APPEAL # PART C – Decision under Appeal The decision under appeal is the May 5, 2015 reconsideration decision of the Ministry of Social Development and Social Innovation (the Ministry) in which the Ministry denied the Appellant a crisis supplement for the purchase of a mattress based on its interpretation of Section 57(3) of the Employment and Assistance for Persons with Disabilities Regulation (EAPWDR) that states a crisis supplement may not be provided for the purpose of obtaining a supplement described in Schedule C of the EAPWDR because a pressure relief mattress is described in Schedule C, Section 3.7. Furthermore the Ministry denied the request because it was not pre-approved by the Ministry therefore the Ministry could not verify that the mattress was the least expensive appropriate medical equipment or device as set out in the general requirements of Schedule C, Section 3. PART D – Relevant Legislation Employment and Assistance for Persons With Disabilities Regulation , (EAPWDR) Section 57 and Schedule C, Sections 3(1) and 3.7
APPEAL # PART E – Summary of Facts Preliminary Information: The hearing was delayed when in progress when all participants were disconnected due to issues with the teleconference system. All participants were reconnected after approximately 10 minutes and the hearing was successfully completed. The evidence before the Ministry at the time of reconsideration included the following: ● A note dated March 24, 2015 from a medical doctor prescribing a pressure relief mattress for the Appellant. ● A letter dated February 23, 2015 from an Occupational Therapist (OT) summarizing the Appellant`s medical history and recommending a pressure reducing memory foam mattress for the Appellant. The letter also states the OT explained to the Appellant that the ministry would not fund a queen size mattress but might fund a pressure reducing overlay or a single mattress and that the Appellant did not like these options. The OT also suggests the queen size bed was needed so that the Appellant could sleep with her boyfriend. The Appellant`s mother went and bought a good mattress from a local furniture store based on the sales person saying the ministry process for funding would take a long time and because the Appellant could not wait and did not want a single bed. ● A quote from a furniture store dated February 17, 2015 for a double memory foam mattress with pressure releasing foam for $499.95; and ● The Appellant’s Request of Reconsideration (RFR) dated April 2, 2015. The Appellant receives PWD benefits as a couple and on February 24, 2015 submitted a request for funding assistance with a bed. On March 12, 2015 the Ministry denied the request because prior approval for the purchase was not obtained and the need had been met (by the Appellant`s mother purchasing a mattress). In the RFR, the Appellant writes that her reason for a request for reconsideration is that her prior bed was over 10 years old, causing her more than one pressure sore. She states that she was unable to transfer on and off from her wheelchair any longer and that she was recovering from a complete break in her leg and her situation was getting more difficult. In order to come home from the hospital after the break in her leg she had to get a new mattress. She adds that to transfer and to get dressed she needs a queen size bed. In an additional page the Appellant explains she had been in the hospital for over 7 weeks due to a break in her upper right leg. She states it was urgent to get a proper bed when she was going to be discharged. Her home mattress was 10 years old, causing her pressure wounds and difficulty transferring in and out of bed. Because of the pain, wounds and safety when transferring, she went with her mother and found a proper pressure relieving mattress. She had a note from her OT for a new bed but needed a queen size for the amount of room she needs to dress. She does not want to risk falling again. She concludes that she has no way to pay for a new bed and this is the first time she has requested funding for one. At the hearing, the Appellant reviewed the facts that her mattress was 10 years old and needed replacement, that she did wait for the Ministry to help but she was not clear of all the procedures that needed to be followed and thought she had given the Ministry sufficient information. She and her mother found the same type of mattress with pressure relief foam that she had previously, gave the
APPEAL # quote to the Ministry, then her mother charged it with the store with the understanding that the Ministry would pay for it. She explained the mattress had a one month return policy, which is now over and the store is waiting for payment. At the hearing the Ministry stated the funding request for the mattress was first considered as a crisis supplement. However, because the pressure relief mattress is listed as medical equipment in Schedule C, it was ineligible for a crisis supplement. The Ministry stated for the funding to be provided under Schedule C as medical equipment, the requested must be pre- authorized by the Ministry and in this case, the request was not. The Ministry had understood that the mattress was purchased by the mother, based on the letter from the OT and not charged as explained by the Appellant. Upon questioning the Ministry explained that for the mattress to be funded as medical equipment, all requirements must be met and in this case, the Ministry had not pre authorized the mattress purchase. The Panel finds as fact that the following: • The Appellant is a recipient of PWD benefits. • The Appellant’s physician and OT have recommended that she purchase a pressure reducing mattress. • The Appellant found a pressure relief mattress and her mother charged it on or before February 23, 2015. • The Appellant submitted a request for funding assistance for a bed on February 24, 2015. • The Appellant has been using the mattress for longer that one month.
APPEAL # PART F – Reasons for Panel Decision The issue on this appeal is whether the Ministry’s decision to deny the Appellant’s request of a crisis supplement for the purchase of a mattress based on its interpretation of Section 57(3) of the Employment and Assistance for Persons with Disabilities Regulation (EAPWDR) that states a crisis supplement may not be provided for the purpose of obtaining a supplement described in Schedule C of the EAPWDR because a pressure relief mattress is described in Schedule C, Section 3.7 is reasonable. Furthermore is the Ministry’s decision to deny the request because it was not pre-approved by the Ministry therefore the Ministry could not verify that the mattress was the least expensive appropriate medical equipment or device as set out in the general requirements of Schedule C, Section 3 is reasonable. The following legislation applies to this appeal: EAPWDR Section 57(3) A crisis supplement may not be provided for the purpose of obtaining (a) a supplement described in Schedule C, or (b) any other health care goods or services. EAPWDR Schedule C Section 3 3 (1) Subject to subsections (2) to (5) of this section, the medical equipment and devices described in sections 3.1 to 3.12 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. (2) For medical equipment or devices referred to in sections 3.1 to 3.8 or section 3.12, in addition to the requirements in those sections and subsection (1) of this section, the family unit must provide to the minister one or both of the following, as requested by the minister: (a) a prescription of a medical practitioner or nurse practitioner for the medical equipment or device;
APPEAL # (b) an assessment by an occupational therapist or physical therapist confirming the medical need for the medical equipment or device. EAPWDR Schedule C Section 3.7 (1) A pressure relief mattress is a health supplement for the purposes of section 3 of this Schedule if the minister is satisfied that the pressure relief mattress is medically essential to prevent skin breakdown and maintain skin integrity. (2) The period of time referred to in section 3 (3) (b) of this Schedule with respect to replacement of an item described in subsection (1) of this section is 5 years from the date on which the minister provided the item being replaced. In the Appellant’s Notice of Appeal dated May 15, 2015, she argues that the mattress is a necessity for skin breakdown and that she is in need of help for funding. At the hearing, the Appellant argues she urgently needed a pressure relieving mattress, that she needs a queen size mattress in order to dress safely, that she has no funds to pay for a proper mattress and this is the first time she has requested funding for one. Furthermore she argues that she was of the understanding that she had fully explained her need to the Ministry and that the specific procedure as to how to apply for funding for medical equipment was not made clear to her by the Ministry. The Ministry argues it cannot fund the mattress through a crisis supplement because pressure relief mattresses are described as a supplement in Schedule C of the EAPWDR. Secion 57(3)(a) of the EAPWDR provides that a crisis supplement may not be provided for the purpose of obtaining a supplement described in Schedule C. The Panel finds the that pressure relief mattresses are clearly defined in Schedule C, Section 3.7(1) and as such finds the Ministry`s determination that it may not be provided as a crisis supplement under the EAPWDR, Section 57(3) is reasonable. The Ministry is satisfied that the pressure relief mattress is medically essential to prevent skin breakdown and maintain skin integrity as specified in the EAPWDR, Schedule C Section 3.7. Furthermore, under the general requirements set out for the purchase of supplements specified in Schedule C, the Ministry acknowledges the Appellant has no alternate sources of funding to reimburse her mother for the mattress and is satisfied that the mattress has been prescribed by a medical doctor and confirmed by a OT. The Ministry argues that there is insufficient information to establish the mattress is the least expensive appropriate item because the Appellant submitted only a single quote and did not provide any specifics about the type, size, or cost of the actual mattress purchased. The Ministry argues the purchase of the mattress was not pre-approved by the Ministry and without
APPEAL # prior authorization the Ministry is not able to determine if the purchased mattress is the least expensive by comparing pricing from various suppliers. Also the Ministry lacks the information to determine if the purchased mattress is the most appropriate based on the needs of the Appellant, and lacks verification that a queen size bed is medically necessary. Schedule C, Section 3(1)(b) states that all the general requirements set out for funding of medical equipment or devices must be met in order for health supplements to be provided by the minister. Section 3(1)(b)(i) provides that a family unit must receive pre-authorization from the Ministry for the medical equipment or device requested. In this case the Appellant needed the mattress and obtained one by charging it, then made a request for funding to the Ministry and did not wait for pre authorization from the Ministry. The Panel finds the Ministry was reasonable in its decision that the request did not meet the requirement for pre authorization under the EAPWDR, Schedule C, Section 3(1)(b)(i). A further requirement as set out in Section 3(1)(b)(iii) of Schedule C is that the mattress must be the least expensive appropriate medical equipment or device. In this case, the Appellant submitted a single quote for a mattress. The Appellant did not submit any additional information to the Ministry as to the actual type of mattress that was purchased. The Appellant testified a queen size mattress is medically necessary however the letter from the OT speaks of both a single and queen size bed and the prescription from the Appellant’s physician does not specify a size of mattress. The Panel finds the Ministry was reasonable to decide that the quote was insufficient information to determine whether the mattress was the least expensive mattress and the medical information is insufficient to determine whether a queen size mattress is the least expensive appropriate mattress. The Panel finds the Ministry was reasonable in its decision that the request did not meet the requirement as set out in the EAPWDR, Schedule C, Section 3(1)(b)(iii). As the Appellant has not met all the requirements of Schedule C, Section 3(1)(b), the Panel finds the Ministry’s determination to deny the Appellant funding for a mattress was a reasonable application of the legislation in the circumstances of the Appellant. The Panel therefore confirms the Ministry’s decision.
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.