A call of last resort…with results

Tania Baldwin is no quitter, but she was almost out of options.

As a last resort, she picked up the phone and called the Alberta Ombudsman. She’s glad she did. In 2008, her daughter Emma, suffering from progressive hearing loss, had been turned down for a second cochlear implant by the former Calgary Health Region. Tania and her family were told that the Government of Alberta was not funding second implants, and that paying out of pocket for the surgery in Calgary would be in violation of the Canada Health Act.

“Emma was diagnosed with progressive hearing loss and by age three and a half, she was profoundly deaf. She didn’t receive her first cochlear implant until she was four years old, which is late,” explains Tania. “By the time she was five, she spoke and understood at a two and-a-half year old level. So time was of the essence. We knew we had to go to the U.S. and get the second implant.”

Emma, who was first diagnosed with moderate hearing loss at two-and-a-half years old, was falling further behind every day her condition was left untreated. As Tania points out, “We’re all born with two ears,” and that while provincial funding for implants for one ear was welcome, having a second functioning ear would make a significant difference for children like Emma.

“We were led to believe that the government absolutely wouldn’t be covering the second implants anytime soon. We looked at our daughter, thinking, ‘She’s already in kindergarten. She’s going into Grade 1.’ It was urgent.”

After the second hearing device was implanted in Texas, and following speech therapy in Calgary, Emma’s condition improved dramatically.

“We came home, got to work, and noticed huge gains in her speech within a week,” says Tania. “She could hear. She just took off. We worked every day, and went to speech therapy three times a week.”

Eight months after Emma’s surgery, the Alberta government announced it would fund second cochlear implants for every child in Alberta under 10 years of age. It was welcome news, and the Baldwin family hoped they could be reimbursed for having paid for the medical procedure themselves.

After submitting a claim for the cost of the second cochlear implant, the family was turned down by the province’s Out of Country Health Services Committee (OCHSC).

In January 2009, Tania wrote to the OCHSC appeal panel to appeal the decision. She noted that because the service was not available in Canada, and the need to ensure Emma didn’t fall further behind in her speech and language development, their family had no choice but to pursue treatment in the U.S.

Furthermore, the family was never told they could approach the OCHSC for funding for out of country health services prior to going to Texas – despite the fact that health officials knew the family was seeking the second cochlear implant in the U.S.

The panel denied funding, finding that it was an elective service that was available in Alberta.

The case seemed over. But then Tania heard about the Alberta Ombudsman, and gave the office a call.

Soon after, the Ombudsman launched an investigation. From September of 2009 to February 2012, an Ombudsman investigator in our Calgary office reviewed the case, reviewed the appeal, evidence and process, and determined it was a medically-insured service that was not available in Canada.

In reaching its decision to deny funding, the Ombudsman found the appeal panel’s reasons were insufficient. The Baldwins provided a number of reasons why this treatment was urgent, which the panel failed to address. The panel also did not show how it assessed the evidence, state its finding of fact based on the evidence, make a connection between the evidence presented and the conclusion reached, or address the family’s major arguments. The Ombudsman recommended the panel re-hear the appeal.

In January 2012, the panel met and decided to grant the appeal.

For Tania and her family, it was a matter of principle.

“I was discouraged, but I knew I had to fight it. I know life’s not fair, but how it was unfair was that Emma would have been a candidate only eight months later. But when I learned about the Ombudsman, I thought, ‘Well, this is one more avenue. And then if this fails, at least we can hold our heads high. We did what we needed to do. At least we tried.’”

Tania recommends those in a similar position give the Ombudsman’s office a call. Having gotten to the point of exhausting all available options and appeals, Tania recognizes that people can be discouraged and ready to give up.

“The whole process of going through the Ombudsman was helpful, easy, and painless. We’ll be forever grateful. It was an emotional rollercoaster, but I’m pleased with the outcome. It was an absolute bonus to be reimbursed, and a great feeling to know that we were being listened to, and that we were not just being left out in the dark and abandoned. It was a very good feeling to know that we were heard.”