# 2013-033 Pay and Benefits, Medical Treatment, Spectrum of Care (CF SoC)

Case Summary

F&R Date: 2013–06–06

The grievor was referred to a plastic surgeon to address an underlying medical condition. Dissatisfied with the referral, the grievor identified a plastic surgeon outside the normal referral area. The Canadian Forces (CF) authorized the grievor to consult and to be treated by that surgeon. The reimbursement of the grievor's health-related travel expenses was however limited, being based and calculated on the normal referral area. In regard to the surgery, the CF considered that certain of the medical acts performed were purely cosmetic in nature and, as such, not covered under the Canadian Forces Spectrum of Care (CF SoC) policy. This resulted in the grievor having to pay for some of the medical procedures. The grievor disagreed with the limitation of the health-related travel expenses and argued that the medical acts performed were related to the underlying medical condition and that they should therefore be covered by the CF SoC.

The Initial Authority, the Surgeon General, denied the grievance on the basis that the CF SoC policy only provides coverage for medical acts covered under provincial health care plans, whihc was not the case for the medical acts in question. The Initial Authority further stated that the decision to limit the grievor's health-related travel expenses was reasonable.

On the question of the health-related travel expenses, the Committee found that the CF had the option to refuse the grievor's request to consult and be treated outside the normal referral area. They did not. Therefore, the Committee concluded that since duly authorized, the grievor was entitled to a fair and reasonable reimbursement of the real and admissible health-related travel expenses.

With regard to the health coverage provided by the SoC policy, the Committee disagreed with the Initial Authority and determined that the SoC coverage is not necessarily always limited or equivalent to that of provincial health care plans. Addressing the grievor's underlying medical condition, the Committee found that the SoC policy was permissive and provided for discretion. The Committee therefore obtained the professional opinion of the attending surgeon who explained that the medical procedures performed were not purely cosmetic in nature and that they were completed to address the grievor's underlying medical condition. The Committee subsequently shared the attending surgeon's opinion with the Director Medical Policy who maintained its position that the acts were not covered under the CF SoC. The Committee gave significant weight to the attending surgeon's opinion and found that the medical procedures performed on the grievor were not purely cosmetic in nature and that they should entirely be covered under the CF SoC.

The Committee recommended the Chief of the Defence Staff uphold the grievance.

CDS Decision Summary

CDS Decision Date: 2015–01–15

The CDS disagreed with the Committee's findings and recommendation that the grievance be uphold. The CDS did not agree with the Committee's definition of " purely cosmetic" and found that the performed procedures were “enhanced services". Furthermore, the CDS found that the procedures are not covered in Canada by any provincial health care plan, and it would be inappropriate for CAF members to receive better health care than that which is available to Canadian citizens. Finally, the CDS did not agree with the Committee's finding that because the grievor was authorized an out-of-area appointment, the CAF had the obligation to pay for the all the temporary duty expenses.