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 r e c o n s i d e r a t i o n d e 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 ) , d a t e d 0 9 J u l y 2 0 1 4 a p p e l l a n t ' s c o m p l e t e m a n d i b u l a r d e n t u r e a t t h e r a t e D e n t u r i s t , s p e c i f i c a l l y $ 5 8 1 . 2 5 . T h e m i n i s t r y d e t e r m f o r f e e s i n e x c e s s o f t h a t s e t o u t i n t h e S c h e d u l e o f 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 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 i s a b E A A T 0 0 3 ( 1 0 / 0 6 / 0 1 )A P P E A L I 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 D e v e l o p m e n t a n d , w h i c h a p p r o v e d t h e r e p l a c e m e n t o f t h e 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 i n e d t h a t i t i s n o t a u t h o r i z e d t o p r o v i d e c o v e r a g e A l l o w a n c e s D e n t u r i s t . i l i t i e s R e g u l a t i o n , S c h e d u l e C , s e c t i o n s 1 a n d 4 .
APPEA I PART E -Summarv of Facts With the consent of parties, this hearing was conducted in writing pursuant to section 22(3) (b) of the Employment and Assistance Act. The evidence before the ministry at reconsideration consisted of the following: • From the ministry's files: the appellant is designated as a person with disabilities, residing in a care facility and in receipt of a $95 monthly comfort allowance. • A consultation report from a denturist dated 16 May 2014. The denturist writes that it is clear that the appellant needs a lower denture for function of his daily activities and to be able to properly eat and chew. He has an extensive medical history that also tells us this denture is important to not cause more upset or health issues. The denturist attaches a price quote for $1500 (complete mandibular standard, $1000, plus "+L" commercial laboratory procedure, $500). • A letter from a health authority hospital psychiatrist dated 16 May 2014. The psychiatrist writes that without a lower denture, the appellant's ability to properly chew and digest food is compromised; this could lead to a decline in his physical health or him making food choices that do not provide him with a healthy diet. Without his teeth, the appellant's speech is impaired, making it difficult for people to understand him. Given his history of mental illness, and having an intellectual disability, his inability to clearly express himself will cause him stress and anxiety that could lead to a decline in his mental health, possibly leading to hospitalization. The appellant is currently hospitalized because of a decline in his mental health. Not having a full set of teeth could affect his self-image and self-esteem, which could lead to him isolating himself in the community. This social isolation can also lead to a worsening of the symptoms of his mental illness and make it more difficult for his support system to be aware of changes in his physical or mental health. The psychiatrist goes on to write that the circumstances of his loss of his lower denture are not clear, but the appellant experiences some memory loss, and has some difficulty expressing himself. Hospital staff have attempted to search for the lost denture, and have been unsuccessfu I in locating it. • The appellant's Request for Reconsideration, dated 26 June 2014. The appellant gives as reasons that without the requested item, he will not be able to chew food properly. In his Notice of Appeal dated 16 July 2014, the appellant wrote: "I only received $95 per month from PWD and I cannot afford the remaining amount ($918.75). I don't have any family members who could help me. Please reconsider your decision." The following written submissions were received prior to the hearing: • A submission from the appellant dated 24 July 2014. The appellant writes that he is a single man in his mid-50's with a long history of mental illness. He was hospitalized at a health authority hospital before and now he is being transferred to a care facility to work on his rehabilitation. Staff members there are helping him to prepare this submission because he has difficulty in writinq and short-term memorv. He writes that staff at the hospital attempted to EMT 003(10/06/01)
APPEAL I 7 locate is missing lower denture without any success. Due to his memory problem and stress in the midst of being admitted to a psychiatric hospital, he does not remember how and where he lost his lower denture. The balance of his submission goes to argument, listing reasons why the ministry should pay the full costs of the replacement denture (see Part F, Reasons for Panel Decision, below). • A letter from a health authority social worker dated 24 June 2014. The social worker states that although the appellant was granted partial coverage ($581.25) for his denture, he is unable to pay the remaining cost ($918.75). For the duration of the appellant's stay at the care facility, he only receives a comfort allowance of $95 from his PWD status. The social worker writes that the appellant is not employable to earn a substantial amount of money at this time and he does not have any family member who could help. The social worker concludes by stating that upon the appellant receiving the lower denture, the care facility staff will try its best to provide continuous education regarding proper care, storage and maintenance so that he will learn to appreciate not to lose it again. • An e-mail from the ministry dated 06 August 2014, in which the ministry states that its submission will be there reconsideration summary provided in the Record of Ministry Decision. The panel finds that the information provided social worker and the appellant in their submissions on appeal is in support of the information and records before the ministry at reconsideration. Accordingly, the panel admits this evidence under section 22(4) of the Employment and Assistance Act. EAAT 003(10/06/01)
I APPEAL PART F -Reasons for Panel Decision The issue in this appeal is whether the ministry's decision to approve the replacement of the appellant's complete mandibular denture at the rate set out in the Schedule of Fee Allowances -Denturist, specifically $581.25, was reasonable. More specifically, the issue is whether the ministry determination that it is not authorized to provide coverage for fees in excess of that set out in the Schedule of Allowances -Denturist 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 Schedule C of the EAPWDR: Definitions 1 In this Schedule: "basic dental service" means a dental service that (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances -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 for the service in that Schedule, and Dental supplements 4 (1) In this section, "period" means (a) in respect of a dependent child, a 2 year period beginning on January 1, 2009, and on each subsequent January 1 in an odd numbered year, and (b) in respect of a person not referred to in paragraph (a), a 2 year period beginning on January 1, 2003 and on each subsequent January 1 in an odd numbered year. (1.1) The health supplements that may be paid under section 63 [dental supplements] of this regulation are basic dental services to a maximum of (a) $1 400 each period, if provided to a dependent child, and {b) $1 000 each period, if provided to a person not referred to in paragraph (a). (c) Repealed. [B.C. Reg. 163/2005, s. (b).] (2) Dentures may be provided as a basic dental service only to a person (a) who has never worn dentures, or (b) whose dentures are more than 5 years old. (3) The limits under subsection (1.1) may be exceeded by an amount necessary to provide dentures, taking into account the amount remaining to the person under those limits at the time the dentures are to be provided, if (a) a person requires a full upper denture, a full lower denture or both because of extractions made in the previous 6 months to relieve pain, (b) a person requires a partial denture to replace at least 3 contiguous missing teeth on the same arch, at least one of which was extracted in the previous 6 months to relieve pain, or (c) a person who has been a recipient of disability assistance or income assistance for at least 2 vears or a dependant of that person requires replacement dentures. EAAT 003( 10/06/01)
( 4 ) S u b s e c t i o n ( 2 ) { b ) d o e s n o t a p p l y w i t h r e s p e c t p r e v i o u s l y h a d a p a r t i a l d e n t u r e . ( 5 ) T h e d e n t a l s u p p l e m e n t s t h a t m a y b e p r o v i d e d d e s c r i b e d i n s u b s e c t i o n ( 3 ) ( c ) w h o r e q u i r e s ( a ) f e e n u m b e r s 5 2 1 0 1 t o 5 2 4 0 2 p a r a g r a p h ( a ) o f t h e d e f i n i t i o n ' ( b ) f e e n u m b e r s 4 1 6 1 0 , 4 1 6 1 2 , D e n t u r i s t r e f e r r e d t o i n p a r a g r a p t h i s S c h e d u l e . ( 6 ) T h e d e n t a l s u p p l e m e n t s t h a t m a y b e p r o v i d e d r e p l a c e m e n t o f a f u l l u p p e r , a f u l l l o w e r d e n t ( a ) f e e n u m b e r s 5 1 1 0 1 a n d 5 1 1 i n p a r a g r a p h ( a ) o f t h e d e f i n i t i o n ( b ) f e e n u m b e r s 3 1 3 1 0 , 3 1 3 2 0 o r e f e r r e d t o i n p a r a g r a p h ( b ) o f t h S c h e d u l e . ( 7 ) A r e l i n e o r a r e b a s e o f d e n t u r e s m a y b e p r o v i d h a d a r e l i n e o r r e b a s e o f d e n t u r e s f o r a t l e a s A n d f r o m 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 n t u C O M P L E T E D E N T U R E S N o t e : D e n t u r e s a r e a n e l i g i b l e i t e m o n c e e v e r y f i d e n t u r e s w i t h i n f i v e y e a r s o f o r i g i n a l i n s e r t i o n w i l l b y t h e M i n i s t r y . R e f e r t o D e n t u r e P o l i c y . A n y l a b c t h e s t a t e d f e e . A r c h c o d e r e q u i r e d . C o m p l e t e d e n t u r e f e e s i n c l u d e : D I m p r e s s i o n s , i n i t i a l a n d f i n a l j a w r e l a t i o n r e c o r d D T r y i n ; e v a l u a t i o n o R e c o r d s c h e c k D I n s e r t i o n o A d j u s t m e n t s a n d 6 m o n t h s p o s t i n s e r t i o n c a r e i c o n d i t i o n i n g F E E N O . F E E D E S C R I P T I O N F E E 3 1 3 2 0 C o m p l e t e M a n d i b u l a r D e n t u r e 5 8 1 I n t h e r e c o n s i d e r a t i o n d e c i s i o n , t h e m i n i s t r y n o t e s t h r e c e i v e d d e n t u r e s o n 1 7 M a y 2 0 1 2 , w i t h t h e r e c o r d " r e p l a c e m e n t " d e n t u r e s . A s s u b s e c t i o n 4 ( 2 ) o f S c h e d m a y b e p r o v i d e d a s a b a s i c d e n t a l s e r v i c e o n l y t o a y e a r s o l d , t h e a p p e l l a n t w o u l d n o t b e e l i g i b l e f o r a r e m i n i s t r y d r e w u p o n a p r o v i s i o n i n p o l i c y t h a t a l l o w s f r e p l a c e m e n t l e g i s l a t i o n i f t h e d e n t u r e s b e i n g r e p l a c e o r d a m a g e w a s b e y o n d t h e c o n t r o l o f t h e c l i e n t a n d r e s u l t i n c o m p r o m i s e d h e a l t h . T h e m i n i s t r y m a d e a n a p p e l l a n t , a s i t a p p e a r s t h a t t h e l o s s o f h i s d e n t u r e s b e c o m p r o m i s e d w i t h o u t d e n t u r e s . I n t h e r e c o n s i d e r a t i o n d e c i s i o n , t h e m i n i s t r v g o e s o n E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )A P P E A L I t o a p e r s o n d e s c r i b e d i n s u b s e c t i o n ( 3 ) ( a ) w h o h a s t o a p e r s o n d e s c r i b e d i n s u b s e c t i o n ( 3 ) ( b ) , o r t o a p e r s o n a p a r t i a l d e n t u r e , a r e l i m i t e d t o s e r v i c e s u n d e r 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 n t i s t r e f e r r e d t o i n b a s i c d e n t a l s e r v i c e " i n s e c t i o n 1 o f t h i s S c h e d u l e , o r 4 1 6 2 0 a n d 4 1 6 2 2 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  h ( b ) o f t h e d e f i n i t i o n " b a s i c d e n t a l s e r v i c e " i n s e c t i o n 1 o f t o a p e r s o n d e s c r i b e d i n s u b s e c t i o n { 3 ) ( c ) w h o r e q u i r e s t h e u r e o r b o t h a r e l i m i t e d t o s e r v i c e s u n d e r 0 2 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 n t i s t r e f e r r e d t o " b a s i c d e n t a l s e r v i c e " i n s e c t i o n 1 o f t h i s S c h e d u l e , o r r 3 1 3 3 0 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 n t u r i s t e d e f i n i t i o n " b a s i c d e n t a l s e r v i c e " i n s e c t i o n 1 o f t h i s e d a s a b a s i c d e n t a l s e r v i c e o n l y t o a p e r s o n w h o h a s n o t t 2 y e a r s . r i s t : v e y e a r s . T h e r e p l a c e m e n t o f n o r m a l l y n o t b e p a i d o s t s a r e i n c l u d e d i n s n c l u d i n g t i s s u e A M O U N T ( $ ) . 2 5 a t t h e a p p e l l a n t ' s c l a i m s h i s t o r y i n d i c a t e s t h a t h e s h o w i n g t h a t t h e b o t t o m d e n t u r e s w e r e u l e C o f t h e E A P W D R s e t s o u t t h e d e n t u r e s p e r s o n ( b ) w h o s e d e n t u r e s a r e m o r e t h a n f i v e p l a c e m e n t u n t i l J u n e 2 0 1 7 . H o w e v e r , t h e o r e x e m p t i o n s t o t h e o n c e e v e r y f i v e y e a r s d w e r e l o s t o r d a m a g e d b e y o n d r e p a i r , t h e l o s s f a i l u r e t o p r o v i d e a r e p l a c e m e n t d e n t u r e s w o u l d e x c e p t i o n i n t h e p a r t i c u l a r c i r c u m s t a n c e s o f t h e w a s b e y o n d h i s c o n t r o l a n d t h a t h i s h e a l t h w o u l d t o n o t e t h a t t h e a p p e l l a n t ' s d e n t u r i s t i n t e n d s t o
c h a r g e f e e s i n e x c e s s o f t h e r a t e s s e t o u t i n t h e S c h t h a t 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 r o v i d e d u n d e s e r v i c e s . " A " b a s i c d e n t a l s e r v i c e " i s d e f i n e d i n s e c t p r o v i d e d b y a d e n t u r i s t , i s s e t o u t i n t h e S c h e d u l e o o u t i n t h a t S c h e d u l e . T h e p o s i t i o n o f t h e m i n i s t r y i s o f f e e s i n e x c e s s o f t h e r a t e s s e t o u t i n t h e S c h e d u l d i s c r e t i o n i n t h i s m a t t e r . T h e r e f o r e t h e m i n i s t r y i s n o e x c e s s o f t h e 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 s f o r t h e d i f f e r e n c e . T h e p o s i t i o n o f t h e a p p e l l a n t , a s s e t o u t i n h i s s u b m m a i n t a i n h e a l t h y d i e t b y c h e w i n g . I f h e d o e s n o t g e t r e h a b i l i t a t i o n . S e c o n d l y , o t h e r p e o p l e a r e h a v i n g d i f m i s c o m m u n i c a t i o n a m o n g s t a f f a n d c o r e s i d e n t s , w o t h e r s a n d f r o m o b t a i n i n g s o m e v o c a t i o n a l o p p o r t u n w i l l n o t g e t t h e f u l l d i s a b i l i t y a s s i s t a n c e . H i s m o n t h l y c o v e r t h e c o s t . L a s t l y h e d o e s n o t h a v e a n y f a m i l y m h a s n o m e a n s t o a c c e s s a n y e x t r a f u n d s i f t h e m i n i s v o c a t i o n a l w o r k a n d e a r n s o m e m o n e y , b u t t h e e a r n P a n e l f i n d i n g s T h e l e g i s l a t i o n i s c l e a r : s e c t i o n 1 o f S c h e d u l e C o f t h s u c h a s a d e n t u r e , i s p r o v i d e d b y a d e n t u r i s t , t h e m i 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 . A s i n d i c a t e m a n d i b u l a r d e n t u r e ( f e e n u m b e r 3 1 3 2 0 ) , t h e a u t h o r i S c h e d u l e C o f t h e E A P W D R s e t s o u t t h e d e n t a l s u p p r o v i d e a n d , b y r e f e r e n c e t o t h e S c h e d u l e o f F e e s s e r v i c e s . T h e l e g i s l a t i o n d o e s n o t c o n f e r t o t h e m i n i s u n i q u e o r e x c e p t i o n a l c i r c u m s t a n c e s o r i n c a s e s o f c s u p p l e m e n t f o r d e n t u r e s a t r a t e s i n e x c e s s o f t h o s e D e n t u r i s t . A c c o r d i n g l y , t h e p a n e l f i n d s t h a t t h e m i n i s t r y d e t e r m c o v e r a g e f o r f e e s i n e x c e s s o f t h a t s e t o u t i n t h e S c h a p p l i c a t i o n o f t h e l e g i s l a t i o n i n t h e c i r c u m s t a n c e s o f m i n i s t r y ' s d e c i s i o n . E M T 0 0 3 ( 1 0 / 0 6 / 0 1 )A P P E A , I 7 e d u l e o f F e e s -D e n t u r i s t . T h e m i n i s t r y s t a t e s r s e c t i o n 4 o f S c h e d u l e C a r e " b a s i c d e n t a l i o n 1 o f S c h e d u l e C a s a d e n t a l s e r v i c e t h a t , i f f F e e s D e n t u r i s t a n d i s p r o v i d e d a t t h e r a t e s e t t h a t t h e r e i s n o e x c e p t i o n a n d p o l i c y f o r c o v e r a g e e o f F e e s -D e n t u r i s t a n d t h e m i n i s t r y h a s n o t a u t h o r i z e d t o p r o v i d e c o v e r a g e f o r f e e s i n D e n t u r i s t a n d t h e a p p e l l a n t w i l l b e r e s p o n s i b l e i s s i o n o n a p p e a l , i s t h a t h e n e e d s t o b e a b l e t o p r o p e r n u t r i t i o n h e w i l l n o t b e a b l e t o w o r k o n h i s f i c u l t y u n d e r s t a n d i n g h i m . T h i s c o n t r i b u t e s t o h i c h i n t u r n p r o h i b i t s h i m f r o m s o c i a l i z i n g w i t h i t i e s . T h i r d l y , w h i l e h e i s i n t h e c a r e f a c i l i t y , h e a l l o w a n c e i s $ 9 5 a n d t h i s i s n o t s u f f i c i e n t t o e m b e r s o r n e x t o f k i n w h o w o u l d h e l p h i m . H e t r y d o e s n o t c o v e r t h e c o s t . H e w o u l d d o s o m e i n g f r o m s u c h w o r k w o u l d n o t b e s u f f i c i e n t . e E A P W D R s t a t e s t h a t i f a b a s i c d e n t a l s e r v i c e , n i s t r y i s l i m i t e d t o p r o v i d i n g i t a t t h e r a t e s e t o u t d i n t h e r e c o n s i d e r a t i o n d e c i s i o n , f o r a c o m p l e t e z e d r a t e i s $ 5 8 1 . 2 5 . S e c t i o n s 1 a n d 4 o f p l e m e n t s t h a t t h e m i n i s t e r i s a u t h o r i z e d t o D e n t u r i s t , t h e a p p l i c a b l e r a t e s f o r d e n t u r i s t t e r t h e d i s c r e t i o n o r a u t h o r i t y , e i t h e r u n d e r o m p e l l i n g n e e d , t o p r o v i d e a n y d e n t a l s e t o u t 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 i n a t i o n t h a t i t i s n o t a u t h o r i z e d t o p r o v i d e e d u l e o f A l l o w a n c e s D e n t u r i s t i s a r e a s o n a b l e t h e a p p e l l a n t . T h e p a n e l t h e r e f o r e c o n f i r m s t h e
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.