The supplies are vital to his health and well-being. Attached to the notice of appeal are the following: • A drug list from the rehabilitation hospital discharge summary dated June 2010. • A drug list from the pharmacy dated October 2010. • A medication profile from the rehabilitation hospital dated 09 August 2013. • A letter from the ministry to the appellant dated 12 September 2013 advising him that the ministry had approved his request for a number of bowel care products. At the hearing, the appellant described his frustration with his repeated attempts to have the ministry agree to cover his bowel care product needs. He first applied in the fall of 2010, but was denied because the ministry thought that he was living in an extended care facility, not a long-term care facility where these products are not covered. Since then, he had made repeated attempts to have these products covered by the ministry, including making visits to the local office. Nobody he talked to seemed willing or able to help him get the coverage. It was only when he went back to the rehabilitation hospital for a brief stay last summer for surgery and talked to a social worker there, explaining his difficulties and situation, that within a week the ministry finally approved coverage beginning in September 2013. The appellant stated that the lack of coverage had created a lot of stress for him and his family, both financially and emotionally. The lack of coverage resulted in his family having to step in and cover several thousand dollars in costs which they could not afford, and the requested amount of $548 is the amount still owed. In answer to a question, the appellant explained that he did not request the reconsideration of the October 2010 decision because he was in a lot of stress and lost the paperwork and doing so would have resulted in more stress. The ministry stood by its position at reconsideration. The ministry representative stated that she had at hand the ministry's decision letter from October 201O denying the appellant's original request. The letter offered the appellant the opportunity for reconsideration of that decision at that time. The panel finds that the information provided by appellant in his Notice of Appeal and in his testimony at the hearing, and by the ministry at the hearing, is in support of the evidence before the ministry when it made the decision under appeal, clarifying the background to the appellant's original request, its denial and subsequent approval by the ministry. The panel therefore admits as evidence the information provided by GP, the appellant and the witness under section 22(4) of the Employment and Assistance Act. EAAT003(10/06/01)
APPEAL I PART F -Reasons for Panel Decision The issue in this appeal is whether the ministry was reasonable in denying the appellant's request for reimbursement of laxatives as a medical supply. More specifically, the issue is whether the denial of this request on the basis of the ministry's policy set out in its onl ine resources -that a request for general health supplements must be pre-approved by the ministry and the ministry does not accept payment responsibility, except in cases of a life-threatening emergency, for medical supplies purchased prior to approval -is reasonably supported by the evidence or is a reasonable application of the legislation in the circumstances of the appellant. The applicable legislation is from the EAPWDR: Effective date of eligibility 23 (5) A family unit is not eligible for any assistance in respect of a service provided or a cost incurred before the calendar month in which the assistance is requested. How a request to reconsider a decision is made 71 (1) A person who wishes the minister to reconsider a decision referred to in section 16 (1) [reconsideration and appeal rights] of the Act must deliver a request for reconsideration in the form specified by the minister to the ministry office where the person is applying for or receiving assistance. (2) A request under subsection (1) must be delivered within 20 business days after the date the person is notified of the decision referred to in section 16 ( 1) of the Act and may be delivered by (a) leaving it with an employee in the ministry office, or (b) being received through the mail at that office. And from Schedule C of the EAPWDR: General health supplements 2 ( 1) The following are the health supplements that may be paid for by the minister if provided to a family unit that is eligible under section 62 [general health supplements] of this regulation: (a) medical or surgical supplies that are, at the minister's discretion, either disposable or reusable, if the minister is satisfied that all of the following requirements are met: (i) the supplies are required for one of the following purposes: (A) wound care; (B) ongoing bowel care required due to loss of muscle function; (C) catheterization; (D) incontinence; (E) skin parasite care; (F) limb circulation care; (ii) the supplies are (A) prescribed by a medical practitioner or nurse practitioner, (B) the least expensive supplies appropriate for the purpose, and (C) necessary to avoid an imminent and substantial danger to health; (iii) there are no resources available to the familv unit to oav the cost of or obtain EM1 003(10/06/01)
APPEAl ... I the supplies; The ministry's policy is set out on it's Online Resources under Health Supplements and Programs/Medical Supplies/Policy. The relevant part of the policy statement is set out below: Medical or surgical supplies are provided only to clients who are eligible for general health supplements. [see Related Links -Health Supplement Summary] Medical or surgical supplies may be provided to eligible clients when the ministry is satisfied that all of the following requirements are met: • the supplies are prescribed by a medical practitioner or nurse practitioner • the supplies are the least expensive and appropriate for the purpose • the supplies are disposable or reusable where appropriate • the request is pre-approved by the ministry (the ministry does not accept payment responsibility, except in cases of a life-threatening emergency, for medical supplies purchased prior to approval) • only the following can be considered: [includes] o ongoing bowel care required due to loss of muscle function The position of the ministry, as set out in the reconsideration decision, is that the Health Assistance Branch has approved the appellant for laxatives as of the fall of 2013. However the ministry cannot consider reimbursement for over-the-counter medications in the appellant's case laxatives -from the provided list dated from August 2010 to January 2014. In accordance with the ministry' s policy, any request for general health supplements must be preapproved by the ministry and ministry does not accept payment responsibility, except in cases of a life-threatening emergency, for medical supplies purchased prior to approval. At the hearing, the ministry also argued that, when the appellant's original request was denied in October 2010, he was advised of his right to request a reconsideration and did not do so, and therefore the present proceedings cannot be used to revisit a decision taken back in 2010. The appellant's position, as submitted at the hearing, is that his situation has not changed since October 201 O: the supplies are prescribed by a medical practitioner and are necessary to avoid an imminent and substantial danger to his health. This has been recognized by the Health Assistance Branch, which finally approved coverage for the supplies in September 2013, but only after the intervention of the social worker from a rehabilitation hospital who was able to demonstrate that the October 201 O decision was wrong, based on incorrect information that he was staying at an extended care facility, not a long-term care facility where the supplies are not provided. As the ministry has finally recognized its mistake, the appellant submits that it is only fair that the ministry reimburse the costs he has incurred that should've been covered by the ministry since October 2010. Panel findings The panel notes that section 2 of Schedule C of the EAPWDR lists general medical supplements "that may be paid for by the minister. .. " Unlike section 3 of Schedule C, which deals with medical equipment and devices and which requires the pre-approval of the minister, section 2 does not contain such a pre-approval provision. More generally, however, section 23(5) of the EAPWDR clearly states that an aoolicant for a benefit "is not eliqible for anv assistance in respect of a service EMT003(10/06/01)
I APPEAL provided or a cost incurred before the calendar month in which the assistance is requested." The ministry's policy is consistent with section 23(5), while recognizing that there may be circumstances, namely "cases of a life-threatening emergency," where pre-approval is not possible. In the present appeal, the appellant is requesting reimbursement of expenses incurred between his original request, denied in October 2010, and when a subsequent request was approved in September 2013. The panel finds that, in accordance with section 23(5) of the EAPWDR, the ministry was reasonable in denying reimbursement of costs incurred before the request that gave rise to the September 2013 approval for ongoing funding. The appellant's position is also that he should be reimbursed the costs incurred before September 2013 because in his view the ministry clearly erred in denying his request in October 2010. The panel is mindful of the general principle that it is the responsibility of an applicant seeking assistance or a supplement under the legislation -in this case the appellant applying for coverage for bowel care supplies -to provide the information required to establish eligibility. The appellant had the opportunity to request a reconsideration and provide the ministry with the information concerning the type of facility where he was staying and what was provided and not provided. The appellant did not exercise his reconsideration rights, and the 20 business day time limit for seeking reconsideration of the decision under section 71 of the EAPWDR has long since passed. The panel does not have the jurisdiction to revisit that decision. Accordingly, the panel finds that the ministry's decision that the appellant was not eligible for reimbursement of medical supplies was a reasonable application of the legislation in the circumstances of the appellant. The panel therefore confirms the ministry's decision. EAAT 003(1 0/06/01)
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