Reimbursement for an extraordinary expense

Authority Health Insurance BC - Pharmacare, Ministry of Health

Marla had recently arrived in British Columbia as a refugee and had been enrolled in the Medical Services Plan (MSP) for a few months. While she was temporarily in Alberta, Marla’s prosthetic leg broke. She had it repaired in Alberta and then asked PharmaCare to reimburse her for the $900 it cost to repair. Marla was told that she was not eligible for reimbursement because she had not registered in the Fair PharmaCare program. She had been unaware that registration in the Fair PharmaCare program was a separate requirement from enrolment in MSP.

PharmaCare assists with the cost of certain prescription drugs and medical supplies once an eligible person has paid an annual deductible that ranges from $0 - $10,000. The $10,000 deductible is automatically assigned to a person who is enrolled in MSP but has not registered with Fair PharmaCare and provided information about their annual income. As Marla had not registered with Fair PharmaCare, she was automatically given a deductible of $10,000; however, based on her actual income, her eligible deductible was far lower.

We investigated whether PharmaCare had followed a reasonable procedure in responding to Marla’s request for reimbursement. In the course of our investigation, we learned that there might be other barriers to Marla’s eligibility for reimbursement. In particular, policy required pre-approval for any prosthetic work in excess of $400 and it required that services be provided by an approved supplier.

We had a number of discussions with PharmaCare staff who confirmed that the repair was done by an approved supplier. As a result of our consultation, PharmaCare decided that Marla’s circumstances were unusual and agreed on an exceptional basis to process her claim for reimbursement of the prosthetic. Marla was very pleased with this outcome and we considered the complaint to be settled.

Category Health
Type Case Summary
Fiscal Year 2012
Location The Lower Mainland