I APPEAL PART C -Decision under Appeal Under appeal is the March 24, 2014 Ministry of Social Development and Social Innovation Reconsideration Decision denying coverage for a root canal and a non-bonded composite core, under sections 63, 64, 69, and schedule C of the Employment and Assistance for Persons with Disabilities Regulation. A request for reconsideration with respect to a crown was not granted on the basis no minlstry decision had taken place about the appellant's eligibility for this dental supplement, because a request for a crown had not been submitted to Pacific Blue Cross. PART D -Relevant Legislation Employment and Assistance for Persons with Disabilities Regulation (EAPWDR) section 63, 64, 69 and schedule C, and Schedule of Fee Allowances -Emergency Dental-Dentist EMT003(10/06/01)
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 w • A s a P e r s o n w i t h D i s a b i l i t i e s , t h e a p p e l l a n t i s e a n d 6 4 a n d S c h e d u l e C , s e c t i o n s 4 a n d 5 o f t h e E A P • F e b r u a r y 1 2 , 2 0 1 4 l e t t e r f r o m t h e a p p e l l a n t , a t d e t e r m i n a t i o n f o r m w i t h t h e c o s t o f a r o o t c a n a l a n d c n e c e s s a r y t o a l l e v i a t e i n f e c t i o n a n d p r e v e n t w o r s e n i n h e r d e n t a l c o v e r a g e w o u l d n o t c o v e r t h e c o s t . • F e b r u a r y 2 7 , 2 0 1 4 l e t t e r f r o m t h e a p p e l l a n t ' s d t h e r a p y w a s n e e d e d , a n d t h e t o o t h w a s c o l d s e n s i t i v e • M a r c h 7 , 2 0 1 4 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 , i n w a n d c r o w n s h e w o u l d e x p e r i e n c e m o r e d a m a g e t o h e t h r e a t e n s h e r h e a l t h . S h e s a i d s h e s u f f e r e d a h e a r t a i n 2 0 0 5 , a n d w a n t s t o m a i n t a i n h e r d e n t a l h e a l t h s o h • M i n i s t r y ' s s c h e d u l e o f f e e a l l o w a n c e s f o r c r o w n • 2 0 p a g e M i n i s t r y o f S o c i a l D e v e l o p m e n t " D e n t o f s e r v i c e s a n d f e e a m o u n t s u n d e r t h e h e a d i n g S c h e D e n t i s t E f f e c t i v e A p r i l 1 , 2 0 1 0 . W i t h i n P a r t C P r e a m ( i . e . , d e n t u r e s , r o o t c a n a l t r e a t m e n t , r e s t o r a t i o n s i n e c o v e r e d a n d a n y w o r k b e y o n d t h e i m m e d i a t e r e l i e f o f • A p p e l l a n t ' s d e n t a l c l a i m s h i s t o r y , i n d i c a t i n g f i l l i t h e r a p y a n d p r e f a b r i c a t e d p o s t i n s e r t e d F e b r u a r y 1 9 • T h e m i n i s t r y p a i d $ 9 8 9 . 9 6 f o r b a s i c d e n t a l s e r v f r o m A p r i l 9 , 2 0 1 3 t o F e b r u a r y 6 , 2 0 1 4 . E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )I A P P E A L # a s l i g i b l e f o r d e n t a l s u p p l e m e n t s u n d e r s e c t i o n s 6 3 W D . t a c h i n g a F e b r u a r y 6 , 2 0 1 4 d e n t a l p r e r o w n f i t t i n g , s t a t i n g t h e p r o c e d u r e s a r e g , a n d r e q u e s t i n g $ 8 5 8 e x t r a c o v e r a g e b e c a u s e e n t i s t , s a y i n g b e c a u s e o f d e e p d e c a y , r o o t c a n a l a n d e x t r e m e l y p a i n f u l t o p e r c u s s i o n . h i c h t h e a p p e l l a n t s a i d w i t h o u t t h e r o o t c a n a l r t e e t h a n d g u m s , l e a d i n g t o i n f e c t i o n t h a t t t a c k i n 2 0 0 4 a n d a l m o s t d i e d f r o m d i v e rt i c u l i t i s e r g e n e r a l h e a l t h d o e s n o t d e t e r i o r a t e . a n d b r i d g e w o r k , e f f e c t i v e A p r i l 1 , 2 0 1 0 . a l S u p p l e m e n t D e n t i s t " d o c u m e n t i n c l u d i n g a l i s t d u l e o f F e e A l l o w a n c e s E m e r g e n c y D e n t a l b l e i t i s s t a t e d " S e r v i c e s o u t s i d e t h i s s c h e d u l e x c e s s o f t h e 2 y e a r m a x i m u m ) w i l l n o t b e p a i n w i ll n o t b e c o n s i d e r e d . " n g a n d p u l p c a p p i n g i n A p r i l 2 0 1 3 , r o o t c a n a l , 2 0 1 4 . i c e s f o r t h e a p p e l l a n t ' s d e n t a l c l a i m s r e c e i v e d
P A R T F R e a s o n s f o r P a n e l D e c i s i o n T h e i s s u e i s t h e r e a s o n a b l e n e s s o f t h e m i n i s t r y ' s d e c n o n b o n d e d c o m p o s i t e c o r e b e c a u s e t h e l i m i t f o r b a s r e a c h e d , a n d t h e p r o c e d u r e s a r e n o t l i s t e d i n t h e s c h R e l e v a n t L e g i s l a t i o n E m p l o y m e n t a n d A s s i s t a n c e f o r P e r s o n s w i t h ) D e n t a l s u p p l e m e n t 6 3 ( 1 ) S u b j e c t t o s u b s e c t i o n s ( 2 ) a n d ( 3 ) , t h e m i n i s t e s e c t i o n 4 [ d e n t a l s u p p l e m e n t s ] o f S c h e d u l e C t h a t i s s u p p l e m e n t i s p r o v i d e d t o o r f o r a p e r s o n i n t h e f a m i l u n d e r ( a ) s e c t i o n 6 2 ( 1 ) ( a ) , ( b ) ( i i i ) , ( d ) o r ( e ) [ g e n e r a l h e a l t ( b ) s e c t i o n 6 2 ( 1 ) ( b ) ( i ) o r ( i v ) , ( d . 1 ) , ( d . 3 ) o r ( f ) , i f ( i ) t h e p e r s o n i s u n d e r a g e 6 5 a r i d t h e f a m i l y u n i t i s M e d i c a r e P r o t e c t i o n A c t , o r ( i i ) t h e p e r s o n i s a g e d 6 5 o r m o r e a n d a n y p e r s o n i n a l l o w a n c e o r t h e f e d e r a l g u a r a n t e e d i n c o m e s u p p l e m ( c ) s e c t i o n 6 2 ( 1 ) ( b ) ( i i ) o r ( d . 2 ) , ( c . 1 ) s e c t i o n 6 2 ( 1 ) ( c ) , o r ( d ) s e c t i o n 6 2 ( 1 ) ( g ) . ( 2 ) A p e r s o n e l i g i b l e t o r e c e i v e a h e a l t h s u p p l e m e n t u t h e s u p p l e m e n t ( a ) w h i l e a n y p e r s o n i n t h e f a m i l y u n i t i s ( i ) u n d e r a g e 6 5 a n d r e c e i v i n g a p e n s i o n o r o t h e r p a ( i i ) a g e d 6 5 o r m o r e a n d r e c e i v i n g t h e f e d e r a l s p o u s s u p p l e m e n t , a n d ( b ) f o r a m a x i m u m o f o n e y e a r f r o m t h e d a t e o n w h i c h s e r v i c e s o n l y . ) E m e r g e n c y d e n t a l a n d d e n t u r e s u p p l e m e n t 6 4 ( 1 ) S u b j e c t t o s u b s e c t i o n s ( 2 ) a n d ( 3 ) , t h e m i n i s t e s e c t i o n 5 o f S c h e d u l e C t o o r f o r a f a m i l y u n i t i f t h e h e t h e f a m i l y u n i t w h o i s e l i g i b l e f o r h e a l t h s u p p l e m e n t s ( a ) s e c t i o n 6 2 ( 1 ) ( a ) , ( b ) ( i i i ) , ( d ) o r ( e ) [ g e n e r a l h e a l t E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )A P P E A L I i s i o n t o d e n y p a y m e n t f o r a r o o t c a n a l a n d a i c d e n t a l s e r v i c e s f o r t h e p e r i o d h a d b e e n e d u l e f o r e m e r g e n c y d e n t a l s e r v i c e s . D i s a b i l i t i e s R e g u l a t i o n ( e x c e r p t s ) r m a y p r o v i d e a n y h e a l t h s u p p l e m e n t s e t o u t i n p r o v i d e d t o o r f o r a f a m i l y u n i t i f t h e h e a l t h y u n i t w h o i s e l i g i b l e f o r h e a l t h s u p p l e m e n t s h s u p p l e m e n t s ] , r e c e i v i n g p r e m i u m a s s i s t a n c e u n d e r t h e t h e f a m i l y u n i t i s r e c e i v i n g t h e f e d e r a l s p o u s e ' s e n t , n d e r s e c t i o n 6 2 ( 1 ) ( b ) ( i i ) o r ( d . 2 ) m a y r e c e i v e y m e n t u n d e r t h e C a n a d a P e n s i o n P l a n , o r e ' s a l l o w a n c e o r t h e f e d e r a l g u a r a n t e e d i n c o m e t h e f a m i l y u n i t c e a s e d t o b e e l i g i b l e f o r m e d i c a l r m a y p r o v i d e a n y h e a l t h s u p p l e m e n t s s e t o u t i n a l t h s u p p l e m e n t i s p r o v i d e d t o o r f o r a p e r s o n i n u n d e r h s u p p l e m e n t s ] ,
I A P P E A ( b ) s e c t i o n 6 2 ( 1 ) ( b ) ( i ) o r ( i v ) , ( d . 1 ) , ( d . 3 ) o r ( f ) , i f ( i ) t h e p e r s o n i s u n d e r a g e 6 5 a n d t h e f a m i l y u n i t i s r e c e i v i n g p r e m i u m a s s i s t a n c e u n d e r t h e M e cf i c a r e P r o t e c t i o n A c t , o r ( i i ) t h e p e r s o n i s a g e d 6 5 o r m o r e a n d a n y p e r s o n i n t h e f a m i l y u n i t i s r e c e i v i n g t h e f e d e r a l s p o u s e ' s a l l o w a n c e o r t h e f e d e r a l g u a r a n t e e d i n c o m e s u p p l e m e n t , ( c ) s e c t i o n 6 2 ( 1 ) ( b ) ( i i ) o r ( d . 2 ) , ( c . 1 ) s e c t i o n 6 2 ( 1 ) ( c ) , o r ( d ) s e c t i o n 6 2 ( 1 ) ( g ) . S c h e d u l e C H e a l t h S u p p l e m e n t s " e m e r g e n c y d e n t a l s e r v i c e " m e a n s a d e n t a l s e r v i c e n e c e s s a r y f o r t h e i m m e d i a t e r e l i e f o f p a i n t h a t , ( a ) i f p r o v i d e d b y a d e n t i s t , ( i ) i 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 E m e r g e n c y D e n t a l D e n t i s t , t h a t i s e f f e c t i v e A p r i l 1 , 2 0 1 0 a n d i s o n f i l e w i t h t h e o f f i c e o f t h e d e p u t y m i n i s t e r , a n d ( i i ) i s p r o v i d e d a t t h e r a t e s e t o u t i n t h a t S c h e d u l e , D e n t a l s u p p l e m e n t s 4 ( 1 ) I n t h i s s e c t i o n , " p e r i o d " m e a n s ( a ) i n r e s p e c t o f a d e p e n d e n t c h i l d , a 2 y e a r p e r i o d b e g i n n i n g o n J a n u a r y 1 , 2 0 0 9 , a n d o n e a c h s u b s e q u e n t J a n u a r y 1 i n a n o d d n u m b e r e d y e a r , a n d ( b ) i n r e s p e c t o f a p e r s o n n o t r e f e r r e d t o i n p a r a g r a p h ( a ) , a 2 y e a r p e r i o d b e g i n n i n g o n J a n u a r y 1 , 2 0 0 3 a n d o n e a c h s u b s e q u e n t J a n u a r y 1 i n a n o d d n u m b e r e d y e a r . ( 1 . 1 ) T h e h e a l t h s u p p l e m e n t s t h a t m a y b e p a i d u n d e r s e c t i o n 6 3 [ d e n t a l s u p p l e m e n t s ] o f t h i s r e g u l a t i o n a r e b a s i c d e n t a l s e r v i c e s t o a m a x i m u m o f ( a ) $ 1 4 0 0 e a c h p e r i o d , i f p r o v i d e d t o a d e p e n d e n t c h i l d , a n d ( b ) $ 1 0 0 0 e a c h p e r i o d , i f p r o v i d e d t o a p e r s o n n o t r e f e r r e d t o i n p a r a g r a p h ( a ) . E m e r g e n c y d e n t a l s u p p l e m e n t s 5 T h e h e a l t h s u p p l e m e n t s t h a t m a y b e p a i d f o r u n d e r s e c t i o n 6 4 [ e m e r g e n c y d e n t a l a n d d e n t u r e s u p p l e m e n t s ] o f t h i s r e g u l a t i o n a r e e m e r g e n c y d e n t a l s e r v i c e s . E M T 0 0 3 ( 1 0 / 0 6 / 0 1 )
I APPEA Appellant's Position The appellant argues the treatment for which she requests coverage is necessary to alleviate infection that would get worse without treatment, and that with her history of a heart attack and diverticulitis, she wants to maintain her dental health so her general health does not deteriorate. She says she cannot afford the cost, and that the treatment should be assessed as a situation that qualifies for additional coverage when the basic coverage has been exhausted. Ministry's Position The ministry argues section 63 of the EAPWD provides a maximum of $1000 for basic dental services over the two year period ending December 31, 2014, during which $989.96 has been paid, leaving only $10.04. Under section 64 the ministry may provide health supplements set out in section 5 of Schedule C. The health supplements that may be provided for "emergency dental service", defined as a dental service for the immediate relief of pain, are specified in the Schedule of Fee Allowances-Emergency Dental-Dentist. Root canal therapy and a non-bonded composite core in conjunction with crown are not included, and therefore the ministry is not authorized to provide coverage for the root canal and non-bonded composite core. The ministry says it does not have any discretion in this matter. Panel's Decision It is undisputed that $989.96 was paid for the appellant's basic dental services during the two year period which will end December 31, 2014. While the appellant's dentist recommended root canal therapy, EAPWD section 63 and Schedule C limit the amount payable for basic dental services to $1000 in each two year period. Under EAPWD section 64, emergency dental service health supplements may be provided. However, in Schedule C the "emergency dental service" definition limits such services to those listed in the Schedule of Fee Allowances -Emergency Dental-Dentist. Root canals and non-bonded composite cores are not listed, and the document specifically states root canals are not covered. In applying the legislation the ministry does not have discretion, and the panel therefore finds the ministry's decision was a reasonable application of the applicable enactment in the circumstances of the appellant, and confirms the decision. As the request for a crown was not submitted to Pacific Blue Cross (confirmed by the dental office), and consequently there was no ministry decision to be reconsidered, in accordance with section 16 of the EAPWDA there is no reconsideration decision subject to appeal. Therefore, the panel did not address that issue. EAAT003(10/06/01)
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