Ministry of Social Development and Poverty Reduction

PART C – Decision under Appeal The decision under appeal is the reconsideration decision of the Ministry of Social Development and Social Innovation (the ministry) dated 31 August 2016 that denied the appellant designation as a person with disabilities (PWD). The ministry determined that the appellant did not meet all of the required criteria for PWD designation set out in the Employment and Assistance for Persons with Disabilities Act, section 2. Specifically, the ministry determined that the information provided did not establish that the appellant has a severe mental or physical impairment that in the opinion of a prescribed professional (i) directly and significantly restricts her ability to perform daily living activities (DLA) either continuously or periodically for extended periods; and, (ii) as a result of those restrictions, she requires help to perform those activities. The ministry determined that the appellant satisfied the other 2 criteria: she has reached 18 years of age and her impairment in the opinion of a medical practitioner is likely to continue for at least 2 years. PART D – Relevant Legislation Employment and Assistance for Persons with Disabilities Act (EAPWDA) – section 2 Employment and Assistance for Persons with Disabilities Regulation (EAPWDR) – section 2

PART E – Summary of Facts The evidence before the ministry at reconsideration consisted of the following: 1. The appellant’s PWD Designation Application dated [no day] March 2016. The Application contained:  A Self Report (SR) completed by the appellant.  A Physician Report (PR) dated 01 April 2016, completed by the appellant’s general practitioner (GP), who has known the appellant for 5 years and seen her 2-10 times over the past year.  An Assessor Report (AR) dated 08 April 2016, completed by a social worker (SW) who has known the appellant for 2 weeks and seen her once. 2. The appellant’s Request for Reconsideration submitted on 30 August 2016, attached to which are the following:  A second Self Report (SR2), undated.  A letter from the appellant’s GP dated 19 August 2016.  A submission by the appellant’s advocate, undated (reconsideration submission).  A letter of support from the appellant’s roommate dated 25 August 2016. In the PR, the GP diagnoses the medical condition related to the appellant’s impairment as Raynaud’s Disease (onset approx. 2005). The panel will first summarize the evidence from the PR, the AR and GP’s letter as it relates to the PWD criteria at issue in this appeal. Severity/health history Physical impairment PR: Under Health History, the GP writes: “Daily living chores causes severe pain. Coming into contact with any cold objects exacerbates an already painful condition, which causes [illegible] pains.” Under Degree and Course of Impairment the GP indicates that the impairment is likely to continue for two or more years, commenting, “Chronic pain and discomfort affecting quality of life as well as daily living.” As to functional skills, the GP reports that the appellant can walk 2 - 4 blocks unaided, can climb 5+ steps unaided, is limited to lifting 5 to 15 lbs., and there is no limitation to remaining seated. The GP indicates that the appellant has not been prescribed medication and/or treatments that interfere with her ability to perform DLA, commenting, “Awaiting further investigation. Stress test negative.” GP’s Letter: In the letter, the GP writes: “[The appellant] has severe Raynaud disease. [She] can walk 4 blocks in ideal weather conditions, but is limited in cold conditions and thus hampering her and doing housework

and shopping. Frequent affection of her condition during summer resulting in hot clammy hands and in winter she experiences cold fingers multiple times a day.” AR: Regarding mobility and physical ability, the SW assesses the appellant as follows (comments in parenthesis): Walking indoors – periodic assistance from another person required (cannot walk on bare feet at all). Walking outdoors – continuous assistance from another person or unable (from Sept – April can only stay outdoors for 10-15 min). Climbing stairs – Independent. Standing – periodic assistance from another person required (faints frequently, 10-15 min. standing only). Lifting – independent. Carrying and holding – periodic assistance from another person (poor circulation makes this very difficult). The SW comments: “When the weather is cold or wet (Sept – April ) hands & feet become white, cold and more difficult to manipulate. This can take 10 – 45 minutes to recover from.” In providing additional comments, the SW writes: “Raynaud’s Syndrome is very limiting for this woman. She cannot do activities she enjoys such as walking outdoors in cool weather or taking her grandchildren to the park. It makes many activities of daily living very challenging.” Mental impairment PR: The GP assesses the appellant as having no difficulties with communications. The GP indicates that the appellant has no significant deficits with cognitive and emotional function. AR: The SW assesses the appellant's ability to communicate as good for speaking, reading, and hearing, and poor for writing, explaining: “Hands get very cold & white when trying to use a pen or keyboard. This happens multiple times/day. Can take 10 – 45 min to recover to be able to write again.” Regarding cognitive and emotional functioning, the SW indicates that the appellant's mental impairment has the following impacts: Major impact: none. Moderate impact: bodily functions. Minimal impact: emotion (anxiety) and impulse control. No impact: consciousness, insight and judgment, attention/concentration, executive, memory, motivation, motor activity, language, psychotic symptoms, other neuropsychological problems, and other emotional or mental problems.

The SW comments: “Bodily functions – Difficult to hold or prepare cold foods. Cannot touch cold water. Difficult to sleep if hands or feet get cold.” Ability to perform DLA PR: The GP indicates that the appellant’s impairment directly restricts her ability to perform DLA. The GP assesses the appellant as restricted in her ability to perform the following DLA on a continuous basis: personal self care, meal preparation, management of medications, basic housework, daily shopping, mobility inside the home, and mobility outside the home. The GP assesses the appellant as independent for use of transportation, management of finances, and social functioning. The GP comments: Can manage but severely limited. AR: The SW assesses the assistance required for managing DLA as follows (the SW’s comments in parentheses): Personal care – independent for dressing, toileting, transfers in/out of bed, and transfers on/off of chair; periodic assistance from another person required for grooming (must use warm water), bathing (cannot walk on cold ground, or stand in cold shower stall), feeding self/regulating diet (cannot touch cold food for long – when hands cold cannot prepare foods, difficulty opening jars). Basic housekeeping – periodic assistance from another person required for laundry (difficult to touch wet clothing), and basic housekeeping (can only use warm H2O). Shopping – continuous assistance from another person for unable for going to and from stores, reading prices and labels, paying for purchases and carry purchases home (Avoids if weather is too cold or wet. Cannot carry any cold items. If store is too cold it causes problems. Only shops for 20 min. at the time. Very difficult to hold bags of groceries.); independent for making appropriate choices. Meals – continuous assistance from another person or unable for meal planning, food preparation and cooking (Eats simple, easy to prepare foods. Cannot hold cold items, will have difficulty holding utensils if hands are cold. Cannot open jars when hands are cold); independent for safe storage of food. Pay rent and bills – independent in all aspects. Medications – independent in all aspects. Transportation – independent for getting in and out of the vehicle and using transit schedules and arranging transportation; continuous assistance from another person or unable for using public transit (Cannot wait for transit outdoors). The SW adds: “Due to poor circulation, fainting is an issue. Standing for 10 – 15 min. can be a problem. Fall risk due to fainting.” With respect to social functioning, the SW assesses the appellant as independent for making appropriate social decisions, interacting appropriately with others and securing assistance from others; requiring periodic support/supervision for developing and maintaining relationships and

dealing appropriately with unexpected demands (Avoids social situations that might cause hands or feet to get cold, such as walking outdoors or going to the swimming pool). The SW assesses the impact of the appellant's mental impairment on her immediate social and extended social networks as good functioning. Help provided/required PR: The GP indicates that the appellant does not require any prostheses or aids to compensate for her impairment. In commenting on help required for DLA, the GP writes, “Can manage but severely limited.” AR: The SW indicates that help is provided to the appellant by community service agencies. The SW does not indicate that the appellant requires any of the listed aids to compensate for her impairment. GP’s letter: The GP lists the current aids for the appellant’s condition: thermal socks, thicksoled shoes, bathtub rubber mat, gloves – latex for housekeeping, woolen for outdoors, foot and hand warmers in winter, sockettes in summer. Self report In describing how her Raynaud’s Syndrome/phenomena affects her life, she writes that: On any given day, her hands are always extremely cold, making it very uncomfortable to touch her own skin, put on underwear and socks. She always runs tap water until water is warm, as cold water makes her fingers icy cold and the cold shivers run through her body. Cleaning with a damp cloth turns her fingers white and painful. Clenching hands, such as with vacuuming or sweeping, has the same affect. She cannot walk barefoot at home, as toes and soles of feet hurt instantly. Even in socks and slippers her feet hurt multiple times a day. She must step from bathmat directly onto a pre-warmed shower stall floor. When chilblains are active, it is painful to wear slippers or shoes and therefore she cannot go out. Food preparation is painful – handling cold food, such as cheese, vegetables, refrigerated jars, turns her fingers white before meal is even eaten. She must wear gloves to handle food in the freezer. If car door handle is wet her hands whiten and cause pain. With gloves on, scraping the windshield causes agony. She must also wear gloves to drive 8 months of the year. She has to wear gloves in supermarkets to push her cart and to handle vegetables, cold and frozen meats, and beverages. Many times after being outside for 15 minutes plus, her hands and feet are so cold and frozen she cannot trust her ability to drive and must wait till she is “defrosted” – this can

take to 30 minutes of pins and needles. When outdoors, either running errands or for pleasure, she cannot keep her hands from freezing and going white. Gloves help only superficially, maximum 10 minutes, then she has difficulty handling car keys, holding bags, blowing her nose, etc. Carrying supermarket bags cuts off circulation to fingers. She adds that her Raynaud’s Syndrome has affected her quality of life because she can no longer take long walks 8 - 9 months/year and she cannot use public swimming pools for exercise as her hands and feet turn white in the cold change rooms and the water is now too cold, exacerbating and speeding the freezing process. She refers to an attached sheet, not found in the Appeal Record. Request for Reconsideration SR2: In SR2, a 3-page typewritten letter, the appellant writes that she is diagnosed with a severe condition of Raynaud’s syndrome – a severe intolerance for cold. It is a circulation problem that mainly affects the hands and feet. She writes that in her GP’s letter [not found in the Appeal Record] her physician specifically wrote that there are no treatments or aids that are successful with people that have this condition. She follows her physician’s recommendations about ways to prevent flare-ups and how to manage her pain, including wearing gloves when outside the house, covering metal objects with cloth in the house before she touches them and using a padded bathmat to avoid the cold floor. There are no medical devices available to help with her condition, and she does all she can to attempt to provide extra insulation from the cold. In her letter, the appellant provides argument relating to the original decision. In this context, she describes how her condition affects her daily functioning, summarized by the panel as follows:  While she can walk 4 blocks in heated mall, this distance outside, especially in a humid environment, would result in immediate and acute discomfort. If she goes out and becomes cold her feet go numb and she is unable to drive herself home and she does not know how much pressure to apply to the gas pedal. This is not just from September to April, as in the warmer months her hands and feet sweat excessively from an overabundance of blood pushed her fingertips and feet, making them extremely sweaty and clammy, making wheel holding and using her feet almost impossible in the summer months.  When indoors, even in the summer, her feet and hands are always cold. She wears slippers indoors all year round. Carrying and holding are very difficult most of the time as the use of her fingers is severely limited. Meal prep is mostly done by her roommate. Even making a sandwich is very difficult and pain lasts for over an hour. The difficulty is that the cutlery is metal and is cold and the plates feel cold, the vegetables are wet and freeze her hands. She has difficulty opening jars as her muscles do not work when cold.  In terms of housework, holding a vacuum or wet cloth, doing dishes, and yard work are very difficult. The only reason she is able to “semi-function” is because when she is warm enough she will attempt to do chores or activities that will make life easier when she does have an outbreak. She relies heavily on others to help her function.

 Because of her financial limitations, she cannot afford someone to come in and do her laundry, make meals or wash her floors. The fact that she cannot afford it does not mean that she does not need it.  In addition to the pain she experiences when completing any tasks she also is not able to clench or move her hands and feet. When she has an attack, it is much more than just pain. Not only are her hands and feet in pain, but they are numb, she cannot clench her hands. Her entire body breaks out in shivers and she often has to go to bed under the covers to warm up. The after-effects of an attack are the most painful, as when her body starts to warm up the blood returns to her extremities.  Her disability has had a huge impact on her emotional well-being. She cannot go swimming anymore, something she once enjoyed. She is no longer able to enjoy gardening, going for walks with her family or attending a movie. As a result she needs to stay inside and is more isolated. This affects her emotionally. Even touching her grandchild for a hug makes her flinch. She does have help from her roommate, but that is all. Because of her lack of ability to be out and socializing, she does not maintain friendships. She cannot drive to see her friends, go on the ferry to visit her family, go to local events or go to places in nature. Even when she has friends visit her house, if her disability is bad that day, just conversing with them is difficult because she is distracted by the pain. Interacting with people on the computer is difficult because the computer itself is cold. Letter from roommate: In her letter, her roommate writes that the appellant has constant problems with regular household chores, as well as day-to-day functions, not only in winter but throughout the year. There have been many instances where she has had to drive the appellant when she has been in pain. In winter she cannot hold the wheel or even open the door of the car because of the intense and immediate pain. In the warm months, her hands are flooded with blood, making driving very difficult, as her hands are clammy and very sweaty, so it is difficult for her to properly hold the steering wheel. There have been many instances where the appellant could not attend the local food bank due to her disability, so the roommate would go in her place. The lineup is located outside and requires standing for over an hour on the concrete floor, something that the appellant cannot tolerate. In the past, when she attempted this, she came back with chilblains on her feet from standing in the cold, resulting in a doctor visit pain for days afterwards. The roommate also witnessed the appellant’s difficulty in making food, especially preparing refrigerated or frozen foods. She also has problems with handling wet laundry, and washing dishes and even showering gives her very significant negative reactions. They have attempted to adapt their home to better suit the appellant's disability, despite limited means, by heating their home more than average, placing rugs in bathrooms and kitchen and also having towels and gloves easily accessible so that the appellant can use them to open the drawers and handle cutlery. Advocate’s submission:

The advocate’s submission went to argument regarding the original decision (see Part F, Reasons for Panel Decision, below). Notice of Appeal In her Notice of Appeal, dated 02 September 2016, the appellant writes: “My doctor & I believe I meet all the criteria necessary for Disability designation.” The hearing At the hearing, the appellant submitted 2 information articles from the Internet on Raynaud’s disease/syndrome. The roommate also showed the panel and the ministry colour photos on her smart phone of the appellant’s hands when normal and when cold and hot. She explained that it was too costly for her to have them printed in colour. The appellant read from a prepared statement arguing that the reconsideration decision did not take into account the information provided by the appellant, her roommate or her advocate submitted at reconsideration and did not give sufficient weight to the GP’s letter submitted at the same time. The appellant noted that she submitted the reconsideration material on 30 August 2016, and the reconsideration decision was dated the next day. She suggested that, given the fast turn-around, this material was not given the consideration it merited. The appellant’s roommate also argued along the same lines (see Part F, Reasons for Panel Decision, below). During the course of their presentations, the appellant and her roommate provided the following additional information on how her condition affects daily living:  The appellant provided further details regarding her fainting episodes: when she goes from a hot location to a very cold location she has on occasion fainted; this has happened 15-20 times, and now occurs about once a year.  Her roommate usually does all food preparation.  Piles of towels are left near the fridge to use when taking items out.  In ideal conditions she will leave the house on her own, but for no more than 10-20 minutes. Her roommate will go with her 90% of the time.  Details on clammy hands – wet, sweating, dripping, super-sensitive, very uncomfortable, texture irritates; at the same time her feet sweat badly and act like ‘suction cups’ when she walks  Details on cold hands – when blood drains out of her hands she feels pain – when they warm up the pain is worse, so she controls the warming of her hands at home by putting her hands in warm water until the blood circulation returns. Unable to do this in public places, so her hands hurt and she is unable to alleviate the pain when she goes from cold to warm locations.  The appellant cannot manage her finances because she cannot go out in the cold to drop off her rent cheque. The appellant volunteered that the SW completed the AR on the basis of a conversation by phone. The ministry stood by its position at reconsideration. The ministry representative explained that

consideration of the appellant’s Request for Reconsideration was prioritized because her deadline had been extended. As a result the reconsideration decision was completed the day after the request was received. Admissibility of additional information The ministry did not object to the admissibility of the testimony of the appellant and her roommate. The panel finds that the information provided by the appellant and her roommate/advocate in their testimony at the hearing is in support of the information and records before the ministry at reconsideration, as it tends to corroborate the information provided by the appellant in her SR and at reconsideration. The panel therefore admits this testimony as evidence pursuant to section 22(4) of the Employment and Assistance Act.

PART F – Reasons for Panel Decision The issue in this appeal is whether the ministry decision that determined that the appellant did not meet three of the five statutory requirements of Section 2 of the EAPWDA for designation as a person with disabilities (PWD) is reasonably supported by the evidence or is a reasonable application of the legislation in the circumstances of the appellant. The ministry found that the appellant met the age requirement and that, in the opinion of a medical practitioner, her impairment is likely to continue for at least two years. However, the ministry was not satisfied that the evidence establishes that:  the appellant has a severe physical or mental impairment;  the appellant's DLA are, in the opinion of a prescribed professional, directly and significantly restricted either continuously or periodically for extended periods; and,  as a result of these restrictions, the appellant requires the significant help or supervision of another person, the use of an assistive device, or the services of an assistance animal to perform DLA. The following section of the EAPWDA applies to this appeal: 2 (1) In this section: "assistive device" means a device designed to enable a person to perform a daily living activity that, because of a severe mental or physical impairment, the person is unable to perform; "daily living activity" has the prescribed meaning; "prescribed professional" has the prescribed meaning. (2) The minister may designate a person who has reached 18 years of age as a person with disabilities for the purposes of this Act if the minister is satisfied that the person has a severe mental or physical impairment that (a) in the opinion of a medical practitioner is likely to continue for at least 2 years, and (b) in the opinion of a prescribed professional (i) directly and significantly restricts the person's to perform daily living activities either (A) continuously, or (B) periodically for extended periods, and (ii) as a result of those restrictions, the person requires help to perform those activities. (3) For the purposes of subsection (2), (a) a person who has a severe mental impairment includes a person with a mental disorder, and (b) a person requires help in relation to a daily living activity if, in order to perform it, the person requires (i) an assistive device, (ii) the significant help or supervision of another person, or (iii) the services of an assistance animal. The following section of the EAPWDR applies to this appeal: 2 (1)For the purposes of the Act and this regulation, "daily living activities", (a) in relation to a person who has a severe physical impairment or a severe mental impairment, means the following activities: (i) prepare own meals; (ii) manage personal finances; (iii) shop for personal needs; (iv) use public or personal transportation facilities; (v) perform housework to maintain the person's place of residence in acceptable sanitary condition; (vi) move about indoors and outdoors;