PART C -Decision under Appeal The Appellant appeals the reconsideration decision of the Ministry of Social Development and Social Innovation ("Ministry") dated August 11, 2014, in which the Ministry denied the Appellant's request for custom-made foot orthotics on the basis that the request did not meet the criteria set out in section 3.10(3)(d) of Schedule C of the Employment and Assistance for Persons with Disabilities Regulation, that is, that the requested custom-made foot orthotics be made from a hand cast mold. PART D -Relevant Legislation Employment and Assistance for Persons with Disabilities Regulation ("EAPWDR"), s. 62 and Schedule C, Health Supplements, sections 3 and 3.10. EAAT 003(10/06/01)
PART E-Summary of Facts The evidence before the Ministry at the reconsideration included the following: • A Ministry Orthoses Request and Justification Form signed by the Appellant on March 5, 2014, with section 3-assessment-completed by a pedorthist on March 19, 2014 (2 pages) (the "Orthoses Request Form"), discussed below; • An estimate sheet from an orthotics company dated March 19, 2014, estimating the cost of bilateral foot orthotics for the Appellant at $400 (1 page); • A letter dated February 13, 2014 from the Appellant's doctor (1 page) stating, "This patient needs bilateral orthotics fitted for pes plan us"; • The Ministry's medical equipment and devices decision summary dated June 5, 2014 (3 pages) with attached notes from the original adjudicator (1 page), discussed below; and • The Appellant's request for reconsideration dated July 4, 2014, in which the Appellant wrote that he needed an extra month to gather the needed documents for reconsideration and that the orthotics provider told him that "3D cast has been covered by the ministry for their other clients and that hand cast mold would cost more than the 3D cost." On the Orthoses Request Form, the Appellant's pedorthist indicated in question 1 that the Appellant requires a "bilateral foot orthotic made of ABS plastics to support medial longitudinal arch, flexor hallucis tendon and plantar fascia." Question 4 of the Orthoses Request Form required the pedorthist to answer the question, "If the orthosis is a custom-made foot orthotic, will it be made from a hand cast mold?" The Orthoses Request Form asks the pedorthist to check one of two boxes in response to this question -the first is marked "No" and the second is marked "Yes, please explain." In response to question 4, the pedorthist checked the box next to "Yes, please explain" and added the explanation "casted using 3D volumetric model of the patient's foot." The notes of the Ministry adjudicator who prepared the June 5, 2014 medical equipment and devices decision summary indicate that on June 3, 2014, the adjudicator "left message to supplier to call back. Supplier confirms that hand cast model will be used on Section 4 [of the Orthoses Request Form] but mention "3D volumetric model" in their explanation. Need clarification if this method is the computerized version ... " The adjudicator's notes for June 5, 2014 are, "No success contacting this supplier through phone, no call back. Their website mentions that they use "sophisticated digital mapping technology to create a topographic map of each foot." The adjudicator's notes indicate that on June 5, 2014, "ministry regulations require that custom-made foot orthotics are made from a hand cast mold using a plaster of paris slipper cast. The minister is not satisfied." · Prior to the hearing, the Appellant submitted a letter dated September 6, 2014 from his pedorthist who completed the Orthoses Request Form. In this letter, the pedorthist writes that the bilateral foot orthotics for the Appellant "will be casted by hand in a foam impression box. This casting method will deliver a 3 dimensional volumetric model of the patient's foot when filled with plaster to build the required foot orthotic device. The orthotic device will be fabricated in our lab to the specifications of the above mentioned foot [mold]." The Ministry did not object to the admission of the September 6, 2014 letter from the Appellant's pedorthist. The panel finds that the September 6, 2014 letter from the Appellant's pedorthist clarifies the information provided on the Orthoses Request Form; in particular, that the requested custom-made foot orthotics for the Aonellant will be made from a hand cast mold usinq 3 dimensional volumetric EMT003(10/06/01)
r modeling, which involves a foam impression box that is then filled with plaster. The panel admits the September 6, 2014 letter of the Appellant's pedorthist under section 22(4)(b) of the Employment and Assistance Act as written testimony in support of information that was before the Ministry at the time the decision being appealed was made. The Ministry notes that the Appellant receives disability assistance and is eligible to receive health supplements (in this case, custom-made foot orthotics) under section 62 and Schedule C of the EAPWDR. The Ministry also notes that the Appellant's physician has confirmed that the requested custom-made foot orthotics are medically required and the minister is satisfied that the custom-made foot orthotics are medically essential to achieve or maintain basic functionality because they will improve the Appellant's physical functioning that has been impaired by a neuro-musculo-skeletal condition. The Ministry notes that the Appellant does not have the resources available to him to purchase the requested custom-made foot orthotics. EAA T003( 10/06/01)
PART F -Reasons for Panel Decision The issue on this appeal is the reasonableness of the Ministry's reconsideration decision of August 11, 2014, denying the Appellant's request for custom foot orthotics on the basis that his request does not meet the eligibility criteria set out in section 3.10(3)(d) of Schedule C of the EAPWDR that the requested custom-made foot orthotics must be made from a hand cast mold. Applicable Legislation The Appellant meets the criteria set out in section 62 of the EAPWDR which provides as follows: General health supplements s. 62(1) Subject to subsections (1. 1) and (1.2), the minister may provide any health supplement set out in section ... 3 [medical equipment and devices] of Schedule C to or for a family unit if the health supplement is provided to or for a person in the family unit who is (a) a recipient of disability assistance, The eligibility requirements for medical equipment and devices, which includes custom-made foot orthotics, are set out in section 3 of Schedule C of the EAPWDR. Custom-made foot orthotics are specifically addressed in s. 3.1 0 of Schedule C of the EAPWDR. Schedule C -Health Supplements Medical equipment and devices 3(1) Subject to subsections (2) to (5) of this section, the medical equipment and devices described in section 3.1 to 3.11 of this Schedule are the health supplements that may be provided by the minister if (a) the supplements are provided to a family unit that is eligible under section 62 [general health supplements] of this regulation, and (b) all of the following requirements are met: (i) the family unit has received the pre-authorization of the minister for the medical equipment or device requested; (ii) there are no resources available to the family unit to pay the cost of or obtain the medical equipment or device; (iii) the medical equipment or device is the least expensive appropriate medical equipment or device. Medical equipment and devices -orthoses 3.10(1) In this section, "off the shelf", in relation to an orthosis, means a prefabricated, mass-produced orthosis that is not unique to a particular person; "orthosis" means (a) a custom-made or off-the-shelf foot orthotic; (b) ... (2) Subject to subsections (3) to (11) of this section, an orthosis is a health supplement for the purposes of section 3 of this Schedule if (a) the orthosis is prescribed by a medical practitioner or a nurse oractitioner, EAAT 003(10/06/01)
( b ) t h e m i n i s t e r i s s a t i s f i e d t h a t t h e o rt h o s i s i s m f u n c t i o n a l i t y , ( c ) t h e m i n i s t e r i s s a t i s f i e d t h a t t h e o r t h o s i s i s r e ( i ) t o p r e v e n t s u r g e r y ; ( i i ) f o r p o s t s u r g i c a l c a r e ; ( i i i ) t o a s s i s t i n p h y s i c a l h e a l i n g f r o ( i v ) t o i m p r o v e p h y s i c a l f u n c t i o n i n g s k e l e t a l c o n d i t i o n , a n d ( d ) t h e o r t h o s i s i s o f f t h e s h e l f u n l e s s ( i ) a m e d i c a l p r a c t i t i o n e r o r n u r s e i s m e d i c a l l y r e q u i r e d , a n d ( i i ) t h e c u s t o m m a d e o rt h o s i s i s f i t t t h e r a p i s t , p h y s i c a l t h e r a p i s t o r p ( 3 ) F o r a n o r t h o s i s t h a t i s a c u s t o m m a d e f o o t o r t h o o f t h i s s e c t i o n , a l l o f t h e f o l l o w i n g r e q u i r e m e n t s m u s ( a ) a m e d i c a l p r a c t i t i o n e r o r n u r s e p r a c t i t i o n e r c o m e d i c a l l y r e q u i r e d ; ( b ) t h e c u s t o m m a d e f o o t o r t h o t i c i s f i t t e d b y a n o p h y s i c a l t h e r a p i s t o r p o d i a t r i s t ; ( c ) R e p e a l e d ( d ) t h e c u s t o m m a d e f o o t o rt h o t i c m u s t b e m a d e ( e ) t h e c o s t o f o n e p a i r o f c u s t o m m a d e f o o t o r t h e x c e e d $ 4 5 0 . ( 9 ) S u b j e c t t o s e c t i o n 3 o f t h i s S c h e d u l e , t h e l i m i t o n t h e u s e o f a p e r s o n a s a h e a l t h s u p p l e m e n t f o r t h e p n u m b e r s e t o u t i n C o l u m n 2 o f T a b l e 1 o p p o s i t e t h e T a b l e 1 I t e m C o l u m n 1 O r t h o s i s 1 C u s t o m m a d e f o 2 S u b s e c t i o n s 3 . 1 0 ( 4 ) -( 8 ) o f S c h e d u l e C o f t h e E A P W a p p l y t o t h e a p p e l l a n t ' s r e q u e s t ( c u s t o m m a d e f o o t w o rt h o p a e d i c f o o t w e a r , k n e e b r a c e , u p p e r e x t r e m i t y b s u b s 3 . 1 0 ( 1 ) ) a d d r e s s e s t h e r e p l a c e m e n t o f o rt h o s e T h e A p p e l l a n t s a y s t h a t h i s r e q u e s t e d c u s t o m m a d e 3 . 1 0 ( 3 ) ( d ) h e a r g u e s t h a t h i s p e d o r t h i s t i n d i c a t e d o o r t h o t i c s a r e c u s t o m m a d e f r o m a h a n d c a s t m o l d b y A p p e l l a n t a r g u e s t h a t i n t h e S e p t e m b e r 6 , 2 0 1 4 l e t t e O r t h o s e s R e q u e s t F o r m , c l e a r l y s t a t i n g t h a t t h e r e q u m o l d . T h e A p p e l l a n t s a i d t h a t h e w a s n o t a b l e t o r e a t h e r e c o n s i d e r a t i o n b e c a u s e h i s o e d o r t h i s t w a s o u t o E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )e d i c a l l y e s s e n t i a l t o a c h i e v e o r m a i n t a i n b a s i c q u i r e d f o r o n e o r m o r e o f t h e f o l l o w i n g p u r p o s e s : m s u r g e r y , i n j u r y o r d i s e a s e ; t h a t h a s b e e n i m p a i r e d b y a n e u r o m u s c u l o p r a c t i t i o n e r c o n f i r m s t h a t a c u s t o m m a d e o r t h o s i s e d b y a n o r t h o t i s t , p e d o r t h i s t , o c c u p a t i o n a l o d i a t r i s t . t i c , i n a d d i t i o n t o t h e r e q u i r e m e n t s o f s u b s e c t i o n ( 2 ) t b e m e t : n f i r m s t h a t a c u s t o m m a d e f o o t o r t h o t i c i s r t h o t i s t , p e d o r t h i s t , o c c u p a t i o n a l t h e r a p i s t , f r o m a h a n d c a s t m o l d ; o t i c s , i n c l u d i n g t h e a s s e s s m e n t f e e , m u s t n o t t h e n u m b e r o f o r t h o s e s t h a t m a y b e p r o v i d e d f o r u r p o s e s o f s e c t i o n 3 o f t h i s S c h e d u l e i s t h e d e s c r i p t i o n o f t h e a p p l i c a b l e o rt h o s i s i n C o l u m n 1 . C o l u m n 2 L i m i t o t o r t h o t i c 1 o r 1 p a i r D R a d d r e s s s p e c i f i c t y p e s o f o r t h o s e s t h a t d o n o t e a r , o f f t h e s h e l f f o o t w e a r , o f f t h e s h e l f r a c e , c r a n i a l h e l m e t a n d t o r s o o r s p i n e b r a c e ) a n d s , w h i c h d o e s n o t a p p l y t o t h e a p p e l l a n t ' s r e q u e s t . f o o t o r t h o t i c s m e e t t h e r e q u i r e m e n t s o f s u b s e c t i o n n t h e O r t h o s e s R e q u e s t F o r m t h a t t h e r e q u e s t e d c h e c k i n g t h e b o x " Y e s , p l e a s e e x p l a i n . " T h e r , h i s p e d o r t h i s t h a s c l a r i f i e d t h e a n s w e r o n t h e e s t e d o r t h o t i c s a r e t o b e m a d e f r o m a h a n d c a s t c h h i s p e d o r t h i s t t o g e t t h e f u rt h e r i n f o r m a t i o n f o r f t o w n o n v a c a t i o n .
T h e M i n i s t r y h a s d e t e r m i n e d t h a t t h e A p p e l l a n t ' s r e q e l i g i b i l i t y r e q u i r e m e n t s s e t o u t i n s u b s e c t i o n 3 . 1 0 ( 2 ) t h e E A P W D R . T h e M i n i s t r y i s s a t i s f i e d t h a t t h e r e q e s s e n t i a l t o a c h i e v e o r m a i n t a i n t h e A p p e l l a n t ' s b a s a n d t h a t t h e y a r e r e q u i r e d t o i m p r o v e t h e A p p e l l a n t ' n e u r o m u s c u l o s k e l e t a l c o n d i t i o n ( a s r e q u i r e d b y s u A p p e l l a n t ' s p h y s i c i a n c o n f i r m e d t h a t a c u s t o m m a d e s u b s . 3 . 1 0 ( 2 ) ( d ) ( i ) a n d s u b s . 3 . 1 0 ( 3 ) ( a ) ) . T h e M i n i s c u s t o m m a d e f o o t o r t h o t i c s w o u l d b e f i t t e d b y a p e d 3 . 1 0 ( 2 ) ( d ) ( i i ) a n d i n s u b s . 3 . 1 0 ( 3 ) ( b ) ) o r t h a t t h e c o s w o u l d b e l e s s t h a n $ 4 5 0 ( t h e r e q u i r e m e n t s e t o u t i n T h e p a n e l n o t e s t h a t 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 o f S c h e d u l e C , w h i c h h a s b e e n r e p e a l e d t h e r e f e r r e c o n s i d e r a t i o n d e c i s i o n n o t e s t h a t s u b s e c t i o n 3 . 1 0 ( r e q u e s t e d c u s t o m m a d e f o o t o r t h o t i c s m u s t b e m a d i n f o r m a t i o n p r o v i d e d b y t h e A p p e l l a n t ' s p e d o r t h i s t i n o r t h o t i c s w i l l b e c a s t e d w i t h a 3 D v o l u m e t r i c m o d e l . t h a t i t h a d a t t e m p t e d t o c o n t a c t t h e A p p e l l a n t ' s p e d o a n d c o n f i r m t h e m e t h o d u s e d f o r c u s t o m f o o t o r t h o t i s a t i s f i e d " t h a t t h e A p p e l l a n t ' s r e q u e s t h a d m e t t h e r e o f t h e E A P W D R . A t t h e h e a r i n g , t h e M i n i s t r y ' s r e p r e s e n t a t i v e a g r e e d A p p e l l a n t ' s r e q u e s t e d o r t h o t i c s w i l l b e c a s t e d b y h a n P a n e l ' s D e c i s i o n I n o r d e r t o o b t a i n c u s t o m m a d e f o o t o r t h o t i c s , t h e A p c r i t e r i a s e t o u t i n s u b s e c t i o n s 3 , 3 . 1 0 ( 2 ) a n d 3 . 1 0 ( 3 ) t h e M i n i s t r y a g r e e s t h a t t h e A p p e l l a n t ' s r e q u e s t e d c u s e t o u t i n s u b s e c t i o n s 3 a n d 3 . 1 0 ( 2 ) , a n d t h r e e o f t h e C . T h e o n l y i s s u e o n t h i s a p p e a l i s w h e t h e r t h e A p p 3 . 1 0 ( 3 ) ( d ) ; t h a t i s , t h a t t h e r e q u e s t e d c u s t o m m a d e f T h e p a n e l n o t e s t h a t i n t h e O r t h o s e s R e q u e s t F o r m c h e c k e d " y e s " i n a n s w e r t o t h e s p e c i f i c q u e s t i o n , " i f t b e m a d e f r o m a h a n d c a s t m o l d ? " T h e p a n e l n o t e s t r e q u e s t e d f o r c u s t o m m a d e f o o t o r t h o t i c s r e s t s o n t h t o h i s " y e s " a n s w e r t o q u e s t i o n 4 o n t h e O rt h o s e s R e t h e p a t i e n t ' s f o o t . " I n h i s l e t t e r o f S e p t e m b e r 6 , 2 0 1 4 o r t h o t i c s w i l l b e c a s t e d b y h a n d i n a f o a m i m p r e s s i o n m o d e l o f t h e A p p e l l a n t ' s f o o t w h e n t h e b o x i s f i l l e d w T h e p a n e l a c c e p t s t h e e v i d e n c e o f t h e A p p e l l a n t ' s p e o n t h e O r t h o s e s R e a u e s t F o r m a n d c o n f i r m s t h a t t h e E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )u e s t f o r c u s t o m m a d e f o o t o r t h o t i c s m e e t s t h e a n d 3 . 1 0 ( 3 ) ( a ) , ( 3 ) ( b ) a n d ( 3 ) ( e ) o f S c h e d u l e C o f u e s t e d c u s t o m m a d e f o o t o r t h o t i c s a r e m e d i c a l l y i c f u n c t i o n a l i t y ( a s r e q u i r e d b y s u b s . 3 . 1 0 ( 2 ) ( b ) ) s p h y s i c a l f u n c t i o n i n g t h a t h a s b e e n i m p a i r e d b y a b s . 3 . 1 0 ( 2 ) ( c ) ( i v ) ) . T h e M i n i s t r y a l s o f i n d s t h a t t h e f o o t o r t h o t i c s i s m e d i c a l l y r e q u i r e d ( a s r e q u i r e d b y t r y d o e s n o t d i s p u t e t h a t t h e A p p e l l a n t ' s r e q u e s t e d o r t h i s t ( t h e r e q u i r e m e n t s e t o u t i n s u b s . t o f t h e r e q u e s t e d c u s t o m m a d e f o o t o r t h o t i c s s u b s . 3 . 1 0 ( 3 ) ( e ) ) . , t h e M i n i s t r y e r r o n e o u s l y r e f e r s t o s u b s . 3 . 1 0 ( 3 ) ( c ) e n c e s s h o u l d b e t o s u b s . 3 . 1 0 ( 3 ) ( d ) . T h e M i n i s t r y ' s 3 ) ( d ) o f S c h e d u l e C r e q u i r e s t h a t t h e A p p e l l a n t ' s e f r o m a h a n d c a s t m o l d a n d i t s t a t e s t h a t t h e t h e O r t h o s e s R e q u e s t F o r m i n d i c a t e s t h a t t h e T h e M i n i s t r y s t a t e d i n i t s r e c o n s i d e r a t i o n d e c i s i o n r t h i s t o n A u g u s t 7 a n d A u g u s t 1 1 , 2 0 1 4 " t o i n q u i r e c s w i t h n o s u c c e s s . T h e r e f o r e , t h e m i n i s t e r i s n o t q u i r e m e n t o f s u b s e c t i o n 3 . 1 0 ( 3 ) ( d ) o f S c h e d u l e C t h a t t h e S e p t e m b e r 6 , 2 0 1 4 l e t t e r c l a r i f i e s t h a t t h e d i n a f o a m i m p r e s s i o n b o x . p e l l a n t ' s r e q u e s t m u s t m e e t a l l o f t h e r e l e v a n t o f S c h e d u l e C o f t h e E A P W D R . A s n o t e d a b o v e , s t o m m a d e f o o t o r t h o t i c s m e e t s a l l o f t h e c r i t e r i a f o u r c r i t e r i a s e t o u t i n s u b s . 3 . 1 0 ( 3 ) o f S c h e d u l e e l l a n t ' s r e q u e s t m e e t s t h e c r i t e r i a s e t o u t i n s u b s . o o t o r t h o t i c s a r e m a d e f r o m a h a n d c a s t m o l d . o f M a r c h 1 9 , 2 0 1 4 , t h e A p p e l l a n t ' s p e d o r t h i s t h e o r t h o s i s i s a c u s t o m m a d e f o o t o r t h o t i c , w i l l i t h a t t h e M i n i s t r y ' s d e n i a l o f t h e A p p e l l a n t ' s e e x p l a n a t i o n a d d e d b y t h e A p p e l l a n t ' s p e d o r t h i s t q u e s t F o r m , " c a s t e d u s i n g 3 D v o l u m e t r i c m o d e l o f , t h e p e d o r t h i s t e x p l a i n e d t h a t t h e A p p e l l a n t ' s b o x t h a t w i l l d e l i v e r a 3 d i m e n s i o n a l v o l u m e t r i c i t h p l a s t e r t o c o n s t r u c t t h e o r t h o t i c . d o rt h i s t w h i c h c l a r i f i e s h i s a n s w e r t o q u e s t i o n 4 r e a u e s t e d c u s t o m m a d e o r t h o t i c s w i l l b e m a d e
f r o m a h a n d c a s t m o l d , a s r e q u i r e d b y s u b s . 3 . 1 0 ( 3 f i n d s t h a t t h e M i n i s t r y ' s d e n i a l o f t h e A p p e l l a n t ' s r e q n o t m e e t t h e c r i t e r i a t h a t i t b e m a d e f r o m a h a n d c a o f t h e E A P W D R i s n o t r e a s o n a b l e b a s e d o n t h e e v i O r t h o s e s R e q u e s t F o r m , a s c l a r i f i e d i n t h e S e p t e m b A c c o r d i n g l y , t h e p a n e l r e s c i n d s t h e M i n i s t r y ' s r e c o n t h e m i n i s t e r f o r a d e t e r m i n a t i o n a s t o t h e a m o u n t . E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )) ( d ) o f S c h e d u l e C o f t h e E A P W D R . T h e p a n e l u e s t e d c u s t o m f o o t o r t h o s i s o n t h e b a s i s t h a t i t d i d s t m o l d a s s e t o u t i n s u b s . 3 . 1 0 ( 3 ) ( d ) o f S c h e d u l e C d e n c e p r o v i d e d b y t h e A p p e l l a n t ' s p e d o r t h i s t i n t h e e r 6 , 2 0 1 4 l e t t e r . s i d e r a t i o n d e c i s i o n a n d r e f e r s t h e d e c i s i o n b a c k t o
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.