College of Chiropodists of Ontario v. Infanti, 2021 ONCOCOO 11

Ontario (College of Chiropodists of Ontario) v. Infanti, 2021 ONCOCOO 11

Index as: Ontario (College of Chiropodists of Ontario) v. Infanti, 2021 ONCOCOO 11

THE DISCIPLINE COMMITTEE OF THE COLLEGE OF CHIROPODISTS OF ONTARIO

IN THE MATTER OF a Hearing directed by the Inquiries, Complaints and Reports Committee of the College of Chiropodists of Ontario pursuant to Section 26(1) of the Health Professions Procedural Code being Schedule 2 of the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, as amended.

BETWEEN:

COLLEGE OF CHIROPODISTS OF ONTARIO

• and -

JOHN JOSEPH INFANTI, D.Ch.

PANEL MEMBERS:

Cesar Mendez Chair, Public Member

Eliot To Professional Member

Ramesh Bhandari Public Member

COUNSEL FOR THE COLLEGE:

Debra McKenna

COUNSEL FOR THE MEMBER:

Daniel Goldbloom

INDEPENDENT LEGAL COUNSEL:

Luisa Ritacca

Hearing Date: October 18, 2021

Decision Date: October 18, 2021

Release of Written Reasons: November 16, 2021

DECISION AND REASONS

This matter came on for hearing before a panel of the Discipline Committee on October 18, 2021. With the consent of the parties, this matter was heard electronically.

The Allegations

1. The allegations against the Member as stated in the Notice of Hearing, dated November 29, 2019, are as follows:

2. John Joseph Infanti (“Mr. Infanti” or “Member”) was at all material times a registered member of the College.

3. During the period in or about June 1, 2015 to December 12, 2017, the Member engaged in professional misconduct within the meaning of the following paragraphs of section 1 of the Professional Misconduct Regulation, O. Reg. 750/93 under the Chiropody Act, 1991:

a. paragraph 2 (failing to meet or contravening a standard of practice of the profession), and, in particular, the College’s standards pertaining to:

i. Assessment and Management;

ii. Patient Relations;

iii. Records;

iv. Prescription Custom Foot Orthoses; and/or

v. Prescription Footwear;

b. paragraph 10 (practising the profession while the member is in a conflict of interest);

c. allegation withdrawn;

d. paragraph 17 (failing to keep records as required by the regulations);

e. allegation withdrawn;

f. paragraph 20 (signing or issuing, in the member’s professional capacity, a document that contains a false or misleading statement);

g. allegation withdrawn;

h. allegation withdrawn;

i. paragraph 30 (contravening the Chiropody Act, 1991, the Regulated Health Professions Act, 1991, or the regulations under either of those Acts), specifically:

i. Ontario Regulation 750/93 under the Chiropody Act, 1991, as specified in this Notice of Hearing;

ii. Ontario Regulation 203/94 under the Chiropody Act, 1991, and, in particular, (allegation withdrawn) and Records (Part III); and/or

iii. section 51(1)(c) of the Health Professions Procedural Code, being Schedule 2 to the Regulated Health Professions Act, 1991; and/or

j. paragraph 33 (engaging in conduct or performing an act, in the course of practising the profession that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable, or unprofessional).

PARTICULARS OF THE ALLEGATIONS

1. At all material times, the Member was a chiropodist registered with the College to practise chiropody in Ontario.

2. During the period in or about June 1, 2015 to December 12, 2017 (the “Relevant Period”), the Member was engaged in the practice of chiropody at the Hamilton Urban Core CHC, and at the Averie Medical Laser Clinic (the “Clinic”), both located in Hamilton, Ontario.

3. On or about December 12, 2017, the College received a complaint from Green Shield Canada (“GSC”) about the Member (the “Complaint”).

4. As set out in the Complaint, GSC regularly conducts reviews with respect to the services and/or products that are provided to GSC plan members and/or their dependents.

5. In or about 2017, GSC conducted a review in relation to the Member.

6. Specifically, as part of a claims verification process, GSC reviewed the claims for custom orthotics and orthopaedic footwear that identified the Member as the treating/dispensing practitioner at the Clinic.

7. From approximately June 1, 2015 to June 20, 2017, there were approximately 2436 claims submitted to GSC (the “Claims”).

8. All of the Claims were for plan members belonging to the same sponsored benefit plan for Hamilton Health Sciences Centre (“HHSC”). The benefit plan coverage for HHSC included two (2) pairs of orthopaedic shoes every twelve (12) month period and two (2) pairs of custom-made foot orthotics every three (3) calendar years per plan member.

9. The Claims were submitted to GSC manually using the insurer’s standard claims form for custom-made orthotics and orthopaedic footwear (“Claims Form”).

10. The Claims were all signed by the Member. Among other information provided, the Claim Form certified that the Member provided the treatments and the Claims were accurate.

11. The total value of the Claims was approximately $1,545,716.05. As a result of the Claims, GSC paid $1,436,143.03 to the Clinic directly via electronic funds transfer.

12. On or about February 27, 2017, GSC issued confirmation of services requests to160 plan members randomly selected from the Claims (“Confirmation Requests”).

13. As summarized in Appendix “A”¹, the responses to the Confirmation Requests on behalf of 77 patients confirmed the following information:

(a) the patients ranged in age from 4 to 68 years old;

(b) 62 patients were prescribed two pairs of orthopaedic shoes;

c) most (if not all) of the patients were prescribed over-the-counter shoes;

(d) of the 62 patients who were prescribed two pairs of orthopaedic shoes, 36 patients were also prescribed two pairs of custom-made orthotics;

(e) in total, 42 patients were prescribed both orthopaedic shoes and orthotics;

(f) 38 patients were prescribed two pairs of orthotics; and,

(g) there were approximately 12 plan members for which multiple members of the family were prescribed orthopaedic shoes and/or custom orthotics or both by the Member.

14. On or about March 6, 2017, GSC requested that the Member provide supporting documents for the treatments provided to 77 patients (the “Records Request”).

15. information sought for the Records Request included preliminary assessment records, treatment plans, clinical records, prescriptions, attendance records, financial records, and supplier invoices. A list of the Records Request is attached as Appendix “B”.

16. The Member responded to the Records Request in or about March 27, 2017.

17. As the records provided in reply to the Records Request were incomplete and/or lacked the necessary treatment details, GSC representatives attended at the Clinic on or about June 21, 2017, to conduct an onsite audit of a limited number of patient files.

18. During the audit, GSC representatives sought to review any additional documents that were available to verify the treatments provided by the Member. However, the information provided and reviewed was identical to the documents previously produced by the Member in response to the Records Request, with the exception of an appointment record that was also provided for review.

19. While conducting the audit, the GSC representatives also spoke to the Member. At that time, the Member described himself as a “minimalist”, or words to that affect, in terms of the information that he documents in his records and he did not feel that he needed to record every detail pertaining to his assessments and/or dispensing.

20. The Member also made comments to the affect that he was not required to follow-up with his patients as he provided patients with enough information at the time of dispensing and patients were advised to return if they had issues.

21. Contrary to the information contained in the Claims Forms, orthotics prescribed by the Member were not dispensed by the Member. Rather, orthotics prescribed by the Member were dispensed to his patients by the Clinic staff who were not members of the College.

22. In particular, the Confirmation Requests confirmed that the following patients were orthotics by the Clinic staff:

• K.F – 2016.11.03

• E.K – 2016.03.04

• C.M.P. – 2017.10.17

• S.N – 2016.12.14

• M.P - 2016.04.18

• D.P – 2016.10.05

• S.S. – 2106.11.08

• M.S. – 2016.11.11

• S.V. – 2016.12.21

• A.W – 2017.01.04

23. In addition, as described in the Complaint, GSC confirmed through its claims verification process that several of the Member’s patients had been offered and/or received incentives, including offers of free shoes and/or compression stockings and/or other benefits.

24. In particular, the following patients were identified as having been offered and/or received incentives:

• S.A. (date of service – 2016.09.01 and 2016.10.07)

• A.E. (date of service – 2016.08.04)

• K.F. (date of service – 2016.11.03)

• H.S. (date of service – 2016.05.25)

Member’s Plea

2. The Member admitted that he engaged in professional misconduct as described in the Notice of Hearing, save for those allegations the College advised that it would be withdrawing.

3. The Panel conducted an oral plea inquiry and was satisfied that the Member’s admissions were voluntary, informed, and unequivocal.

Publication Ban

4. With the consent of the parties, the Panel imposed a publication ban over the patient names or any other identifying information mentioned in the course of the hearing, including any mention in the exhibits filed. Further, the Panel directed that the patient files made available during the course of the hearing would remain under seal pending a further order of this Discipline Committee.

Agreed Statement of Facts

5. The parties advised that they had reached an agreement as to the facts, which was set out in the Agreed Statement of Facts tendered as an exhibit. The Agreed Statement of Facts provided as follows:

6. During the period from June 1, 2015 to December 12, 2017, the Member was engaged in the practice of chiropody at the Hamilton Urban Core CHC and at the Averie Medical Laser Clinic (the “Clinic”), both located in Hamilton, Ontario.

7. The Member did not have an ownership stake in the Clinic and worked as an independent contractor. The Member did not manage the Clinic’s financial relationships with shoe stores and did not set prices to be charged for custom orthotics or orthopaedic footwear. However, the Member was aware of what the Clinic charged.

8. The Member was the only chiropodist who worked at the Clinic.

9. On or about December 12, 2017, the College received a complaint from Green Shield Canada (“GSC”) about the Member (the “Complaint”). As set out in the Complaint, GSC regularly conducts reviews with respect to the services and/or products that are provided to GSC plan members and/or their dependents.

10. In or about 2017, GSC conducted a review in relation to the Member.

11. Specifically, as part of its verification process, GSC reviewed the benefit claims for custom orthotics and orthopaedic footwear that identified the Member as the treating/dispensing practitioner at the Clinic.

12. According to the Complaint, there were approximately 2,436 claims submitted to GSC during the period from June 1, 2015 and June 20, 2017, and all or almost all of the claims had been submitted on behalf of plan members belonging to the same sponsored benefit plan for Hamilton Health Sciences Centre (“HHSC”). Attached as Schedule “A” ²is a report of the GSC claims between the period from June 1, 2015 to June 20, 2017 for the Clinic.

13. The benefit plan coverage for HHSC included two (2) pairs of orthopaedic shoes every twelve (12) month period and two (2) pairs of custom-made foot orthotics every three (3) calendar years per plan member.

14. The claims were submitted to GSC manually using the insurer’s standard claims form for custom-made orthotics and orthopaedic footwear.

15. The claims forms submitted to GSC were all signed by the Member. Among other information provided, the claim form certified that the Member provided the treatments and that the benefit claims were accurate.

16. According to the Complaint, the total value of the claims submitted for the period from June 1, 2015 to June 20, 2017, was approximately $1,545,716.05. GSC paid $1,436,143.03 to the Clinic directly via electronic funds transfer.

17. During its claims verification process, GSC requested that the Member provide supporting documents in relation to the treatments he provided to 77 patients. Among other details, the documents sought by GCS included preliminary assessment records, treatment plans, clinical records, prescriptions, attendance records, financial records, and supplier invoices.

18. A list of the patient records requested by GSC is attached as Schedule “B”. A copy of the Member’s patient records is attached as Schedule “C”.

19. The Member admits that he prescribed orthotics and/or footwear to the patients identified in Schedule “B” on or about the dates identified in Scheduled “B”. In addition, the Member admits that the fees listed in Schedule “B” were the fees charged for the treatments he prescribed.

20. With respect to prescribed orthopaedic footwear, the shoes dispensed to the patients listed in Schedule “A” were off-the-shelf, commercially available shoes.

21. If the Member were to testify it would be his evidence that the shoes fell within GSC coverage, which applied to off-the-shelf, non-modified orthopaedic shoes prescribed by a chiropodist. GSC informed the Member that GSC used the guidelines set out by the Pedorthic Association of Canada to determine which shoes the plan covered, and that this guide listed features that should be found in a shoe to allow it to qualify as orthopaedic.

22. The College does not allege that any of the shoes or orthotics prescribed were inappropriate or harmful to treat the conditions from which the patients suffered.

23. Were the Member to testify, his evidence would be that the Clinic maintained a supply of non-modified orthopaedic shoes on the premises, as well as samples. Specifically, the clinic maintained a supply of Asics, Saucony, and New Balance shoes, which were covered under the GSC plan. The Clinic also had a shoe catalogue from the Ontario Orthotic Lab from which shoes could be ordered for patients.

24. Were the Member to testify, his evidence would be that some patients were also sent to one of two identified local shoe stores with instructions to select an appropriate orthopaedic shoe given the patient’s condition. However, the Member admits that the records attached at Schedule “C” do not reflect such directions were given to patients.

25. The Clinic maintained an ongoing relationship the shoes stores mentioned in the above paragraph and received discounts on shoes from these shoe stores that had been negotiated by the Clinic.

26. If the Member were to testify, it would be his evidence that all treatments he prescribed to the patients listed in Schedule “B” were medically necessary. However, the Member admits that his patient records, included at Tab “C”, are deficient insofar as they lack sufficient clinical details to demonstrate compliance with the College’s various standards, as outlined below, and particularly whether alternative treatments other than the prescription of custom foot orthotics and/or orthopaedic shoes might also have been considered for the patients listed in Schedule “B”.

27. The Member admits that the deficiencies in his records effectively preclude a complete documentary review of the appropriateness of his prescriptions, thereby frustrating the College’s oversight role in conducting an objective, document-based review of patient management.

28. In particular, the Member’s records at Schedule “C” do not include the following information:

• a sufficiently detailed medical history obtained from the patients including, among other things, references to medications, comprehensive descriptions of patient symptoms, and pertinent details about any surgeries (such as knee/hip surgery);

• reasonable information about the Member’s examinations, clinical findings, diagnoses, and assessments;

• reasonable information about treatment plans;

• reasonable information about all significant advice given to patients, including advice about the benefits and material risks of the prescribed treatments and the patient’s alternative treatment options;

• reasonable information about patient follow-up, including any circumstances in which patients declined a follow-up appointment that was offered to them; or

• a differential diagnosis.

24. In addition, the Member admits that, in relation to the patients listed in Schedule “B”, he permitted staff to dispense products, including orthotics. The Member’s patient records in that regard are unclear as to who dispensed the products to his patients.

25. If the Member were to testify, it would be his evidence that he misunderstood the requirements of the Orthotics Standard, which was in place at the time. It was the Member’s understanding that it was permissible for staff to dispense orthotics in circumstances where patients were uncooperative and refused to attend the Clinic when the Member could see them. The Member admits that his patient records do not include any notes regarding why the orthotics were not dispensed by the Member in particular cases, or who dispensed the orthotics. The Member now understands that the College’s interpretation of the standard in place at the relevant time was that Clinic staff were not permitted, in any circumstances, to dispense orthotics and orthotics were required to dispensed by a member of the College. In any event, the Member understands that the College’s standard was amended on October 23, 2020 to bring added clarity to the members-only dispensing requirement.

26. The following written standards of the College are the standards of practice of the profession:

• Records

• Assessment and Management

• Patient Relations

• Prescription Custom Foot Orthoses

• Prescription Footwear

27. The Member admits that he engaged in professional misconduct and is guilty of professional misconduct within the meaning of the following paragraphs of section 1 of the Professional Misconduct Regulation, O. Reg. 750/93:

a. paragraph 2 – failing to meet or contravening a standard of practice of the profession, and, in particular, the College’s standards pertaining to:

i. Records;

ii. Assessment and Management;

iii. Patient Relations;

iv. Prescription Custom Foot Orthoses; and

v. Prescription Footwear;

b. paragraph 10 – practicing the profession while the member is in a conflict of interest;

c. paragraph 17 – failing to keep records as required by the regulations;

d. paragraph 20 – signing or issuing, in the member’s professional capacity, a document that contains a false or misleading statement; ³

e. paragraph 30 – contravening the Chiropody Act, 1991, the Regulated Health Professions Act, 1991, or the regulations under either of those Acts, specifically:

i. Ontario Regulation 750/93 under the Chiropody Act, 1991 as specified in this Notice of Hearing;

ii. Ontario Regulation 203/94 under the Chiropody Act, 1991 (specifically, Part III “Records”); and/or

iii. section 51(1)(c) of the Health Professions Procedural Code, being Schedule 2 to the Regulated Health Professions Act, 1991; and/or

f. paragraph 33 – engaging in conduct or performing an act, in the course of practicing the profession that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional.

Decision and Reasons on Liability

6. The Panel considered the evidence presented and the Member’s admissions and found that the Member engaged in professional misconduct as alleged in the Notice of Hearing, save for those allegations which were withdrawn. In particular, the Panel was satisfied that the admitted conduct represents a failure to meet or a contravention of the standards of the profession pertaining to; Records, Assessment and Management, Patient Relations, Prescription Custom Foot Orthoses, and Prescription Footwear, and that the failure to comply with these professional standards amounts to professional misconduct.

7. Additionally, the Panel agreed that the profession would reasonably regard the admitted breaches in the professional standards, as well as the various business practices admitted to by the Member, such as; practicing while in a conflict of interest and signing documents that contained false and/or misleading statements, as not only unprofessional, but also dishonourable.

Penalty

8. Counsel for the College, as well as the Member, advised the Panel that a Joint Submission as to Penalty had been agreed upon. The Joint Submission as to Penalty provides as follows:

THE PARTIES agree and jointly submit that the Discipline Committee make the following orders with respect to this matter:

(i) An oral reprimand;

(ii) An order suspending the Member’s certification of registration for a period of seven (7) months commencing on November 8, 2021 – two months of which will be remitted upon the Member successfully completing the ProBe ethics course and the University of Toronto record-keeping course as outlined in paragraph 3(a) below;

(iii) An order directing the Registrar to impose terms, conditions, and limitations on the Member’s certificate of registration requiring the following:

(a) Prior to returning to practice, the Member shall successfully complete the ProBe ethics course and the University of Toronto record-keeping course at his own expense;

(b) Upon returning to practice, the Member is prohibited from imaging, casting, prescribing, constructing, fitting, dispensing and/or ordering the fabrication of orthotics and orthopaedic shoes for a period of six (6) months (the “Restricted Period”). The Member is additionally not entitled to assign these duties to anyone else at his clinic, regardless of whether he receives a fee, during the Restricted Period, but shall refer such duties to another chiropodist in good standing at another clinic not affiliated with the Member’s clinic.

(c) At his own expense, the Member will receive supervision of his chiropody practice with a supervisor approved by the Registrar for a period of one (1) year from the date on which the Member returns to practice from the suspension. The terms of the supervision are as follows:

• The supervisor shall visit with the Member in person on at least four (4) occasions – twice in the first six months and twice in the last six months;

• The visits with the supervisor will be unannounced;

• The supervisor shall determine the length of each visit;

• In conducting the supervision, the supervisor shall discuss ethics, practice management, record-keeping and compliance with the College’s standards with the Member;

• The supervisor shall prepare a report to the Registrar after the second (2) visit and after the fourth (4) visit;

• The Member shall seek and obtain consent from his patients to share personal health information with his supervisor in order to allow the supervisor to review client files and engage in review;

• The Member shall provide the supervisor with the Discipline Committee’s decision and then provide written confirmation to the Registrar, signed by the supervisor, that the supervisor has received and reviewed the decision;

(d) In the event that the Member obtains employment during the twelve (12) months following the date that the Member is able to return to practice after his suspension, the Member shall:

• notify any current or new employers of the Discipline Committee’s decision, and;

• ensure the Registrar is notified of the name, address, and

• telephone number of his employer(s) within fifteen (15) days of commencing employment;

• provide his employer(s) with a copy of:

o the Discipline Committee’s order;

o the Notice of Hearing;

o the Agreed Statement of Facts (excluding the schedules);

o the Joint Submission on Penalty;

o the Discipline Committee’s decision; and

o have his employer forward a report to the Registrar within fifteen (15) days of commencing employment confirming that the employer has received the documents noted above and agrees to notify the Registrar immediately upon receipt of any information that the Member is not complying with the College’s standards;

(iv) An order that the Discipline Committee’s decision be published, in detail with the Member’s name, in the College’s official publication, on the College’s website, and/or on the College’s public register;

(v) The College and the Member agree that if the Discipline Committee accepts this Joint Submission as to Penalty and Costs, there will be no appeal or judicial review of the decision to any forum.

Decision and Reasons on Penalty

9. The Panel was satisfied that the proposed penalty was appropriate and reasonable in the circumstances, and makes the order accordingly.

Mitigating factors considered by the Panel in reaching it’s decision:

10. The Member has been registered with the College for many years and this was the Member’s first time appearing before the College’s Discipline Committee.

11. By admitting the allegations of professional misconduct and entering into an Agreed Statement of Facts and a Joint Submission as to Penalty, the Member has saved the College considerable time and expense, which would have been incurred had the matter proceeded on a contested basis.

Aggravating factors considered by the Panel in reaching it’s decision:

12. The professional misconduct was not an isolated incident; rather it consisted of any incidents occurring over a lengthy period of time.

13. The Member’s conduct was consistent with a deliberate pattern which appeared to be specifically motivated by financial gain rather than grounded in the best interest of patients.

14. The Member is a seasoned practitioner and longstanding registrant of the College. During this time, the Member should have been involved in activities that would have specifically kept him informed, updated, and well versed in the issues that arose in these circumstances.

15. By admitting the allegations of professional misconduct and entering into Agreed Statement of Facts and a Joint Submission as to Penalty, the Member has saved the College considerable time and expense, which would have been incurred had the matter proceeded on a contested basis.

16. The publication and reporting of the case on the College website and other publications sent out by the College will act as a specific deterrence to the Member and a general deterrence to the profession as a whole.

17. The publication and reporting of the case on the College website and in other publications is consistent with the College’s mandate to protect the public and to do so in a fair and transparent manner.

18. The professional misconduct was not an isolated incident; rather it consisted of many incidents occurring over a lengthy period of time, and so the suspension and other components of the penalty are appropriate in the circumstances.

19. The panel is satisfied that the penalty order proposed in the Joint Submission as to Penalty is reasonable in light of the admitted professional misconduct.

20. Further, the panel is satisfied that the penalty order proposed in the Joint Submission as to Penalty is within the range of penalties imposed in similar cases.

21. Similarly, the panel is satisfied that the costs agreed to are proportional to the admitted misconduct and aligned with costs awarded in similar cases by this Discipline Committee.

Costs

22. Following the conclusion of the hearing, the Panel was advised that the parties had agreed to an order that the Member pay costs to the College in the amount of $25,000.00 within seven (7) days of the date of this order.

23. Upon reading the College submission and being advised that the parties are in agreement with the quantum of costs, the panel is satisfied that the costs agreed to are proportional to the admitted misconduct and in alignment with costs awarded in similar cases by this Discipline Committee.

Reprimand

24. At the conclusion of the hearing, having confirmed that the Member waived any right to appeal, the panel delivered its reprimand found in Schedule A.

SCHEDULE A

Reprimand

As you know, Mr. Infanti, as part of its penalty order this Discipline panel has ordered that you be given an oral reprimand. You agreed to this term of order as part of your joint submission on penalty filed during the course of the hearing.

The fact that you have received this reprimand will be part of the public portion of the Register and, as such, part of your record with the College.

Although you will be given an opportunity to make a statement at the end of the reprimand, this is not an opportunity for you to review the decision made by the Discipline panel, nor a time for you to debate the merits of our decision.

The panel has found that you have engaged in professional misconduct in several different ways, including failing to adhere to a number of the College’s standards

We are particularly concerned that this case involved multiple breaches of the standards over the course of several years and with respect to a significant number of patients.

Your misconduct has brought discredit to the profession and to yourself. Public confidence in this profession has been put in jeopardy. The public rely on insurance companies and it is important that we has a profession act with integrity and honesty in our dealings with those companies.

Moreover, the result of your misconduct is that you have let down the public, the profession, and yourself.

We need to make it clear to you that your conduct is unacceptable.

Of special concern to us is that fact that the professional misconduct in which you engaged has involved financial gain over the patients’ best interest. This misconduct is all the more disappointing given your experience.

Consequently, it is necessary for us to take steps to impress upon you the seriousness of the misconduct in which you have engaged.

We also want to make it clear to you that while the penalty that this panel has imposed upon you is a fair penalty, a more significant penalty will be imposed by another Discipline panel in the event that you are ever found to have engaged in professional misconduct again.

Footnotes

1. 1The Appendices have not been included in the Panel’s Reasons for Decision
2. 2The schedules have not been included in the Panel’s Reasons for Decision
3. 3The Member admits that the GSC claims forms that he signed were misleading and leave the impression that the Member dispensed all o shoes and orthotics (as required by GSC policy) when this was not the case.