Administratively fair appeal processes must be objective and unbiased.

While on vacation in China, Eve experienced a medical emergency and sought treatment. Upon returning to BC, Eve filled out an out-of-country claim with Health Insurance BC (HIBC) to be reimbursed for approximately $400 worth of expenses not covered by her private insurance.

Eve’s claim was denied by HIBC because she didn’t seek pre-approval for her out-of-country care. Eve then appealed this decision, only to receive a letter indicating that the treatment she received – a root canal – was not an insured benefit.

Unsatisfied, Eve reached out to us for assistance.

In response to our investigation, the ministry explained that when it reviewed Eve’s claim, the documents she provided indicated that the root canal was not performed in an acute care hospital. The ministry explained that reimbursements are only provided for medically necessary dental care completed in an acute care hospital by a licensed oral or dental surgeon.

However, upon reviewing Eve’s file, the ministry determined that in its communication with her, the reasons for its decision could have been clearer. We asked the ministry to write a letter to Eve with a better explanation for its decision, which was agreed to.

We also noted that the same staff member reviewed both Eve’s initial claim and her appeal. A key element of an administratively fair appeal process is for a different person to review an appeal to be objective and unbiased by avoiding a person reviewing their own decision. We spoke to HIBC about this and learned it did not have a policy that requires a different person to review an appeal. To ensure appeals are administratively fair, we asked it to incorporate this practice into its appeal policy, which it agreed to do.