PART C-D e cis ion under Appeal T he Ministry o f S ocial Dev elop ment and So c i a l Innovation (the ministry) r dated 8 Ju ly 2014 det ermined t h at the a ppe llant was ex c es s of t hos e provided at Schedul e C of the Em p Disabili ties Reg u l at ion (EAPWDR) fo r emer gency dental services provided to D ecember 2 013 a nd not eligible for funding for implant Schedule of the EAPWDR. P A RT D -Rel evant Legi s lat i on Employm ent an d Ass i s tan c e for P erso ns wit h D isab · . . . E A P WDR Schedule C, Section s 4 an d 5 . EAAT 003(10/06/01) I APPEAi e consid eration decisi on no t el ig ib le for ad dit ional funding for fee s in l oyment an d Ass i s t a n ce f or Persons wit h him at the end of s beca use they are not allowe d under a ny iliti e s R egu l a t ion (EAPW D R), s ec tion s 6 3 and 6 4 .
I APPEAL PART E -Summary of Facts The appellant was not in attendance at the hearing. After confirming that the appellant was notified, the hearing proceeded under section 86(b) of the Employment and Assistance Regulation (EAR). The following evidence was before the ministry at the time of reconsideration: • In 201 O the appellant was the victim of a serious assault that left him in a coma with major injuries to his jaw that was shattered, losing front teeth, and deaf in one ear. At the time, 2 metal plates and a hinge were incorrectly placed in his jaw and caused the appellant 3 years of excruciating pain. In 2013 Crime Victims Assistance (CVA) awarded the appellant funding for 50% of all costs to repair all the damages that were done provided the work is completed before the end of 2014 because of time limitation. • A letter dated 20 November 2013 by the province of BC (CVA) to the appellant's dentist indicates acceptance of the program submitted by the dentist and providing 50% of funding for the treatment proposed. The total fees submitted were $8,795.00 while the provincial fee rate was $8,691.80, based on which the CVA would cover 50% or $3,345.90. • Another letter by the CVA dated 6 December 2013 indicates approval for another tooth extraction at a cost of $190.00 for which it will cover 50%. • In December 2013 a dental treatment plan was elaborated for the appellant, spanned over 1 year starting 24 December and the appellant is claiming fees for stage 2 of 4. • On 24 December 2013, a first treatment was performed, the 'surgery', consisting of the removal of the incorrect metal plates, the extraction of a number of troublesome teeth and gum reconstruction. • An account statement dated 6 March 2014 refers to those services performed on 24 December 2013 for which the total dentist fees were $2,431.85 and for which the ministry indicated being able to cover $814.14, as per ministry rates in Schedule C of the EAPWDR for basic dental services. However, the ministry determined that those services qualified as emergency dental services and $739.14 were transferred from the appellant's basic dental plan to his emergency dental plan since that amount was the maximum the ministry could approve according to its rates determined by Schedule C for emergency dental services. • A printout of a Pacific Blue Cross (PBC) Standard Dental Claim Form dated 24 December 2013 for dental services performed that same day for a total of $2,395.00 signed by the dentist and the appellant. • A letter dated 30 December 2013 by the appellant's dentist indicating the treatment performed and that the appellant required immediate care to remove all sources of infection and urging PBC to provide benefits to the appellant "as he required the necessary treatment urgently". • A printout of a PBC Standard Dental Claim Form dated 31 December 2013 indicating a total fee of $36.85 for dental services. • A copy of a cheque dated 21 January 2014 by the province of BC (CVA program) to the appellant's dentist for dental services rendered to the appellant on 24 December 2013 for an amount of $1, 197.50. • A series of documents (11 pages) appearing to be PBC file printout lists dental services claims received for 2013 and up to 11 February 2014 for a total of approved claims of $971.1 9 while the total claim is $4,178.65. • An Account Statement by the appellant's dentist dated 6 March 2014 indicates that dental services provided to the aooellant from 16 Auqust 2013 until 26 Februarv 2014 cost a total of EAA T003(10/06/01)
I APPEAL $2,563.70, while CVA paid $1,292.50, the insurance (PBC) $814.14 and the appellant $500.00 leaving a balance of $79.79 due at that date. • A document titled "Proposed Treatment Plan" dated 6 March 2014 by the appellant's dentist for the next stage of his treatment indicates the following: o Code 79941 Implant, single stage X 3 at $2,000.00 each; o Code 92304 Deep sedation 4 units at $400.00 o Total: $6400.00 o Handwritten on the document is indicated that the CVA will pay $3,148.00 and the ministry $55.63 for a total of $3,204.03, leaving the appellant with an amount of $3,195.97 "this is the amount not covered and will be patient portion". • In his request for reconsideration dated 23 June 2014, the appellant requests information about why the ministry rejected his claim. He also indicates the following: o He received a significant bill for the December 2013 surgery and while CVA paid 50% of the fees, the remaining amount was significant and the ministry denied payment for emergency dental services and used his basic dental services' amount to pay, leaving him to borrow money from his employer to cover the balance. o Since the surgery done in December 2013, the appellant stated he had less than ½ the normal dental pains he was suffering before and almost no headaches since. He had suffered severe migraines and excruciating pain for over 3 years prior to the surgery. He still suffers great pain when eating and some discomfort continually but it is minimal compared to what he had previously endured. o He indicated that the total amount he will have to pay for that dental plan after CVA pays half will be approximately $13,000. In his Notice of Appeal dated 21 July 2014, the appellant indicated that he then understood the funding that the ministry can provide through the dental program. He realized the program does not allow payment for any implants but suggests 2 of the implants could be attached to a bridge that would be inserted after the implants are in and that there is bridgework funding in the ministry dental program. He explained that because he is missing 4 teeth and a bridge would be attached to the 2 adjacent teeth, it would make a 6 tooth bridge that would be unsound and not stable enough without a secure anchoring. He acknowledged that the other implants would not be admissible as not related to bridgework. EAAT 003(10/06/01)
I APP EA PART F Re ason s f or Pa nel Decisio n The iss u e u nd er appe al in this ca s e i s whethe r the min istry's d e cision t hat the appellan t was no t eligible for additional f u n ding for fees in exce ss of those pro v i d ed a t Schedule C of th e EAPWDR for emerg ency de ntal ser v ice s prov i d ed to him at the end of De ce mbe r 2 013 and not e l i gi ble for fundi ng for im plan t s b e caus e the y a re not allowed un de r any S chedul e of the EAPWDR w as either a reas o nab le app licatio n of t he legi s latio n o r r easonably suppo r te d by the evidence. The ap plicable le gislatio n i s as fol lows: For general dent a l s uppl e ments: 63 (1 ) S ubjec t t o sub section s (2) and (3 ) , th e mi nister may provid e a ny h eal th sup plem ent set o ut in sec tion 4[dent al s u pplemen ts] of S c he dule C that is p r ovid e d to o r for a family unit if the hea lt h s uppleme nt is pr ovided to or for a p e rson i n the fa mily unit who is elig ib le for h ealth sup pleme nts under (a) s e ction 6 2 (1) (a) , (b) ( iii), (d) or (e) [g e neral h e al t h s u pple m e nts], ... F or emergency d ent al sup plem ent : 64 (1) Subj e ct t o subsecti ons (2 ) a nd (3), the mi ni s te r may pr o vid e an y health supp l eme nts set ou t in s ec tion 5 of Schedul e C to or for a fam ily unit i f the health sup plem ent is pr ovided t o or for a person i n the f a m i l y unit who is el i gibl e for he a l th su pp leme nts u nder ( a ) secti o n 62 ( 1) (a ) , (b) (ii i), (d) or (e ) [g eneral hea lt h suppl eme nts] , . .. Sch edul e C def ine s servic es to be pr ovided: 1 In this Sc hedule : ... "ba s ic de ntal service" me a ns a d e nta l se r vice that (a) if prov ide d by a d entist, (i) is set o ut i n t he Schedule o f Fee A l lo w anc es -Dentis t that is effe cti ve Apr il 1, 20 1 0 a nd is o n f ile w i t h the of fic e of th e deputy minis t er, an d ( i i) i s p rovided a t th e r ate set o u t fo r the s ervi ce i n that Schedul e , ( b ) if p rovid ed by a dentur ist, (i) is set ou t in the Sch ed ul e o f Fee Allowanc es -De n turis t that is e ffect ive Apr il 1 , 20 1 0 an d is on fi le with the office o f th e deputy mi ni s te r, an d (ii) is provided at th e rate s e t out for the serv ice in that Schedule, and (c ) i f provided by a dental hygienist, (i) is set out in the Schedule of Fee Allowances -Dental Hygienist 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 for the service in that Sche dule; ... "emergency dental service" means a dental service necessary for the immediate relief of pain that, (a) if pr o vided by a dentist, (i) i s set out in the Sche dule of Fee Allowances Emerge n c y 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 p rovided b y a dentu r ist, (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; ... EAA T003(10/06/01)
4 (1) I n this se ction, " pe riod" means (a) in respect of a depen dent chil d, a 2 year p er i od subsequ ent J anu ary 1 i n an od d numbered year, an (b} in respect of a person n ot r ef er red to in par agraph 2 003 and on each subsequent January 1 in an odd n (1. 1) The he alth su pplements t h at m ay be pa id u nder regulati on are bas ic dental services to a maximum of (a) $1 400 e ach p eriod, if provided t o a dependent child, (b} $1 000 p erson no t ref erred to in par agraph ( a ) , ... 5 The health supp l ements that m a y be paid for under section 64 [emergency dental and dentur supp lements] of t his r eg ulation are emergency dental services. The min istry a r g ued that the legislation does not auth excess of what is alrea dy provided for those dental Sch edule of Fee Allo wances -Dentist. Further the ministry indicated ser vic e s p r ovided to the a pp el la n t i n Dec ember 2 0 13 were for deter m ined those dental se rvic e s were eme rgenc y s. 64 of the EAPWDR ins tead of s. 63 (basi c d enta l appell ant' s ba s ic den t al service s of $73 9 .14. Since f unde r s. 5 of Sched ule C of the E APWDR , the l e g islation did payment of any fee s in excess or a ny proce dur e t hat that t he 3 i mplants requ ested b y th e app e llan t for phas a pproved f o r p ayment as th ey are not set out in any o e ven if t h ey could b e co nsi der ed as part of bridgew a pproved p r ocedure . The appe l lant a rgued tha t the surgery perf ormed a nd th de ntal tre atme nt p lan and to rel ieve his p ain and the whol e. Init iall y he a r gued that t h e f unds f o r hi s Dece de ntal services a l lowan ce s but rathe r fro m t he em ergen depletin g his basic ser vices; the pa ne l note s th a t the mi appellant's cl aim in that respect. He further argu ed that the whole program would cost him ove $27,000.00 and that the CVA would only cover½ of those costs, leaving him with roughly $13 to pay. He requested that the ministry provide him with a l a ltern a tiv ely , that his allowable earnable income be applied completely to pay for dental work. Fin ally, th the implant s c ou ld not be approved for funding, he requested that 2 of the implants be part of bridgewo rk that is ot herwise el igible for fundin g by t h because 4 of h is f r ont t e eth are mi ssing and attaching the b feasible as it would end up being a 6-tooth bridge, not providing a secure anchoring, while the 2 implants would ensure secure anchoring. The panel notes that this appeal included information about a comprehensive 4-phase treatment plan that could cost over $27,000.00 but that the reconsideration decision was only dealing with 2 specific is sues that ar e part o f that treatment plan: the dental serv 2 013 /ohase 1) a nd the 3 implant s t h a t wou ld be part of ohase 2. The panel EAAT003(10/06/01) I A P PEAl 7 beg inning on J anuary 1 , 20 0 9 , and on each d (a), a 2 year period beginning on Jan uary 1, umbered year. section 63 [d e nta l su p plements] of this eac h period, if provided to a e or iz e any payment for d ental serv ices t h at are in services in Schedule C of the EAPW DR and the t hat when it re alized th e d ental t he i mmedi ate relief of pain , i t w a s dent al serv ices a nd fees we re deter m ined u nd er services) which allo wed a trans fe r b ack to the e es f o r those d ent al s e rvi c es w ere d etermin e d not autho rize the m ini stry to ap pr ove the w a s not covered . Finally, the min is try ar g ued e 2 of h is 4 ph as e tre atment c ould not be f the mini str y's Schedule s under the E APW D R, or k si nce the y are no t part of any bridgew ork e impl a nts w ere n e ces sary for h is 4-phase min ist r y s houl d only con si d er the plan as a m ber s urger y s hou ld n o t c ome f r om h is ba s ic · cy denta l services allowan c es an d no t ni stry di d re ctify this is sue an d accepted the r , 0 00 .0 0 oa n for those d e nt al services or, increased and that the additio nal amounts be e a ppellant ar gued that while he understood why e m inist ry as those implant s a re n ecessary ridge t o the 2 tee t h o n either si de is no t i ces provided t o the appe llant in Dece mber will therefore limit its
findings to those two issues . Fees in excess for December 2013 dental servic e s: The panel fi nds t hat the evidence sho ws that the dental s by his dentist in Dece mber 2013 were to reli e ve p ain suffering ex c ru c iat ing pain for 3 y ears and the s urgery ministry's de terminatio n t h at tho se serv ices q ualifi ed The panel notes that t h e l e g islation i s clea r as to what specifically determines t h at health sup plements must EAPWDR and no flex ibility is pro vide d to t he ministr Sc h e dule of Fee Allowances -Emergency De n tal -Dentist Thu s, t he panel f inds that the ministry reasonably dete excess of t he pre-dete rmined f ees listed in the legislation. Implants for pha se 2 of the appellant's dental t re a tment T h e appellant ack nowledged that im plant s were n o by th e minis t r y und er the legislatio n b ut arg ue d that w hile the m in is try in dic at e d at the he ari ng tha t th e proposed rout e pr o p o s ed b y the appellant's d entist a nd th at o den t ures, where f ees c oul d be appr o v ed acc or d ing to S t hat now here in the Schedu le of Fe e All owances -the panel finds th e min ist ry reas onab l y deter mined of denta l s er vices, as propo sed by the appel la nt f or Earning exemp tion I l o an: The pa nel fin ds t hat there i s no p rovisi on by legisl ation s peci a l agree ment with th e app e ll an t all ow ing him to have additiona l am ou nt s earne d to p ay for den t al servic es mi n i stry to l e nd to th e ap pellant any fund s to pa y f o min is try reason ably de t erm ined it had no author ity to enter into any of th Conc lusion: Therefore, the panel finds that the ministry's deci sion enactment in the cir cumstances of the appe llant and confirms EMT003(10/06/01) I A P PEAL erv ices (surgery) provided to the appellant as the appe lla nt ex plained h e had been r eally d i d alle viate his pain and thus finds the as eme r g ency dental serv i c es was reasonable. f unding can b e prov ided: s. 64 o f the EAPWDR b e s et out in s. 5 o f Sc hedule C of the y to go over and beyond those fees listed in the or cover procedures that are not listed. r m in ed it had n o authority to provide fees in plan: t lis ted i n the dental services that can be appro ved they coul d b e c onsidered a s part of brid g e work implants were par t of a v er y exp ens ive th e r routes could have bee n ex plored, l ike chedu le C of the EAPWDR. Th e pa n el n otes Denti st can fees for i mpl ants be fou nd a n d th u s , it coul d not cov er t hos e fees for imp lant s as part phase 2 o f his trea tment plan. t ha t coul d autho rize the ministry t o enter int o a an e ar n in g e x emption a nd u se the n or is there an y dispositio n t h at wo u ld a llow th e r his dental se r v ic es and thus co nclude s that the os e 2 sp e cial a greements. was a reas o nable application of the applicable th e de cision.
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.