Exceptional circumstances - additional considerations for essential dental treatment

The maximum limit of $1,000 in a 52-week period for a Special Needs Grant for essential dental treatment can be exceeded in exceptional circumstances.

Exceptional circumstances are those which set a client apart from others in a similar situation.

To help you decide if a client has exceptional circumstances to exceed the maximum limit you should also consider whether any of the following situations apply:

• whether the client could have reasonably afforded or been able to access regular dental check-ups
• whether the cause of the oral health issue is special or unusual when compared with others with the same or a similar issue e.g. they have an underlying health condition or take a medication that increases risk of tooth decay
• whether the oral health issue was reasonably foreseeable

When considering whether a client could afford or access regular dental check-ups you should determine if they have high essential outgoings, e.g. accommodation, employment, or health costs.

Example

Ariki has been suffering from significant tooth pain when she eats and drinks for the last few days. She's just been to the dentist who advised she'll need a root canal on one of her incisors and a filling in one of her pre-molars.

The cost of the consultation, x-ray and treatment is $1,379.

Ariki has been getting Sole Parent Support for the last 3 years. Her accommodation costs are high, she gets Accommodation Supplement and Temporary Additional Support to help her with the rent.

Ariki has not been able to reduce her essential costs and has not been able to increase her income because of her parental responsibilities. Ariki has not been able to put aside any money for regular dental check-ups.

She also didn't start experiencing symptoms until recently, so she didn't have a specific reason to see a dentist any earlier. This means Ariki's oral health issues weren't identified and treated early, and the cost of treatment is now much higher than it would have been.

In this case exceptional circumstances exist because Ariki was not in a financial position to be proactive about her oral health by having regular dental check-ups and had no indication that she had any oral health issues.

Ariki is now facing essential dental treatment costs over the maximum payment limit for reasons beyond her control.

You should consider any information provided by a client or their dentist that explains why the client may have special or unusual circumstances relating to their dental needs, e.g. the client has a health condition or takes medication that affects their oral health.

Example

Nick has been experiencing tooth sensitivity lately and went to the dentist to get it checked out. It turns out that Nick has widespread early tooth decay and requires fillings in 4 teeth to address his tooth sensitivity and to prevent his oral health deteriorating.

The cost of the consultation, x-rays and treatment is $1,168. When talking to Nick about what might have caused his tooth decay, the dentist identified that Nick has good oral hygiene, but he takes regular medication for blood pressure issues which is highly likely to have caused his tooth decay. Nick was not aware that this is a side effect for some people.

In this case exceptional circumstances exist because Nick's oral health issues were probably caused by a regular medication he must take. This sets him apart from other people in similar circumstances.

You'll need to establish if a client could reasonably foresee that they would develop the oral health issue that means they now need essential dental treatment. The client dentist may have provided advice on what they can do to improve their oral health to prevent issues in the future, and they may not have followed the advice.

Example

Emeni has been suffering from bad breath and swelling around some of his teeth. He went to see his dentist who advised Emeni that he needs two teeth extracted and a filling in one other tooth, totalling $670.

Emeni received a Special Needs Grant for essential dental treatment of $515 earlier in the year. At the time, the dentist discussed with that Emeni that he had not been taking basic care of his oral health and advised he needed to brush his teeth twice a day and floss once a day. This is advice Emeni had been given by his dentist several times before. Unfortunately Emeni has continued not to take care of his oral health, and it has deteriorated as a result.

Exceptional circumstances do not exist because Emeni could have reasonably foreseen and prevented this issue by improving his oral health. He can get a Special Needs Grant for essential dental treatment of up to $475, but the shortfall will need to be considered under recoverable assistance.