1 SUPREME COURT OF NOVA SCOTIA Citation: Bresson v.nova Scotia (Community Services), 2016 NSSC 64 Date: Docket: SYD No Registry: Sydney Between: Jainey Lee Bresson v. Nova Scotia (Department of Community Service) Applicant Respondent LIBRARY HEADING Judge: The Honourable Justice Patrick J. Murray Heard: December 8, 2015, in Sydney, Nova Scotia Oral Decision: January 18, 2016 Subject: Issues: Result: Judicial Review The Applicant sought a review of the decision of the Income Assistance Appeal Board finding that she did not qualify for orthodontic work as a special need. It was submitted by her dentist that she required these services to alleviate pain and associated jaw problems. The grounds for Judicial Review were: 1) the Board s decision was unreasonable; 2) the Board erred in law and in its application of the Employment and Income Assistance Act and Regulations; 3) the Appeal Board s findings were unreasonable in light of the evidence. Under the Regulations the Board had authority to seek advice from an expert to resolve a question before them. Regulation 24A(1)(3)(b), and 25(1) permitted the Department to seek out
2 and accept the dental consultant s opinion in deciding that the services sought were not a viable medical procedure. The weighing of evidence by the Board was entitled to deference. The decision reached was within the range of possible outcomes and was not unreasonable. The Application for Judicial Review was dismissed. Cases cited: McIntyre v. Nova Scotia (Community Services), 2012 NSCA 106; Newfoundland and Labrador Nurses Union v. Newfoundland and Labrador (Treasury Board),  3. S.C.R. 708; Worth v. Nova Scotia (Community Services), 2014 NSSC 366; Employment Support and Income Assistance Act, 2000, c.27, s.2; Casino Nova Scotia v. NSLRB, 2009 NSCA 4; Dunsmuir v. New Brunswick, 2008 SCC 9 (CanLII),  1 S.C.R THIS INFORMATION SHEET DOES NOT FORM PART OF THE COURT'S DECISION. QUOTES MUST BE FROM THE DECISION, NOT THIS LIBRARY SHEET.
3 SUPREME COURT OF NOVA SCOTIA Citation: Bresson v. Nova Scotia (Community Services), 2015 NSSC 64 Date: Docket: SYD No Registry: Sydney Between: Jainey Lee Bresson v. Nova Scotia (Department of Community Service) Applicant Respondent Judge: Heard: The Honourable Justice Patrick J. Murray December 8, 2015, in Sydney, Nova Scotia Oral Decision: January 18, 2016 Counsel: Jainey Lee Bresson, self-represented Applicant Debbie Brown for the Respondent, Department
4 Page 2 By the Court: Introduction  The Applicant, Ms. Bresson, is in receipt of income assistance. She suffers from pain and other problems associated with her jaw and teeth as a result of an assault. She made a request to the Department of Community Services for services that include orthodontic work as a special need. The Department handles such requests in administering the Income Assistance Program.  Ms. Bresson s request was denied by the Department. She appealed to the Income Assistance Appeals Board. The Board dismissed her appeal on the basis that the services requested were not medically appropriate, necessary or effective to deal with her problems. Instead, the Applicant was referred to an oral surgeon.  The Applicant seeks a judicial review of the Appeal Board s decision. The following are the grounds relied upon by Ms. Bresson. 1. The decision of the Appeal Board was not reasonable in light of the evidence before it. 2. The Appeal Board erred in applying the law and did not apply the statute or regulations correctly.
5 Page 3 3. The Appeal Board s findings of fact were unreasonable in light of the decision.  The Applicant seeks an Order reversing the decision of the Appeal Board. Statement of Facts The Facts As Found by the Appeal Tribunal and recorded in the decision are as follows:  The Appellant made a request for dental services which are not identified under the Employment Support and Income Assistance (ESIA) Policy that pertains to the ESIA Dental Fee Guide. Only those dental services listed with procedure codes under the Dental Fee Guide are approved items as Special Needs that can be provided by the ESIA Program.  Department of Community Services received an Essential Medical Form from physicians with whom the Appellant had consulted in hopes of having her medical issues resolved. The recommendations of the physicians who had filed Essential Medical Treatment (EMT) forms were reviewed by the Department of Community Services individually. In each instance, the Department of Community Services officials determined that the certain stipulations as required
6 Page 4 in ESIA Regulations and/or ESIA Policy pertaining to the Appellant s request for services were not met, and, therefore, dismissed.  In one case the orthodontic request was made by the Appellant s physician Dr. Oei. As he is not a dentist, it was determined that his recommendation is outside the scope of his expertise.  In some cases, the Essential Medical Treatment (EMT) form was not forwarded or not accompanied with a treatment plan and the appropriate treatment codes; in another instance, an oral surgeon (Dr. Fay) had requested full orthodontic treatment and correction of occlusion with orthodontic surgery, but he failed to forward a treatment plan and the appropriate treatment codes. Eventually, the surgeon reviewed the Appellant s case further and determined that he misunderstood the purpose of the Appellant s visit.  The physician, in this case, indicated that his recommended procedures would be for cosmetic purposes only and would not benefit the Appellant s medical issues. He withdrew his recommendation for orthodontic procedures.  The Appellant s dentist, Dr. Knickle, had filled out an EMT form and had requested a full assessment by an orthodontic and oral maxillofacial surgeon. She
7 Page 5 also noted that orthodontics and corrective jaw surgery was needed for jaw malocclusion and temporomandibular disorder and not for aesthetics.  Dr. Adams, the dental advisor for the Department of Community Services through Quikcard, reviewed Dr. Knickle s documentation, and he also sought the opinion, advice, and recommendation from Dr. Morrison, an oral surgeon at the VG Hospital. Dr. Morrison had a familiarity with the Appellant s case history; he also possessed medical expertise in the treatment and issues that confront the Appellant.  Dr. Morrison did not recommend orthodontics as he didn t feel it would solve Ms. Bresson s medical issues.  As a result, following Dr. Adams communication with Dr. Morrison, Dr. Adams determined that orthodontal services did not support the medical appropriateness, necessity, and effectiveness of the requested service as required in ESIA Regulation 24A(1) 3b and Regulation 25. Respondent Department s Position  The Respondent is the Department of Community Services. The Department says the Court should not disturb the Assistance Appeal Board
8 Page 6 decision between the Department of Community Services and Jainey Lee Bresson dated August 22,  The Department s position is that the Assistance Appeal Board s decision falls within a range of possible outcomes based upon the evidence before the Board and its governing legislation. What is the applicable Standard of Review?  The standard of review in matters of income assistance appeals has been determined by jurisprudence. In the case of McIntyre v. Nova Scotia (Community Services), 2012 NSCA 106, the court held as follows and I adopt paragraphs of that decision:  I disagree that an administrative tribunal s interpretation of its home legislation generally attracts a correctness standard of review. In Canada (Canadian Human Rights Commission) v. Canada (Attorney General),  3 S.C.R. 471, Justices LeBel and Cromwell for the Court said: In substance, if the issue relates to the interpretation and application of its own statute, is within its expertise and does not raise issues of general legal importance, the standard of reasonableness will generally apply and the Tribunal will be entitled to deference. In Alberta (Information and Privacy Commissioner) v. Alberta Teachers Association,  3 S.C.R. 654, Justice Rothstein for the majority said:  The narrow question in this case is: Did the inquiry automatically terminate as a result of the Commissioner extending the 90-day period only after the expiry of that period? This question involves the interpretation of s. 50(5) PIPA, a provision of the Commissioner s home statute. There is authority that [d]eference will usually result where a
9 Page 7 tribunal is interpreting its own statute or statutes closely connected to its function, with which it will have particular familiarity (Dunsmuir, at para. 54; Smith v. Alliance Pipeline Ltd., 2011 SCC 7,  1 S.C.R. 160, at para. 28, per Fish J.). This principle applies unless the interpretation of the home statute falls into one of the categories of questions to which the correctness standard continues to apply, i.e., constitutional questions, questions of law that are of central importance to the legal system as a whole and that are outside the adjudicator s expertise,... [q]uestions regarding the jurisdictional lines between two or more competing specialized tribunals [and] true questions of jurisdiction or vires (Canada (Canadian Human Rights Commission) v. Canada (Attorney General), 2011 SCC 53,  3 S.C.R. 471, at para. 18, per LeBel and Cromwell JJ., citing Dunsmuir, at paras. 58, 60-61). To similar effect Celgene, para 34.  The Board s interpretation and application of the Employment Support and Income Assistance Act, and the regulations and policies under that Act - the Board s home legislation - would be entitled to deference, meaning a reasonableness standard, subject to the exceptions mentioned in these passages from Canadian Human Rights Commission and Alberta Teachers Association. Here, there is no constitutional issue, conflict or overlap between two tribunals, or issue of jurisdiction or vires. Had Ms. McIntyre submitted that the regulations were ultra vires the Act, that issue would be of central legal importance, not within the particular institutional expertise of the Board, and would be subject to correctness review. Ms. McIntyre does not suggest that the regulations are ultra vires. Her submissions are purely interpretive.  In the judicial review of the Board s decision, the reviewing court s standard to the Board s application of the Board s home legislation is reasonableness.  As in McIntyre, the issue in this appeal involves the interpretation of the Board s own statute or home legislation the Regulations under the Act. The exceptions to deference, mentioned in Canadian Human Rights Commission and Alberta Teachers Association, do not apply. The reviewing court s standard to the Board s decision is reasonableness.
10 Page 8  This means the Court does not readily accept the tribunal s decision or necessarily impose its own view. Rather, the reviewing court shows respect for the Legislature s choice of a decision maker, by analyzing that tribunal s reasons to determine whether the result, factually and legally, occupies a range of possible outcomes. Newfoundland and Labrador Nurses Union v. Newfoundland and Labrador (Treasury Board),  3. S.C.R. 708, paras 11, per Abella, J. for the Court.  The second ground of appeal herein stated the decision was incorrect in law. Reasonableness and not correctness is the appropriate standard and this Court will therefore apply the reasonableness standard to this judicial review. Analysis  The Applicant s family physician Dr. Oei completed the necessary form on behalf of the Applicant recommending that orthodontic be provided to Ms. Bresson. As a family physician, orthodontics is not his field of expertise. The Regulations require that the evaluation be given by a person within in the appropriate scope of work.  Dr. Fay, an oral surgeon also gave an opinion in writing which clearly stated that Ms. Bresson required these services. Through his office staff information was
11 Page 9 subsequently relayed (by from Aliesje MacInnis, November 14 th, 2014) that Dr. Fay had misunderstood the nature of Ms. Bresson s request and on reconsideration felt the services would be for cosmetic reasons and not medical reasons.  In the circumstances I think it would have been prudent for the Department to require a written letter from Dr. Fay to this effect, especially where he was rescinding his opinion. On balance however, I do not think receiving this information by was unreasonable.  Thirdly, Dr. Knickle gave a clear opinion as to the status of Ms. Bresson s medical problems. Dr. Knickle recommended full orthodontic work to alleviate her problems and went so far as to say it was not for cosmetic purposes.  Dr. Knickle s completion of the Essential Medical Treatment form was the third opinion, supporting Ms. Bressen s request, subject only to the reversal by Dr. Fay.  In its submission the Department of Community Services stated at this point it was confronted with conflicting medical information. Thus the need to consult with their dental advisor Dr. Adams. At paragraph 36 of its legal brief the Respondent submits:
12 Page 10 Recognizing there were conflicting opinions on the purpose and necessity of the requested treatment, Dr. Adams consulted with Dr. Morrison, an oral and maxillofacial surgeon with the VG Hospital, Dr. Morrison checked Ms. Bresson s condition. Dr. Adams did not support the request for orthodontic treatment as the medical evidence did not support the medical appropriateness, necessity and effectiveness of the requested treatment. The Department weighed the evidence and rejected Ms. Bresson s request for orthodontic treatment, but supported a referral to an oral surgeon. The Appeal Board Member also weighed all of the evidence and upheld the Department s decision.  The handwritten note by Dr. Adams at Tab 7 of the record is a critical piece of evidence on this review. It reads as follows: Jan. 23/15 I spoke to Dr. Morrison (Oral Surgeon) V.G. He checked Jainey s file and pointed out she had been there several times for different reasons. He also said that orthodontics usually not needed in Class III cases and rarely cause TMJ concerns. Also orthodontics is not guaranteed to help TMJ cases.  The Applicant argues in her brief that this handwritten note is what the Department relied upon to make its decision. This was not a medical report directly from Dr. Morrison. It was a handwritten note from the Department s medical advisor reporting on his conversation with Dr. Morrison.  The Applicant argues that the Department and the Appeal Board Member rejected the Essential Medical Treatment forms of Ms. Bresson s doctors, even though they were signed and dated, in favor of what is essentially second hand (hearsay) information of Dr. Adams and was not supported by any medical plan.
13 Page 11  The Respondent Department submits it was not the note that was relied upon but rather the advice and recommendation by Dr. Adam s as evidenced by his signing off the bottom of the EMT form completed by Dr. Knickle.  The Respondent states as follows in their brief. Ms. Bresson submits the Department made their decision based on the handwritten note of Dr. Adams. This is incorrect. The Department based their decision on the advice and recommendations of Dr. Adams found in the bottom portion of the Request for Essential Medical Treatment form which completed by Dr. Knickle. Dr. Adams advised the requested treatment did not meet the criteria for coverage under the Special Considerations Policy and he recommended a referral to an oral surgeon only.  A close review of that part of the form reveals that Dr. Adams states, No. to the question of whether Ms. Bresson s requested treatment is recommended. No further details are given in the space provided on the form.  There are boxes which can be checked or ticked to indicate the reason for the denial. I note that the box stating that the services are medically inappropriate, unnecessary and ineffective, was not selected by Dr. Adams.  While this is a technical argument, the authority for the Department to seek advice from a person qualified is with respect to that very issue; the medical appropriateness, necessity, and effectiveness of an item of special need requested. Regulations 24(a) and 25(1) and (2) are attached as Appendix A.
14 Page 12  This is repeated in subsection 25(2). Both sections 25(1) and (2) state that this advice must be taken into consideration in determining whether the item or service is a special need under section 24A.  This suggests to me that the Department of Community Services did rely on the information in the note of Dr. Adams, summarizing his conversation with Dr. Morrison.  Certainly, both in the analysis and in the conclusion the Appeal Board placed considerable weight on Dr. Morrison s advice and or opinion.  In the analysis Mr. Beaton in the Appeal Board s decision stated: Dr. Knickle s recommendation was processed by way of the ESIA Essential Medical Policy which included a review of all of Dr. Knickle s EMT documentation regarding Ms. Bresson s condition. This review was carried out by Dr. Adams, a dental consultant from Quikcard. Dr. Adams as part of the review chose to speak with Dr. Morrison, an oral surgeon at the VG Hospital, to seek his expert advice/opinion and well as to seek any recommendations regarding the best medical manner in which to proceed in the case of Ms. Bresson. Dr. Morrison was familiar with case history of the Appellant as she was seen several times at the VG in the past. Dr. Morrison with expertise in the filed dealt with Ms. Bresson s medical issues stated that he would not recommend orthodontics; he felt that orthodontics would not solve the Appellant s medical problem. Dr. Adams after consulting with Dr. Morrison arrived at the decision that the medical evidence did not support the Appellant s request for dental services and as medically appropriate, necessary, nor effective as required ESIA Regulation 24(A)(1) 3b and ESIA Regulation 25(1).
15 Page 13  In the conclusion the Appeal Board stated: DCS officials have no alternative in this type of case but to ensure that all necessary criteria are met when they are required to decide whether a client does nor does not qualify for the services which have been requested. DCS personnel determined that the Appellant, Ms. Jainey Lee Bresson did not fulfill the requirements as set out in ESIA regulations 24 and 25. The determination of DCS was that the medical evidence did not support the Appellant s request for dental services and as medically appropriate, necessary, nor effective as required in ESIA Regulation 24(A(1)3b and ESIA Regulation 25(2). As DCS made this determination in arriving at its decision to dismiss orthodontics as a viable medical procedure to resolve the Appellant s issues, it also rules out the request for an orthodontic consultation. The Board adhered to the appropriate administration of those ESIA Regulations and ESIA Policies as they pertain to this case.  The Applicant s main argument is that the Appeal Board member accepted the note as a medical opinion on which to determine the heart of this matter.  The Department of Community Services held the Applicant, Ms. Bresson, to a very strict standard throughout her submission of the various medical forms.  In most instances they were not accepted as there was no treatment form or dental codes provided. This is not unreasonable. The decision itself stated there is a protocol which must be adhered to to enable the Department to assess whether the regulations are being met. For example, codes determine cost, and cost is one of the considerations under Regulation 24A(3)(c).  On these facts, did the Department of Community Service follow the same level of scrutiny, in accepting the opinions of Dr. Adams and Dr. Morrison? The
16 Page 14 Board concluded that the DCS officials complied with the ESIA Regulations and Policies in turning down the Applicant s request for Special Needs.  The weight of the evidence up to that point supported Ms. Bresson s request. She made significant efforts to provide what was required for a determination of what was essential to health.  The real question for this court is, was the Appeal Board s decision reasonable? The reasonable standard is one of deference. Whether or not a reviewing court agrees with it or whether or not a reviewing court thinks it is correct, is not the test. In those instances the decision stands as long as it meets the test of reasonableness.  In the recent case of Worth v. Nova Scotia (Community Services), 2014 NSSC 366, the court discussed how the reasonableness standard is to be applied in paragraph 11: Given that the appropriate standard of review is reasonableness, the question arises as to how to apply the standard. In Dunsmuir v. New Brunswick, 2008 SCC 9 (CanLII),  1 S.C.R. 190, the Supreme Court of Canada explained that reasonableness is a deferential standard and one which recognizes that the questions before administrative tribunals may have the potential for a number of reasonable conclusions. Reviewing courts must respect the decision making process of adjudicative bodies with regard to both the facts and the law as well as the reasons offered in support of a decision.
17 Page 15  The Appeal Board s decision contains a thorough analysis of all the issues. It is the Appeal Board s home statute that was being considered. The Board is, as a result, very familiar with the Act, Regulations and related matters.  The Respondent makes a compelling argument that the reasonable standard has been met in this case, and thus submits the Court should not interfere with the Board s decision. At paragraph 50 of its brief the Department states: The Board Member recognized the efforts of Ms. Bresson in obtaining the various medical forms and that the purpose of the Act was to provide for the assistance of persons in need and, in particular, to facilitate their movement toward independence and self-sufficiency. The Board Member also noted, however, the regulations are passed and put in place as laws by government, and DCs officials are obligated to determine which ESIA Regulations and ESIA policies are relevant to any case and to justly administer these regulations accordingly In order to qualify, however, the Board Member recognized certain conditions had to be met. The Board Member found that based on the evidence before him and the ESIA and Regulations that the conditions had not been met in this case.  The question is does the Board s decision fall within the range of acceptable outcomes which are factually and legally defensible? Decision:  Applying the reasonableness standard, deferential as it is, it should be predicated on facts that are reasonably supported by the evidence and reliable for the purpose of reaching the ultimate decision.
18 Page 16  The purpose of the Employment Support and Income Assistance Act, 2000, c.27, s.2, is: s.2 The purpose of this Act is to provide for the assistance of persons in need and in particular to facilitate their movement toward independence and self-sufficiency.  If the purpose of the Act is to be genuinely pursued, the medical evidence obtained should be clear, cogent and convincing in terms of the Applicant s own health, not what may or may not be the norm.  The medical evidence relied upon by the dental consultant for DCS, Dr. Adams was that orthodontic work is not usually needed and rarely causes TMJ concerns, and is not guaranteed to help TMJ cases. Dr. Morrison stated he was familiar with Ms. Bresson and reviewed her file.  While it was not unreasonable for the Department to seek out advice from its dental consultant, the question is was it reasonable for the Board to rely on the information obtained, to arrive at the decision on the appeal?  In Casino Nova Scotia v. NSLRB, 2009 NSCA 4, the Court of Appeal elaborated on the Dunsmuir v. New Brunswick, 2008 SCC 9 (CanLII),  1 S.C.R. 190, reasonableness test. Justice Fichaud, Oland and Hamilton, JAA, concurring, described the first approach as identifying the process used in the
19 Page 17 decision making and whether there is a justifiable, intelligible and transparent reasoning path throughout the tribunal s conclusion. What this means is whether the reviewing court can understand why the tribunal made its decision.  In the present case while there is some question as to whether it was actually the note that was relied upon by the Department, it is reasonably clear that Dr. Adams made his decision after consulting with Dr. Morrison. The note contains an indication of the reasons for Dr. Adams decision. I find the reasons for the decision are intelligible meaning they can be understood by this Court.  In Casino the Nova Scotia Court of Appeal described the second step as assessing the outcome so as to determine whether the decision falls within the range of acceptable outcomes that are factually and legally defensible. In doing so regard must be had to the expertise and experiences of the Board in dealing with the legislation (in this case the ESIA Act and Regulations) on a day to day basis. (Dunsmuir at para. 49)  In the case before me the Board affirmed the Department s finding to dismiss orthodontics as a viable medical procedure to resolve the Applicant s issues and as a result ruled out the request for an orthodontic consultation.
20 Page 18  When a factual conclusion of any kind is made by a board or tribunal, such a finding involves the weighing of evidence by the decision maker. It therefore attracts a deferential standard of review, meaning it is to be respected if it falls within the range of possible outcomes based upon the evidence and the governing legislation. (Canadian Administrative Law, Regimbald, 1 st ed.)  In this case I find the decision of the Board is entitled to deference. This legislation left certain choices within the Department s ambit, subject to what is reasonable.  The Applicant objected to the medical evidence relied upon by Dr. Adams on the basis that it was hearsay, even double hearsay. Firstly, in Worth, Justice Chipman found it was appropriate within the statutory framework of the ESIA Act for the caseworker to seek out additional information where clarification is required. Further, the court found that reliance on hearsay was not problematic as such evidence is to be expected and is permissible at the Assistance Appeal Board level. I concur with this reasoning for the purposes of this judicial review. (Worth at para. 15)  The Department was entitled to weigh the opinion of Dr. Adams against the various other opinions which Ms. Bresson had provided. Having done so it
21 Page 19 decided that the dental consultant s opinion was the one they were prepared to accept. As a result the Department rejected Ms. Bresson s request for orthodontic treatment but supported a referral to an oral surgeon.  Further, the Appeal Board also weighed the evidence and upheld the Department s decision. As previously stated, a conclusion reached by the weighing of evidence is not something which this Court should interfere with unless it was unreasonable.  The ultimate finding of the Board was that the Respondent Department adhered to the appropriate administration of the ESIA Regulations and Policies as they pertain to Ms. Bresson.  I am satisfied that it was not an unreasonable finding based on the evidence before the Board. It would appear from the record that the referral to the oral surgeon as recommended would stand at this time.  In the result, I am dismissing the application for judicial review made by the Applicant, Ms. Bresson. I do so with all respect and thanks to her for her submissions. Murray, J.
22 Page 20 Appendix A Special need essential for health 24A(1) An applicant or recipient may submit a request for assistance on the form approved by the Director for an item or service that is excluded from the definition of special needs by clause 24(2)(b) or (d) and that is (a) prescribed within the scope of their practice by one of the following health practitioners who is licensed to practice [practise] their profession in Nova Scotia as essential for the health of the applicant or recipient or the spouse or dependent child of the applicant or recipient: (i) physician, (ii) dentist, (iii) nurse practitioner; and (b) provided by a medical professional licensed or registered to practice [practise] in Nova Scotia. (2) Subsection (1) does not apply to a request for medical marijuana or any equipment, supplies, materials or services used in producing or administering medical marijuana. (3) In determining whether an item or service prescribed under clause (1)(a) is a special need under this Section, all of the following must be taken into account: (a) the needs or circumstances of the applicant, recipient, spouse or dependent child; (b) evidence of the medical appropriateness, necessity and effectiveness of the requested item or service; (c) the cost of providing assistance for the requested item or service in comparison to other alternatives that would meet the needs of the applicant, recipient, spouse or dependent child; (d) availability of alternative items or services that are insured under a Provincial health services program or are otherwise funded by government; (e) whether providing the assistance requested will fulfill the purposes of the Act. (4) If a caseworker determines that the item or service is a special need under this Section, these regulations apply to it as a special need. (5) If a caseworker determines that the item or service is not a special need under this Section, the caseworker shall notify the applicant and provide written reasons for the decision, and the decision may be appealed to the Assistance Appeal Board. Section 24A added: O.I.C , N.S. Reg. 291/2013.
23 Page 21 Information to be provided 24B (1) An applicant or recipient may request assistance for an item of special need, and the applicant or recipient shall provide the following information, where applicable, to a caseworker to support the request: (a) an explanation as to why the special need is required; (b) a description of the special need; (c) any documentation from professionals supporting the special need; (d) the monthly or total cost of the special need; Original clause 24A(d) replaced: O.I.C , N.S. Reg. 251/2011. (e) the resources or alternatives that have been investigated with respect to obtaining the special need from other sources; (f) where the cost of the special need exceeds $200, estimates for the cost of the special need from 2 separate providers; and (g) if the special need has already been acquired, an invoice or receipt for the special need. Original clause 24A(g) replaced: O.I.C , N.S. Reg. 251/2011. (2) An applicant or recipient may request assistance for an item of special need in accordance with subsection (1) either before or after the purchase of the item of special need. Original Section 24A renumbered 24B: O.I.C , N.S. Reg. 291/2013. Health or medical need 25 (1) Where an applicant or recipient requests assistance for an item of special need that pertains to the health or medical requirements of the applicant or recipient or the spouse or dependent child of the applicant or recipient, a caseworker may request advice from a person qualified to provide advice in respect of the appropriateness, necessity and effectiveness of the item of special need requested and the caseworker shall take this advice into consideration in determining whether to grant the request. Section 25 re-designated 25(1): O.I.C , N.S. Reg. 291/2013. (2) A caseworker may request advice from a person qualified to provide advice in respect of the medical appropriateness, necessity and effectiveness of an item or service to be taken into account under clause 24A(3)(b), and the caseworker must take this advice into consideration in determining whether the item or service is a special need under Section 24A. Subsection 25(2) added: O.I.C , N.S. Reg. 291/2013. (3) A caseworker who requests advice under subsection (2) must advise their supervisor. Subsection 25(3) added: O.I.C , N.S. Reg. 291/2013.