Ministry of Social Development and Poverty Reduction

Appeal Number 2023-0314 Part C – Decision Under Appeal The decision under appeal is the Ministry of Social Development and Poverty Reduction (the ministry) reconsideration decision (the decision) dated 22 September 2023 where the ministry denied the appellant’s request for coverage of dental treatments for a complete denture and examination fees. The ministry determined it is not authorized to provide coverage for: • fees in excess of the rates set out in the Schedule of Fee Allowances – Denturist, • dental services as a Life-Threatening Need health supplement, or • dental services as a Crisis Supplement.

Part D – Relevant Legislation Employment and Assistance for Persons with Disabilities Act (Act) section 25

Employment and Assistance for Persons with Disabilities Regulation (Regulation), sections 57, 62, 63, 64, and 69, and Schedule C, sections 1, 4, 4.1, and 5.

Schedule of Fee Allowances – Denturist, Emergency Dental – Denturist

Relevant sections of the legislation can be found in the Appendix at the end of this decision.

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Appeal Number 2023-0314 Part E – Summary of Facts A telephone hearing was held on October 30, 2023.

Relevant Evidence before the Ministry at Reconsideration

• A predetermination submitted on 15 May 2023 to Pacific Blue Cross (PBC) on behalf of the ministry for a new patient exam and maxillary denture was approved on May 24, 2023. The amount submitted by the denturist was $2320.00, the maximum approved ministry rate was $605.25, leaving an amount not covered of $1714.75.

The appellant had provided the following comments as submission;

• For 30 years or more the appellant had 100% coverage, after the $100 to $150 office fee. • She went through a lot of dentures in the beginning, using store-bought liners to get through five years. The appellant met a denturist in a major city who recognized her problem and changed her bite profile. Over 5 years later a small hole appeared. • A new denturist built a plate but it only lasted 8 months. A new denture would cost $3000. • The appellant called another office and was told that she does not qualify for five years, and only qualifies for 40% of the approximate price. The bill was over $2000, and her pension is only $700. The denturist then held her teeth hostage until she paid $850 and promised another $850 sixty days later (the panel notes this as the correct amounts reported by the appellant and not $550 as shown by the ministry). • This has caused extreme hardship for the appellant in the last two months, and it will take another two months before she is out of the red, which will only happen if she buys no groceries, no medications, no gas and no winter fuel. The appellant states she is using her overdraft but even that costs money. • As a senior, her health is important, needing to eat vegetables, fruit, and fish, but she cannot afford them and cannot eat them without teeth.

Additional Information provided on Appeal

Included with the notice of appeal was a letter from the BC College of Oral Health Professionals dated 22 September, which also included a Dental Practitioner Questionnaire. The panel notes that only page 1 of 4 pages of the questionnaire had been included in the package.

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Appeal Number 2023-0314 This letter and questionnaire have been provid ed in response to a complaint to the college about the denturist by the appellant.

The letter states the college’s understanding and position that; • the appellant had been seen by a denturist on 3 May 2023 and agreed to a treatment plan, • the appellant had paid $857 as a fifty per cent, non-refundable fee to the denturist, • following a telephone call between the appellant and the denturist to book the next appointment the appellant had been dismissed as a client for verbal abuse of the denturist staff, • the monies were being withheld as work had already been undertaken on the new denture, • its ability to investigate complaints is limited to items which may raise a competency or conduct issue, and that financial compensation or refund of monies cannot be ordered.

The letter offered to consider any further comments the appellant may make upon the Denturist’s response questionnaire.

The single page of the questionnaire contained practitioner and patient information to include name, address, and telephone numbers. The bottom of this first page also includes some description of denture status.

In the notice of appeal, the appellant also provided a handwritten note that referenced the college letter and questionnaire. The appellant stated that; • contrary to the college letter she had not been contacted by telephone by the denturist, and that the telephone number shown as her contact number in the questionnaire was clearly incorrect, • there was a typographical error made by the ministry in the reconsideration decision referring to the amount of deposit paid by the appellant, • she has been accused of something she did not do and has been harmed by being removed from the client list, • she is suffering from financial hardship, and • now has trouble eating as the crack in her current old set of dentures pinches her cheek.

The panel notes the clarification to amounts paid have been reflected in the background information provided above.

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Appeal Number 2023-0314

At the hearing the appellant explained her current situation and reiterated the comments made in her request for reconsideration.

She stated that she has not been able to purchase a replacement denture as she has been dismissed as a client of the denturist and is out of pocket $857.00.

The appellant pointed out that she had been sent a letter to tell her she was being dismissed for verbal abuse of staff over the phone. The appellant, referring to the incorrect telephone number shown on the denturist’s questionnaire, believes this shows that whoever the staff had spoken to, it was not her. She believes this is supported by her assertion that she has never been contacted by the office staff about a second appointment.

The appellant believes that she should not have to pay for denture replacement as she has met the five-year eligibility requirement and has never had to pay for dentures before. This includes services over the last thirty years, as she had her teeth removed early in life.

In questioning the appellant stated that she has not spoken to the denturist about obtaining the contracted replacement denture set or about a refund of the $857 deposit This was because he had accused her of something she did not do – abuse of staff. The appellant is now using ‘gorilla glue’ to seal the repeating crack in her old set of dentures.

The appellant stated that she had her last set of dentures supplied 12 years ago and that is the set she is using now. When a hole appeared in this denture over five years later, she had gone to another practitioner who had built a replacement plate. The cost was only $150 for an office fee. She went back to this practitioner when the plate cracked within six months. The practitioner stated he could not repair the plate and offered to supply a new set for $3000.

Not being able to pay this amount, the appellant carried on for another two months until this plate broke apart. She then went back to using the older set, that is the cracked set she is using now.

Once the appellant visited the new denturist in May of 2023, she only found out about not being eligible for the full cost of replacement when she had completed the office consultation and was at the front desk. The denturist would only return her old denture set after she paid a fee of $857 as a fifty per cent downpayment and agreed in writing to pay the second installment in sixty days.

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Appeal Number 2023-0314

Although surprised at the supposed need to pay the appellant agreed and left the office without incident.

The appellant then contacted the ministry to clarify the eligibility criteria and see if the circumstances of approval had changed. The appellant now understands the criteria of eligibility.

It was only later that she received a letter from the denturist about the claim of verbal abuse.

The appellant confirmed she had contacted the college of oral health professionals to complain about being dismissed as a client by her denturist and not being able to obtain a replacement denture. She has had no further contact with the college following their letter of 22 September 2023 or with the denturist following the office visit, other than the letter she received from him dated 24 May 2023.

In answer to questions the appellant reiterated she had not paid for the replacement plate several years ago believing that the ministry paid for it. She believes she only paid for an office fee.

The appellant states she is now in pain from using the older denture set, maintained by glue. The rough edges which are constantly repaired due to cracking pinch her cheek, pulls skin off and she has a sort of canker on her cheek.

The ministry The hearing was delayed for thirty minutes for the ministry to join the telephone call. The ministry connection to the call was poor and difficult to hear. A number of requests were made to repeat comments. The ministry relied upon the reconsideration decision, simply stating the appellant is eligible for a replacement denture up to the allowable amount shown in the Schedule, and that the ministry cannot pay more than this amount.

At questioning the ministry responded to the appellant’s claim about not paying for previous dentures. The ministry offered that in the past a few denturists would only charge clients the ministry rate, not their full rate. However, this has now changed as time has progressed and professional fees continue to rise, noting the ministry rate has not increased for many years.

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Appeal Number 2023-0314 The ministry, accessing the appellant’s PBC file , stated that the appellant had been approved up to the maximum amount and provided with a new denture in 2017. The total fee charged by the denturist at that time was $1740.00 and the ministry paid the maximum allowed of $605.25 leaving a fee of $1134.75 that must have been paid or absorbed by someone else, possibly the appellant.

The ministry confirmed the maximum amount paid by the ministry in 2017 is the same amount approved in May 2023 by PBC, as it has not changed in the last seven years. The ministry also acknowledged this claim may have been the same treatment as the appellant has described for the manufacture of a new plate several years ago.

The ministry stated that neither it nor the PBC have the power or ability to intercede with the denturist to recover any monies paid by the appellant or arrange for the supply of a new denture to the appellant.

The ministry acknowledged that it would provide information to the college of oral health professionals if they requested it however the ministry would not contact the college directly on the appellant’s behalf. The ministry was sympathetic to the plight of the appellant.

The ministry acknowledged that it included a discussion of emergency dental services in the decision but explained that it would not have looked at this as an option as the crux of this issue is the limitation on the amount that can be paid pursuant to the fee schedule – denturist for an eligible claim for a new denture.

The ministry in response to a concern by the appellant that she now needs to wait five more years until being eligible for a new denture provided comment. The ministry initially stated it has paid the denturist for their portion of the fee, a sum of $605.25. The ministry reiterated that the appellant is eligible for a replacement denture now and has apparently paid the denturist a deposit of half of the residual amount. If she can resolve the issue with the denturist and pays the remainder of the residual amount, she should receive the denture now. When asked to confirm this PBC payment, the ministry, again attempting to access the PBC file, was then not able to confirm in fact whether the ministry portion of $605.25 has been paid to the denturist.

The ministry clarified that if the ministry portion of the fee has been paid then in fact the appellant would not be able to go to another denturist and secure PBC funding. The ministry suggested that if the appellant does go to another denturist, then she should

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Appeal Number 2023-0314 request they seek pre-approval of funding elig ibility from PBC prior to making any contractual agreements.

Admissibility of new information

Apart from the testimony of both parties the appellant has submitted a documentary package. The ministry had no objections to the admissibility of this new information.

The panel determined the additional oral and documentary information is reasonably required for a full and fair disclosure of all matters related to the decision under appeal and therefore is admissible under section 22(4) of the Employment and Assistance Act.

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Appeal Number 2023-0314 Part F – Reasons for Panel Decision The issue on appeal is whether the ministry's reconsideration decision was reasonably supported by the evidence or was a reasonable application of the legislation in the circumstances of the appellant.

Specifically, did the ministry reasonably determine the appellant was not eligible for coverage of dental treatments above the maximum ministry rates (for a complete denture and examination fees).

Appellant Position The appellant argues that she should not have to pay toward the costs of the dental work as she has not had to in the past 30 years. The appellant also seeks assistance in the provision of a denture, which she believes she is entitled to. Further, if she had known that she now has to pay for services she would have saved each month over the five-year qualification period.

Being in pain and without appropriate dentures the appellant is unable to eat properly and is now in financial difficulty following the payment of $857 to a denturist who will now not provide a denture. Lastly the appellant seeks assistance in the reimbursement for the down payment she paid to the denturist.

Ministry Position Assignment to Pacific Blue Cross The ministry states under the Act it may authorize any category of persons to take on any or all of the minister's powers, duties or functions. In the case of dental supplements, the minister's powers, duties or functions are assigned to Pacific Blue Cross.

Basic Eligibility The ministry states, as the appellant is a recipient of disability assistance, she is eligible for coverage of basic dental services and emergency dental services.

Eligibility for Coverage of Dental Fees in Excess of Ministry Rates The ministry argues that it is unable to pay more than the amounts shown in the denturist Fee Schedule and explained in the legislation.

Eligibility for Coverage as a Life-Threatening Health Need or a Crisis Supplement

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Appeal Number 2023-0314 The ministry considered alternative funding or supply means and states the appellant is not eligible for coverage of a complete denture and examination fees as a life-threatening health need, nor is she eligible to receive a crisis supplement to cover dental fees.

Panel Analysis

The panel will first address the relevant sections of the legislation.

Section 25. Act- delegation of minister's powers Section 25 of the Act states, subject to the Regulation, the minister may delegate any or all of the minister's powers, duties or functions under this Act. The panel finds the ministry reasonably determined it could delegate its responsibilities regarding coverage of dental services to Pacific Blue Cross.

Section 57 (Regulation) - crisis supplement Section 57 of the Regulation states the minister may provide a crisis supplement for a family unit that is eligible for disability assistance if the minister considers that failure to meet the expense will result in imminent danger to the physical health of any person in the family unit.

While the panel has noted the appellant is a recipient of disability assistance, the legislation also states that a crisis supplement may not be provided for the purpose of obtaining a supplement described in Schedule C of the Regulation or any other health care goods or services.

The panel acknowledges the importance of the dental work needed, but as the appellant is requesting a dental supplement, which is included in Schedule C, the panel finds the ministry reasonably determined that the appellant was not eligible for coverage of dental work as a crisis supplement under section 57(3) of the Regulation.

Sections 63 (Regulation) - dental supplement

Section 63 of the Regulation states the minister may provide dental and denture supplements (in Schedule C, section 1 and 4) for a recipient of disability assistance.

The panel notes Schedule C defines "basic dental service" as a dental service, that if provided by a denturist, is set out in the Schedule of Fee Allowances - Denturist and is provided at the rate set out in that schedule for the service and the category of the person

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Appeal Number 2023-0314 receiving the service. And "denturist" means a denturist registered with the British Columbia College of Oral Health Professionals. Further that dentures may be provided as a basic dental service to a person whose dentures are more than five years old.

The panel notes the Schedule of Fee Allowances was not provided in the decision, however there is Table 1, that lists ministry rates for fee codes 10010 and 31310 of $24.00 and $581.25 for a total of $605.25. The table is not referenced in the decision discussion. The panel accepts this table as a summary of the information contained within the PBC treatment plan approval document contained within the request for reconsideration package.

The panel accessed the ministry website to view the dental supplement – denturist. Within part B, fee schedule – denturist, the panel notes the code numbers match the above-mentioned dollar amounts for a fee examination and a complete maxillary denture, that being $24.00 and $581.25.

Section 4 (3) of the legislation allows for the maximum amount, of $1000 every two years, for basic dental services to be exceeded in certain circumstances. However, even if the two-year $1000 limit may be exceeded, the amounts in the Fee Schedule still apply. The panel finds that in the circumstances of the appellant, PBC has approved the treatment plan to the full amount listed in the Fee Schedule.

The panel finds the maximum amount payable by the ministry under the legislation for the requested treatment plan to be $605.25. The ministry therefore reasonably determined the ministry is not authorized to provide coverage for fees in excess of the rates set out in the Schedule of Fee Allowances.

Sections 64 (Regulation) - emergency dental and denture supplement Sections 64 of the regulation state the minister may provide emergency dental supplements (in Schedule C section 5) for a recipient of disability assistance.

Schedule C of the Regulation defines "emergency dental service" as a dental service necessary for the immediate relief of pain that, if provided by a dentist, is set out in the denturist fee schedule.

The panel in considering the denturist fee schedule notes that repairs and adjustments to dentures are listed under emergency dental services, although not for the fee code numbers approved by PBC in May 2023 of 10010 and 31310.

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Appeal Number 2023-0314 The ministry did not address any pain circumst ance of the appellant as it was not in front of the ministry at reconsideration and notes that this information has only arisen in appeal. In testimony the ministry has confirmed it addressed emergency dental service solely to determine that any fee payable is limited to those provided in the Schedule of Fee Allowances.

The panel notes that the appellant has testified to suffering from pain as a result of using her old dentures. The panel finds that the appellant may indeed be eligible to obtain emergency dental services to assist with her current pain situation and could consider discussing this with the ministry. The panel finds, however, that the legislation again limits the maximum amount payable to that listed on the Schedule of Fees and that the appellant has already been approved for the maximum funding allowed for dental services 10010 and 31310.

The panel finds therefore that the ministry reasonably determined it is not authorized to provide coverage for fees in excess of the rates set out in the Schedule of Fee Allowances under section 64 of the legislation.

Section 69 (Regulation) - health supplement for persons facing direct and imminent life-threatening health need.

Section 69 of the Regulation states the minister may provide any health supplement set out in sections 2(1)(a) and (f) [general health supplements] and 3 [medical equipment and devices] of Schedule C, if the health supplement is provided for a person who is otherwise not eligible for the health supplement under this Regulation, and if the minister is satisfied that the person faces a direct and imminent life threatening need and the health supplement is necessary to meet that need.

The panel notes that section 2(1)(a) pertains to medical or surgical supplies, section (f) pertains to transportation and section 3 pertains to medical equipment and devices. Dental and denture supplement services are not included in these sections. Therefore, the panel finds the ministry reasonably determined that the appellant was not eligible for coverage under section 69 of the Regulation.

The panel sympathizes with the appellant's difficult situation and acknowledges the appellant's request for an exception to be made. However, the panel is bound by the legislation, as is the ministry.

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Appeal Number 2023-0314 The following comments relate to the circumst ances of the appellant as distinct from the decision.

The panel recognizes the additional complexity that results from dental claims being administered not directly by the ministry, but by a third party (PBC). The panel also acknowledges the appellant’s frustration about the uncertainty as to whether or not funds have been paid to the denturist, which could affect her future eligibility for denture services. The appellant may wish to seek the assistance of an advocate (see section 2 of the appellant’s request for reconsideration application) regarding the issues with the denturist that are beyond the scope of this appeal. The appellant may also wish to contact the ministry for confirmation of the status of PBC payments and about possible help with her current financial situation regarding the inability to purchase heating fuel and food.