PART C -DECISION UNDER APPEAL The decision under appeal is the Ministry of Social Development and Poverty Reduction's (the "ministry ") Reconsideration Decision of December 19, 2018 in which the ministry determined that the appellant was not eligible to receive coverage for a full cast metal crown; pursuant to Schedule C, subsection 4.1(2)(a) of the Employment and Assistance for Persons with Disabilities Regulation {EAPWDR). PART D -RELEVANT LEGISLATION EAPWDR Employment and Assistance for Persons with Disabilities Regulation, Schedule C 4.1(2)(a)
P A R T E S U M M A R Y O F F A C T S T h e i n f o r m a t i o n b e f o r e t h e m i n i s t ry a t t h e t i m e o f r e c o n 1 ) N o v e m b e r 1 4 , 2 0 1 8 T h e m i n i s t r y i n d i c a t e s t h a t o A d a t e d S e p t e m b e r 1 2 , 2 0 1 8 d e n t a l c l a i m s u m m a r i z e d a c l a i m s u b m i s s i o n f o r a f u l e d i t e d b y h a n d t o c o m b i n e t w o f e e c o d e " T o o t h 4 6 c r a c k e d a n d v e ry b i t e s e n s i t i v M , D , B , L ' 1 • o X R a y o f t e e t h o L e t t e r r e t u r n e d t o i n s u r a n c e p r o v i d e r b y O r i g i n a l l e t t e r , d a t e d O c t o b e r 4 , 2 0 1 8 w a r e q u e s t f u r t h e r i n f o r m a t i o n w i t h r e g a r d s P h y s i c i a n r e s p o n d s v i a h a n d w r i t t e n c o m t h a t y o u d o n o t h a v e a d e n t a l p r o s t h e t i c P h y s i c i a n s t a t e s " D u e t o n a t u r e o f m u l t i p r e n d e r t h e r e m a i n i n g t o o t h s t r u c t u r e w e o O c t o b e r 2 3 , 2 0 1 8 I n s u r a n c e p r o v i d e r P r S u m m a r i z e s t h e d e n i a l o f c o v e r a g e f o r t h o O c t o b e r 2 3 , 2 0 1 8 I n s u r a n c e P r o v i d e r D I n s u r a n c e p r o v i d e r d e t a i l s t h e r e a s o n s f o c o n d i t i o n p r e c l u d e s t h e p r o v i s i o n o f r e s t s e c t 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 D e n t i s t . F u r t h e r , t h e c l i n i c a l e x p l a n a t i o n c a n n o t b e m e t t h r o u g h t h e B a s i c D e n t a l c o n f i r m t h a t o n e o f t h e c i r c u m s t a n c e s l i c o � 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 o v a m a k e s i t i m p o s s i b l e f o r h i m t o p l a c e a r e r e a c t i o n o r o t h e r i n t o l e r a n c e t o t h e c o m 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 a t m f o r a r e m o v a b l e p r o s t h e t i c ) . o D e c e m b e r 5 , 2 0 1 8 T h e a p p e l l a n t p r o v i N o v e m b e r 2 8 , 2 0 1 8 l e t t e r / q u e s t i o n n a i r e D e c e m b e r 3 , 2 0 1 8 T h e c o m p l e t e d q u e g e n e r a l i z e d a n x i e t y , 2 ) d u e t o h e r a n x i e t p r o s t h e t i c , a n d 3 ) a p r o s t h e t i c t o o t h w o a b l e t o f u n c t i o n i n e v e r y d a y l i f e , a n d 4 ) t s i d e r a t i o n i n c l u d e d t h e f o l l o w i n g : t h e y h a d r e c e i v e d ; f o r m p r e p a r e d b y t h e a p p e l l a n t ' s p h y s i c i a n w h i c h l c a s t m e t a l c r o w n . T h e m i n i s t ry n o t e s t h a t t h e f o r m i s s i n t o o n e . T h e f o r m i n c l u d e s a p h y s i c i a n s t a t e m e n t e . C r o w n i n d i c a t e d a s d e f i n i t i v e r e s t o r a t i o n . C r a c k s l o c a t e d p h y s i c i a n w i t h e d i t s m a d e O c t o b e r 1 1 , 2 0 1 8 . s s e n t t o t h e p h y s i c i a n b y t h e i n s u r a n c e p r o v i d e r t o t o t h e r e q u e s t f o r c o v e r a g e o f t h e c r o w n . m e n t s . H e p r o v i d e s a l i s t o f m i s s i n g t e e t h a n d i n d i c a t e s . l e f r a c t u r e s a c o m p o s i t e / a m a l g a m r e s t o r a t i o n w o u l d a k , n e c e s s i t a t e s a c r o w n . " e d e t e r m i n a t i o n S u m m a r y e r e q u e s t e d c r o w n e n i a l L e t t e r r d e n i a l : D o c u m e n t a t i o n d o e s n o t i n d i c a t e t h a t t h e d e n t a l 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 m e n t a n d P o v e r t y R e d u c t i o n S c h e d u l e o f F e e A l l o w a n c e s s u b m i t t e d d o e s n o t c o n f i r m t h a t t h i s p a t i e n t ' s n e e d s P r o g r a m . L a s t l y , t h e i n f o r m a t i o n p r o v i d e d d o e s n o t s t e d a b o v e u n d e r s u b s e c t i o n ( b ) e x i s t s ( i . e . , ) t h e d e n t a l b l e p r o s t h e t i c ; 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 o v a b l e p r o s t h e t i c ; a n d o r t h e p e r s o n h a s a n a l l e r g i c 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 r e m o v a b l e p r o s t h e t i c ; a n d 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 r e s p o n s i b i l i t y d e s w i t h h e r r e q u e s t f o r r e c o n s i d e r a t i o n : t o t h e p h y s i c i a n f r o m c o m m u n i t y s e r v i c e s s t i o n n a i r e c o n f i r m i n g 1 ) t h e a p p e l l a n t s u ff e r s f r o m y s h e i s v e ry f o r g e t f u l a n d w o u l d l o s e a r e m o v a b l e d e n t a l u l d c a u s e y o u t o i s o l a t e y o u r s e l f t o t h e p o i n t o f n o t b e i n g h e a p p e l l a n t i s v e r y a w a r e a n d p a r a n o i d a b o u t h e r t e e t h .
Additional Information The appellant submitted on January 15, 2019 and before the oral hearing, additional evidence. The evidence consisted of a January 9, 2019 dated letter addressed to the appellant's physician, and prepared by Community Services. The letter prepared by Community Services was done so by way of questionnaire, and the physician confirmed specifically, that in the opinion of the physician, the nature of the appellant's condition precludes her from having a pre-fabricated, plastic restoration and/or a stainless steel restoration. The representative of the Ministry made no objection to this information being admitted as evidence. The panel found the content of the letter to be relevant and determined it to be admissible, pursuant Section 22 of the Employment and Assistance Act.
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 u n d e r a p p e a l 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 " m i n i s t r y " ) 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 D e c e m b e r 1 9 , 2 0 w a s n o t e l i g i b l e t o r e c e i v e c o v e r a g e f o r a f u l l c a s t m e t a l 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 i l i t i e s T h e r e l e v a n t s e c t i o n o f t h e l e g i s l a t i o n i s a s f o l l o w s : 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 i l i t i e s R 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 ( 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 6 3 . 1 o 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 s o n h a s a d e n t a l c o n b a s i c d e n t a l s e rv i c e s b e c a u s e ( a ) 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 p r o v i s i o n o f t h e r 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 A l l o w a n c e s D e n t i s t , a n d ( b ) o n e of 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 ts : ( 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 o v a b l e ( 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 e s i t i m ( 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 t o l e r a n p r o s t h e t i c ; ( i v ) t h e p e r s o n h o s a m e n t a l c o n d i t i o n t h a t m a k e s i t i m p o r e m o v a b l e p r o s t h e t i c . P a n e l D e c i s i o n T h e m i n i s t r y ' s p o s i t i o n , a s s e t o u t i n t h e r e c o n s i d e r a t i o n c o v e r a g e o f a f u l l c a s t m e t a l c r o w n b e c a u s e s h e d i d n o t S c h e d u l e C s e c t i o n 4 . 1 ( 2 ) ( a ) . S p e c i f i c a l l y , t h e m i n i s t ry a c c w a s e s t a b l i s h e d t h a t s h e h a d a m e n t a l c o n d i t i o n t h a t m a r e m o v a b l e p r o s t h e t i c . H o w e v e r , t h e m i n i s t ry c o n t e n d s t S c h e d u l e C , w h e r e 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 p r s t a i n l e s s s t e e l r e s t o r a t i o n s . T h e a p p e l l a n t ' s p o s i t i o n , s u b m i t t e d a t t h e h e a r i n g , w a s t f o r w a r d b y t h e p h y s i c i a n h a d n o t c l a r i f i e d t h e p r e c l u s i o n E A P W D R . T h e a p p e l l a n t ' s p o s i t i o n w a s t h a t s h e d o e s m e p h y s i c i a n ' s l e t t e r , d a t e d J a n u a r y 9 , 2 0 1 9 , t h e p r e c l u s i o n A s o u t l i n e d , S c h e d u l e C 4 . 1 ( 2 ) ( a ) a n d ( b ) o f E m p l o y m e n t 4 . 1 ( 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 6 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 s o n h a s a d e n t a o f b a s i c d e n t a l s e r v i c e s b e c a u s e ( a ) t h e d e n t a l c o n d i t i o n u n d e r t h e R e s t o r a t i v e S e rv 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 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 P o v e r t y R e d u c t i o n ' s ( t h e 1 8 i n w h i c h t h e m i n i s t r y 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 c r o w n ; p u r s u a n t t o S c h e d u l e C , s u b s e c t i o n 4 . 1 ( 2 ) ( a ) o f t h e R e g u l a t i o n ( E A P W D R ) . e g u l a t i o n , S c h e d u l e C 4 . 1 ( 2 ) ( a ) a n d ( b ) 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 b u t o n l y i f t h e d i t i o n t h a t c a n n o t b e 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 t o r a t i v e s e rv 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 rv i c e s p r o s t h e t i c ; 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 r e m o v a b l e p r o s t h e t i c ; 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 r e m o v a b l e 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 r e s p o n s i b i l i t y f o r a d e c i s i o n , i s t h a t t h e a p p e l l a n t i s n o t e l i g i b l e f o r f u l l m e e t t h e 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 b y t h e E A P W D R , e p t e d t h a t t h e a p p e l l a n t m e t s e c t i o n 4 . 1 ( 2 ) ( b ) , w h e r e i t d e i t i m p o s s i b l e f o r h e r t o a s s u m e r e s p o n s i b i l i t y f o r a h a t t h e a p p e l l a n t h a d n o t e s t a b l i s h e d s e c t i o n 4 . 1 ( 2 ) ( a ) , o f o v i s i o n o f " p r e f a b r i c a t e d " p l a s t i c r e s t o r a t i o n s a n d o r h a t a d m i t t e d l y , t h e d e n t a l c o n d i t i o n i n f o r m a t i o n p u t r e q u i r e m e n t o f s e c t i o n 4 . 1 ( 2 ) ( a ) , o f S c h e d u l e C o f t h e e t t h e r e q u i r e m e n t s , a n d w i t h t h e a d m i s s i o n o f t h e r e q u i r e m e n t s a r e c l e a r l y e s t a b l i s h e d . 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 i l i t i e s R e g u l a t i o n 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 b u t o n l y i f l c o n d i t i o n t h a t c a n n o t b e 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 p r e c l u d e s t h e p r o v i s i o n o f t h e r e s t o r a t i v e s e rv i c e s s e t o u t F e e A l l o w a n c e s D e n t i s t , a n d ( b ) o n e o f t h e f o l l o w i n g
circumstances exists: (iv) the person has a mental condition that makes it impossible for him or her to assume responsibility for a removable prosthetic. The panel finds that the evidence establishes that the appellant did provide a dated January 9, 2019 physician letter prior to the hearing which establishes the said preclusion requirement; specifically, the dental condition precludes the provision of "pre-fabricated" plastic restorations and or stainless-steel restorations. In deliberations, the panel considered that the admissibility of the preclusion information submitted by the appellant was not objected by the ministry. The panel considered that the ministry, at the hearing, had explained that the preclusion requirement information was unclear at the time the decision was made, but not absent. Therefore, the panel finds that the clarifying information submitted does support the information that was before the reconsideration officer at the time the decision was made. Accordingly, the panel finds that the decision of the ministry to deny full coverage of the full metal crown, unreasonably supported by the evidence. Therefore, the panel rescinds the ministry's decision pursuant to section 24(1)(a) and section 24(2)(b) of the Employment and Assistance Act. The appellant therefore is successful in her appeal.
PART G -ORDER THE PANEL DECISION IS: (Check one) [gjUNANIMOUS □BY MAJORITY THE PANEL □CONFIRMS THE MINISTRY DECISION [gjRESCINDS THE MINISTRY DECISION If the ministry decision is rescinded, is the panel decision referred back to the Minister for a decision as to amount? [g!Yes □No LEGISLATIVE AUTHORITY FOR THE DECISION: Employment and Assistance Act Section 24(1)(a) [gj or Section 24(1)(b) D and Section 24(2)(a) D or Section 24(2)(b) [gj PART H -SIGNATURES PRINT NAME Jennifer Armstrong SIGNATURE OF CHAIR DATE (YEAR/MONTH!DAY ) J� Av,nwong, 2019/03/18 PRINT NAME Signed on behalf of: Susan Johnson SIGNATURE OF MEMBER DATE{YEAR/MONTH/DAY) Jennifer Armstrong 2019/03/18 PRINT NAME Kulwant Bal SIGNATURE OF MEMBER DATE(YEAR/MONTH/DAY) 2019/03/18
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.