PART C -Decision under Appeal Under appeal is the Ministry of Social Development and Social Innovation's ("the ministry") July 29, 2014 reconsideration decision denying funding for dental implants and related services for not meeting the legislative requirements in the Employment and Assistance for Persons with Disabilities Regulation, sections 63, 63.1, 64, 69 and Schedule C sections 1, 4, 4.1 and 5. PART D -Relevant Legislation EAPWDR Employment and Assistance f o r Persons with Disabilities Regulation, sections 63, 63.1, 64, 69 and Section C sections 1, 4, 4.1 and 5. EMT 003(10/06/01)
P A R T E S u m m a r 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 • t h e a p p e l l a n t i s a r e c i p i e n t o f d i s a b i l i t y a s s i s t • O c t o b e r 2 9 , 2 0 0 7 d e n t a l r e f e r r a l l e t t e r a d v i s i n a s s o c i a t e d d i m i n i s h e d m e n t a l c a p a c i t y , l i v e d p e r m a n e n t t e e t h w h i c h d i d n o t d e v e l o p a n d r b r u x i s m . T h e a p p e l l a n t h a d p a i n i n t h e r i g h t h i s f o o d h a d t o b e c u t u p i n s m a l l p i e c e s . H e b r o k e i n 2 0 0 5 . T h e d e n t i s t d i a g n o s e d a r e d u t h e a p p e l l a n t ' s t e e t h a n d r e c o m m e n d e d i m a g • M a y 7 , 2 0 0 8 d e n t a l r e p o r t d e s c r i b i n g t h e a p p g r o s s l y w o r n , g r i n d i n g h a b i t s s e c o n d a r y t o h i c i o s e d . T h e d e n t i s t r e c o m m e n d e d n o s u r g e r c o n d i t i o n i n t e r f e r e d w i t h t h e a p p e l l a n t ' s l i f e s t y c o n s i d e r e d . • M a y 3 0 , 2 0 1 3 t r e a t m e n t p l a n w i t h l i s t o f i m p l a $ 4 4 3 2 . 0 0 a n d h a n d w r i t t e n n o t e " p l a c e 2 i m p l w h i l e t h e y i n t e g r a t e t o b o n e " . • M a y 3 0 , 2 0 1 3 p r e d e t e r m i n a t i o n l i s t i n g i m p l a n $ 1 0 , 4 5 1 . 6 5 a n d h a n d w r i t t e n n o t e " W h e n i m p d e n t u r e w i t h a m e t a l s t r e n g t h e n i n g b a r & a t t a t e e t h . " • S e p t e m b e r 2 6 , 2 0 1 3 l e t t e r f r o m d e n t i s t a b o u t d e s c r i b i n g t h e a p p e l l a n t h a s h a v i n g a n u m b e a l m o s t 1 0 0 % o f t h e c o r o n a l t o o t h s t r u c t u r e l o m i s m a t c h e d a r c h e s o f h i s j a w s . T h e p r o p o s e i m p l a n t s a n d f i t t e d a t t a c h m e n t s t o h o l d a r e m m i s a l i g n m e n t . T h e d e n t i s t a d v i s e d t h e d e n t a r e m o v a b l e u p p e r d e n t u r e a s t h e r e w a s n o t e n c o n v e n t i o n a l r e m o v a b l e p a r t i a l d e n t u r e a n d t h e x t r e m e . H e f u r t h e r r e p o r t e d t h e y a t t e m p t e d l o c a l a n a e s t h e t i c , b u t t h e a p p e l l a n t w a s u n a b a n d p s y c h o l o g i c a l r e a s o n s , a n d w a s r e f e r r e d t r e a t m e n t w i t h t h e a p p e l l a n t s e d a t e d . • A p r i l 1 0 , 2 0 1 4 l e t t e r f r o m d e n t i s t s a y i n g t h e a d e n i e d b e c a u s e d e n t a l i m p l a n t s w e r e c o n s i d e w e r e p l a c e d t o r e t a i n a n o v e r d e n t u r e o t h e rw i s r e c o n s i d e r a t i o n a n d o f f e r e d t o s p e a k d i r e c t l y • M a y 1 5 , 2 0 1 4 l e t t e r f r o m a p h y s i c i a n s a y i n g t c h e w s o l i d f o o d s b e c a u s e o f h i s d e n t a l p r o b l e r e c o m m e n d e d t h a t t h e a p p e l l a n t h a v e h i s t e e c o u l d r e s u m e a n o r m a l d i e t . • J u n e 2 0 1 4 d e n t a l s t a t e m e n t o f a c c o u n t s h o w i c r e d i t c a r d . • J u n e 1 0 , 2 0 1 4 e m a i l e d s t a t e m e n t o f a c c o u n t EAA T 0 0 3 ( 1 0 / 0 6 1 0 1 )L _ _ � w a s a n c e . g t h e a p p e l l a n t h a s c e r e b r a l p a l s y w i t h s o m e i n a g r o u p h o m e , a n d h a d a n u m b e r o f e t a i n e d p r i m a r y t e e t h t h a t w e r e d e s t r o y e d b y j o i n t , h e a d a c h e s , c o u l d n o t o p e n h i s j a w w i d e a n d h a d u s e d a n i g h t g u a r d f o r a f e w y e a r s b u t i t c e d v e r t i c a l d i m e n s i o n d u e t o t h e d e s t r u c t i o n o f i n g o f t h e j o i n t . e l l a n t a s v e r y d i f f i c u l t t o t r e a t w i t h h i s f e w t e e t h a s s c e r e b r a l p a l s y , a n d h i s j a w a s g r o s s l y o v e r y a t t h a t t i m e b u t i f t h e p a i n c o n t i n u e d a n d t h e l e , f r e e i n g u p s o m e o f t h e i n t e r f e r e n c e c o u l d b e n t r e l a t e d p r o c e d u r e s a n d t o t a l c h a r g e o f a n t s & m a k e a n i g h t g u a r d t o p r o t e c t i m p l a n t s t a n d d e n t u r e p r o c e d u r e s w i t h a t o t a l c h a r g e o f l a n t s a r e r e a d y i n 3 m o s . M a k e a c o m p l e t e u p p e r c h i t t o t h e 2 i m p l a n t s . R e m o v e t h e r e m a i n i n g r e s t o r a t i v e d e n t a l t r e a t m e n t f o r t h e a p p e l l a n t , r o f m i s s i n g t e e t h w i t h t h e r e m a i n i n g t e e t h w i t h s t a n d a g e n e t i c c o n d i t i o n o f s i g n i f i c a n t l y d t r e a t m e n t c o n s i s t e d o f u s i n g t w o d e n t a l o v a b l e u p p e r o v e r d e n t u r e t o h e l p c o r r e c t t h e j a w l i m p l a n t s w e r e r e q u i r e d t o s t a b i l i z e t h e o u g h r e m a i n i n g t o o t h s t r u c t u r e t o u s e a e f u n c t i o n a l f o r c e s t h e a p p e l l a n t e x e r t s a r e p l a c i n g t h e d e n t a l i m p l a n t s i n t h e i r o f f i c e u s i n g l e t o m a k e i t t h r o u g h t h e p r o c e d u r e fo r e m o t i o n a l t o a p e r i o d o n t i c s s p e c i a l i s t t o p r o v i d e t h e p p e l l a n t t o l d h i m h i s i n s u r a n c e c l a i m w a s b e i n g r e d c o s m e t i c . T h e d e n t i s t s t a t e d t h e i m p l a n t s e i m p o s s i b l e t o t o l e r a t e , a s k e d f o r a b o u t i t . h e a p p e l l a n t h a s c e r e b r a l p a l s y , w a s u n a b l e t o m s , l i m i t i n g h i s d i e t a r y s e l e c t i o n . T h e p h y s i c i a n t h f i x e d a s p e r d e n t a l r e c o m m e n d a t i o n s o h e n g a n A u g u s t 2 6 , 2 0 1 3 b a l a n c e o f $ 3 7 6 0 p a i d b y a n d l e t t e r f r o m d e n t a l c l i n i c s a i n t h e a p p e l l a n t
used $95.41 of his $1000 two year limit. • July 11, 2014 letter from the appellant's mother outlining the appellant's dental history. She said he should not have to suffer the jaw pain, or the humiliation of his facial looks, or not be able to eat his favourite foods which are raw vegetables, apples and the like. She said the appellant's parents, now close to seventy and on pension and in debt because of flood damage to their house, are unable to afford the dental work required. • July 12, 2014 letter in support of the request f o r reconsideration from the appellant's caregiver of 24 years. The caregiver says the appellant stands to lose his ability to partake of and enjoy what the rest of society considers a normal part of day-to-day life -normal mealtimes and contents -possibly his current good health, and certainly his physical appearance will change. She indicates supplemental "ensure" type meal replacement products have been suggested, but says while allowable for the short term, it should not become a way of life as a solution to a situation which is not of the appellant's making. She says the appellant's parents have contributed $5000 to the initial work but cannot now afford the still pending $10,000 identified work. She believes the ministry has a responsibility to the appellant for full assistance in gaining dental implements to allow him to partake of nutritious foods and comfort in community involvement again. • Employment and Assistance Request for Reconsideration form in which the ministry states the appellant had dental work including implants paid by his mother to date, but further treatment requested is in excess of $10,000. • Ministry document Table A-Predetermination May 30, 2013-illustrating that of the recommended procedures totalling $10,451.65, the ministry approved only the removal of teeth at a total of $427 .01. • Ministry document Table B -Treatment Plan May 30, 2013-illustrating that of completed dental work totalling $3,760, the ministry approved only $268.79 for a night guard. • The ministry's 50 page Dental Supplement-Dentist document which provides details of how to confirm eligibility and obtain payment for services rendered. With the Notice of Appeal the appellant's caregiver submits that the ministry is responsible for the health and well being of the appellant, a person with disabilities in the care of the ministry. She indicates that with a change of medical support or insurance carriers during the development of the appellant's dental condition, there ought to have been provision made or "grandfathered" to address such issues. She says the appellant likes cooking and enjoys that he is able to contribute, but this whole social aspect of his life is about to change drastically as meals and mealtime will be a time of social discomfort for him. She states the ministry has advised by letter that they will provide extra funding toward the appellant's nutritional needs by paying f o r a nutritional supplement and vitamins. She goes on to calculate the cost of doing so at $158,400 for the estimated remainder of his life, and suggests that amount is unlikely to be met or exceeded by his current and future dental costs. At the hearing the appellant's advocate, his caregiver, referred to her August 2014 letter. She said the ministry was well aware of the dentist's advice years ago that major dental work would be necessary and that the dentist advised to wait until the appellant had reached maturity before having the work done. She said they had not learned about a change in dental coverage until the appellant was denied funding. It was not an issue when pending work was discussed, and in her experience in the past extensive dental work applied for was usually approved. If they had been made aware of the change the appellant could have used part of his "comfort money" to purchase extended dental coveraqe. The needed treatment has not been done and the annellant has been on soft food for EAAT 003(10/06/01)
a b o u t a y e a r . T h e a p p e l l a n t ' s m o t h e r c o n f i r m e d t h e f i r s t d e n t i s t r e t h e a p p e l l a n t ' s s o c i a l w o r k e r a t t h e t i m e , a n d i t w a s n o r m a l d e n t u r e w o u l d n o t w o r k . 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 s a i d s h e w a s n o t a w a s o m e d e n t a l c o v e r a g e w a s i n c r e a s e d , a n d t h e m i n S h e s a i d t h e r e w a s a s e p a r a t e p r o c e s s f o r d e n t u r e s d e n t i s t s ' s u b m i s s i o n s g o t h e t h e H e a l t h A s s e s s m e n b e e n d o n e i n t h i s c a s e . E M T 0 0 3 ( 1 0 / 0 6 / 0 1 )c o m m e n d e d w a i t i n g , t h a t t h i s w a s d i s c u s s e d w i t h j o i n t l y d e c i d e d t o w a i t . I t w a s c l e a r t h e n t h a t a r e o f a n y d e c r e a s e i n c o v e r a g e , n o t l o n g a g o i s t r y p a y s o n l y w h a t i s l i s t e d i n t h e f e e s c h e d u l e . . T h e d e c i s i o n w a s n o t m a d e i n t h e l o c a l o f f i c e , t d e p a r t m e n t f o r c o n s i d e r a t i o n , a n d t h a t w i l l h a v e
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 r e i m p l a n t s a n d r e l a t e d s e r v i c e s f o r n o t m e e t i n g t h e l e 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 i l i t i e s R e g u l a t i o n , s e c t i o n s 1 , 4 , 4 . 1 a n d 5 . 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 ( E x c e r p t s ) 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 r 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 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 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 ( 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 ) 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 t h e 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 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 ( 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 ) . C r o w n a n d b r i d g e w o r k s u p p l e m e n t -6 3 . 1 ( 1 ) S u b j e c t t o s u b s e c t i o n s ( 1 . 1 ) a n d ( 1 . 2 ) , t h e m i n i s u p p l e m e n t u n d e r s e c t i o n 4 . 1 o f S c h e d u l e C t o a n y ( a ) a r e c i p i e n t o f d i s a b i l i t y a s s i s t a n c e ; 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 r 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 i n 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 ( 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 H e a l t h s u p p l e m e n t fo r p e r s o n s f a c i n g d i r e c t a n T h e m i n i s t e r m a y p ro v i d e t o a f a m i l y u n i t a n y h e a l t h ( f ) [ g e n e r a l h e a l t h s u p p l e m e n t s ] a n d 3 [ m e d i c a l e q u s u p p l e m e n t i s p r o v i d e d t o o r fo r a p e r s o n i n t h e f a m h e a l t h s u p p l e m e n t u n d e r t h i s r e g u l a t i o n , a n d i f t h e m E AA T 0 0 3 ( 1 0 / 0 6 / 0 1 )c o n s i d e r a t i o n d e c i s i o n t o d e n y f u n d i n g f o r d e n t a l g i s l a t i v e r e q u i r e m e n t s i n t h e E m p l o y m e n t a n d s e c t i o n s 6 3 , 6 3 . 1 , 6 4 , 6 9 a n d S c h e d u l e C S W I T H D I S A B I L I T I E S R E G U L A T I O N -2 0 1 0 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 s p r o v i d e d t o o r fo r a f a m i l y u n i t i f t h e h e a l t h 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 e a l t h s u p p l e m e n t s ] , i f 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 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 e s u p p l e m e n t , s t e r m a y p r o v i d e a c r o w n a n d b r i d g e w o r k o f t h e f o l l o w i n g p e r s o n s : m a y p ro 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 h e 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 n t s u n d e r e a l t h s u p p l e m e n t s ] , d i m m i n e n t l i f e t h r e a t e n i n g h e a l t h n e e d · 6 9 s u p p l e m e n t s e t o u t i n s e c t i o n s 2 ( 1 ) ( a ) a n d i p m e n t a n d d e v i c e s ] o f S c h e d u l e C , i f t h e h e a l t h i l y u n i t w h o i s o t h e r w i s e n o t e l i g i b l e f o r t h e i n i s t e r i s s a t i s f i e d t h a t
t o t h e p e r s o n ' s f a m i l y u n i t w i t h w h i c h t o m e e t t h a t n e e d , ( b ) t h e h e a l t h s u p p l e m e n t i s n e c e s s a r y t o m e e t t h a t n e e d , ( c ) t h e p e r s o n ' s 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 d i c a r e P r o t e c t i o n A c t , a n d ( d ) t h e r e q u i r e m e n t s s p e c i f i e d i n t h e fo l l o w i n g p r o v i s i o n s o f S c h e d u l e C , a s a p p l i c a b l e , a r e m e t : ( i) p a r a g r a p h ( a ) o r ( f ) o f s e c t i o n ( 2 ) ( 1 ) ; ( i i ) s e c t i o n s 3 t o 3 . 1 2 , o t h e r t h a n p a r a g r a p h ( a ) o f s e c t i o n 3 ( 1 ) . [ e n . B . C . R e g . 6 1 / 2 0 1 0 , s . 4 ; a m . B . C . R e g . 1 9 7 / 2 0 1 2 , S c h . 2 , s . 8 . ) 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 x c e r p t s ) " b a s i c 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 t h a t ( a ) i f p ro 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 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 , ( 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 f o r t h e s e r v i c e i n t h a t S c h e d u l e , ( b ) i f p r o v i d e d b y a d e n t u r 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 D e n t u r 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 fo r t h e s e r v i c e i n t h a t S c h e d u l e , a n d ( c ) i f p r o v i d e d b y a d e n t a l h y g i e n 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 D e n t a l H y g i e n 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 fi 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 fo r t h e s e r v i c e i n t h a t S c h e d u l e ; " 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 , a n d ( b ) i f p r o v i d e d b y a d e n t u r 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 u r 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 a 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 EM T 0 0 3 ( 1 0 1 0 6 / 0 1 )
( 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 ( 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 ( c ) R e p e a l e d . [ B . C . R e g . 1 6 3 / 2 0 0 5 , s . ( b ) . J ( 2 ) D e n t u r e s m a y b e p r o v i d e d a s a b a s i c d e n ( a ) w h o h a s n e v e r w o rn d e n t u r e s , o r ( 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 5 y e a r s o ( 3 ) T h e l i m i t s u n d e r s u b s e c t i o n ( 1 . 1 ) m a y b e d e n t u r e s , t a k i n g i n t o a c c o u n t t h e a m o u n t r e m t i m e t h e d e n t u r e s a r e t o b e p r o v i d e d , i f ( a ) a p e r s o n r e q u i r e s a f u l l u p p e r d e n t u r e , a m a d e i n t h e p r e v i o u s 6 m o n t h s t o r e l i e v e p a ( b ) a p e r s o n r e q u i r e s a p a r t i a l d e n t u r e t o r e p s a m e a r c h , a t l e a s t o n e o f w h i c h w a s e x t r a c t ( c ) a p e r s o n w h o h a s b e e n a r e c i p i e n t o f d i s a 2 y e a r s o r a d e p e n d a n t o f t h a t p e r s o n r e q u i r ( 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 w h o h a s 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 o r 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 ) s e r v i c e s u n d e r ( a ) f e e n u m b e r s 5 2 1 0 1 t o 5 2 4 0 2 i n t h e S c h e 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 a s i c d e n t a l s ( b ) f e e n u m b e r s 4 1 6 1 0 , 4 1 6 1 2 , 4 1 6 2 0 a n d 4 D e n t u r i s t r e f e rr e d t o i n p a r a g r a p h ( b ) o f t h e 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 w h o r e q u i r e s t h e r e p l a c e m e n t o f a f u ll u p p e r , s e r v i c e s u n d e r ( a ) f e e n u m b e r s 5 1 1 0 1 a n d 5 1 1 0 2 i n t h e S c h 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 a s i c d e n t a l s ( b ) f e e n u m b e r s 3 1 3 1 0 , 3 1 3 2 0 o r 3 1 3 3 0 i n t h 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 e d e f i n i t i o n 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 w h o h a s n o t 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 C r o w n a n d b r i d g e w o r k s u p p l e m e n t -4 . 1 ( 1 ) I n t h i s s e c t i o n , " c ro w n a n d b r i d g e w o r k " m e a n s a ( a ) t h a t i s p r o v i d e d b y a d e n t i s t , ( b ) t h a t 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 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 ( c ) t h a t 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 f o r t h e s e r v i c e ( d ) f o r w h i c h a p e r s o n h a s r e c e i v e d t h e p r e a u t h o ( 2 ) A h e a l t h s u p p l e m e n t m a y b e p a i d u n d e r s e c t i o n b u t o n l y i f t h e m i n i s t e r i s o f t h e o p i n i o n t h a t t h e p e r c o r r e c t e d t h r o u g h t h e p r o v i s i o n o f b a s i c d e n t a l s e r v i ( a ) t h e d e n t a l c o n d i t i o n o r e c l u d e s t h e o r o v i s i o n o f t h EAA T 0 0 3 ( 1 0 / 0 6 / 0 1 )n d e n t c h i l d , a n d 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 ) . t a l s e r v i c e o n l y t o a p e r s o n l d . e x c e e d e d b y a n a m o u n t n e c e s s a r y t o p r o v i d e a i n i n g t o t h e p e r s o n u n d e r t h o s e l i m i t s a t t h e f u l l l o w e r d e n t u r e o r b o t h b e c a u s e o f e x t r a c t i o n s i n , l a c e a t l e a s t 3 c o n t i g u o u s m i s s i n g t e e t h o n t h e e d i n t h e p r e v i o u s 6 m o n t h s t o r e l i e v e p a i n , o r b i l i t y a s s i s t a n c e o r i n c o m e a s s i s t a n c e fo r a t l e a s t e s r e p l a c e m e n t d e n t u r e s . s p e c t 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 ) i d e d 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 ) , w h o r e q u i r e s 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 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 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 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 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 i d e d 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 ) a f u l l l o w e r d e n t u r e o r b o t h a r e l i m i t e d t o 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 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 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 " 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 ro 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 p e r s o n s f o r a t l e a s t 2 y e a r s . d e n t a l s e r v i c e C r o w n a n d B r i d g e w o r k , t h a t i s e f f e c t i v e A p r i l i n i s t e r , i n t h a t S c h e d u l e , a n d r i z a t i o n o f t h e m i n i s t e r . 6 3 . 1 o f t h i s r e g u l a t i o n f o r c r o w n a n d b r i d g e w o r k s o n h a s a d e n t a l c o n d i t i o n t h a t c a n n o t b e c e s b e c a u s e e r e s t o r a t i v e s e r v i c e s s e t o u t u n d e r t h e
R e s t o r a t i v e S e r v i c e s s e c t i o n o f t h e S c h e d u l e o f F e e ( b ) o n e o f t h e f o l l o w i n g c i r c u m s t a n c e s e x i s t s : ( i ) t h e d e n t a l c o n d i t i o n p r e c l u d e s t h e u s e o f a r e m ( i i) t h e p e r s o n h a s a p h y s i c a l i m p a i r m e n t t h a t m a k r e m o v a b l e p r o s t h e t i c ; ( i i i ) t h e p e r s o n h a s a n a l l e r g i c r e a c t i o n o r o t h e r i n a r e m o v a b l e p r o s t h e t i c ; ( i v ) t h e p e r s o n h a s a m e n t a l c o n d i t i o n t h r e s p o n s i b i l i t y fo r a r e m o v a b l e p r o s t h e t i c . ( 3 ) T h e m i n i s t e r m u s t a l s o b e s a t i s f i e d t h a t a h e a d e q u a t e t o c o r r e c t t h e d e n t a l c o n d i t i o n . ( 4 ) A h e a l t h s u p p l e m e n t fo r c ro w n a n d b r i d g e w o t o o t h m o r e t h a n o n c e i n a n y p e r i o d o f 6 0 c a l e 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 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 p p e l l a n t ' s P o s i t i o n T h e a p p e l l a n t a r g u e s t h e r e c o m m e n d e d d e n t a l i m p l d e n t u r e , w i t h o u t w h i c h h e c a n n o t c h e w f o o d . H e s h f a c i a l l o o k s w i t h o u t t e e t h , o r b e r e s t r i c t e d t o a d i e t o T h e a p p e l l a n t s a y s h e i s a p e r s o n w i t h d i s a b i l i t i e s w y e a r s , a n d t h e m i n i s t r y h a s k n o w n fo r y e a r s o f h i s n f u n d i n g t h i s y e a r , t h e m i n i s t r y h a d n e v e r t o l d h i m t h e o p p o r t u n i t y t o a r r a n g e fo r e x t e n d e d d e n t a l i n s u r a n c e M i n i s t r y ' s P o s i t i o n T h e m i n i s t r y a r g u e s t h a t t h e o n l y d e n t a l h e a l t h s u p p 6 3 , 6 3 . 1 a n d 6 4 o f S c h e d u l e C i n t h e E A P W D R . T h i m p l a n t s o r c o m m e r c i a l l a b o r a t o r y f e e s . T h e m i n i s t r s e r v i c e s a s s o c i a t e d w i t h i m p l a n t s o r f o r c o m m e r c i a l p o l i c y a n d t h e m i n i s t r y h a s n o d i s c r e t i o n i n t h i s m a t t e T h e m i n i s t r y a l s o s t a t e s t h a t a l t h o u g h t h e r e i s c o v e r a s e c t i o n 6 9 , t h e a p p e l l a n t d o e s n o t f a c e a d i r e c t a n d i t h e r e i s n o p r o v i s i o n f o r d e n t a l a n d d e n t u r e s u p p l e m EAA T 0 0 3 ( 1 0 1 0 6 / 0 1 )A l l o w a n c e s D e n t i s t , a n d o v a b l e p r o s t h e t i c ; e s i t i m p o s s i b l e f o r h i m o r h e r t o p l a c e a t o l e r a n c e t o t h e c o m p o s i t i o n o r m a t e r i a l s u s e d i n a t m a k e s i t i m p o s s i b l e f o r h i m o r h e r t o a s s u m e a l t h s u p p l e m e n t f o r c r o w n a n d b r i d g e w o r k w i l l b e r k m a y n o t b e p r o v i d e d i n r e s p e c t o f t h e s a m e n d a r m o n t h s . 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 a l s e r v i c e s . a n t s a r e n e c e s s a r y t o e n a b l e h i m t o u s e a o u l d n o t h a v e t o s u f f e r j a w p a i n , t h e h u m i l i a t i o n o f f s o f t f o o d fo r t h e r e s t o f h i s l i f e . h o h a s b e e n i n t h e c a r e o f t h e m i n i s t r y fo r m a n y e e d fo r a s p e c i a l d e n t u r e . U n t i l t h e d e n i a l f o r r e m a y n o t b e c o v e r a g e , g i v i n g h i m n o . l e m e n t s p a y a b l e a r e t h o s e p r o v i d e d i n s e c t i o n s e r e i s n o p r o v i s i o n i n t h e l e g i s l a t i o n f o r d e n t a l y i s t h e r e f o r e n o t a b l e t o p r o v i d e f u n d i n g f o r l a b o r a t o r y f e e s . T h e r e a r e n o e x c e p t i o n s i n r . g e f o r a l i f e t h r e a t e n i n g n e e d u n d e r E A P W D R m m i n e n t l i f e t h r e a t e n i n g n e e d , a n d i n a n y c a s e e n t s .
Panel's Decision The appellant is a disabled adult who lives in care, and because he has a misaligned jaw and no remaining functional teeth he is no longer able to chew his food. The remedy is an upper denture that must be attached to two implants because there is not enough remaining tooth structure to use a conventional removable denture. The ministry has denied funding for the implants and related services on the basis of the applicable legislation. EAPWDR sections 63, 63.1, 64 state the ministry may fund only dental work as provided by Schedule C sections 1, 4, 4.1 and 5, which in turn require the services be set out in the applicable Schedule of Fee Allowances. The schedule does not include dental implants or related services. The ministry says there are no exceptions and that it has no discretion in this matter. The ministry has applied the legislation as written. The panel finds the ministry's decision was reasonably supported by the evidence and confirms the decision. EAA T003(10/06/01)
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.