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The Canada Pension Plan Disability Adjudication Framework
Glossary
- Adjudication Framework
- This document outlines the policies used to determine the medical eligibility of applicants for the Canada Pension Plan disability benefit. It is effective as of May, 2004.
- Allowable Earnings
- Allowable Earnings is a client's total earnings from all work in a calendar year that is equal to or less than the Disability Basic Exemption. A CPP disability beneficiary is allowed to work and earn $4,800 in the 2011 calendar year (adjusted annually) without a requirement to report earnings from employment and without being reassessed on earnings from employment alone.
- Beneficiary
- A CPP contributor who has met the "severe" and "prolonged" criteria and is in receipt of a CPP disability benefit.
- Benevolent Employer
- A "benevolent employer" is someone who will vary the conditions of the job and modify their expectations of the employee, in keeping with her or his limitations. The demands of the job may vary, the main difference being that the performance, output or product expected from the client, are considerably less than the usual performance output or product expected from other employees. This reduced ability to perform at a competitive level is accepted by the "benevolent" employer and the client is incapable regularly of pursuing any work in a competitive workforce.
Work for a benevolent employer is not considered to be an "occupation" for the purposes of eligibility or continuing eligibility for a CPP disability benefit.
- Date of Application
- This is the date an application for Canada Pension Plan is received by the Department. When there is eligibility for retroactive payments the amount is calculated from this date.
- Date of Onset
- The date a person is determined to be disabled for CPP purposes. This date can be no more than 15 months prior to the receipt of the application. Payment begins from the fourth month following this date.
- Difficult/Complex Case
- A case in which the subjective complaints/behaviors related to a mental and/or physical medical condition exceed objective findings; and/or when the recovery time related to a mental and/or physical medical condition greatly exceeds typical duration guidelines.
- Diligence
- As it pertains to onus, is a legal concept. Within the context of this policy, it is closely associated with the concept of fairness and is the foundation of good adjudication. Diligence is defined as careful and persistent effort. While the Department and the person are responsible for different aspects of the process, it is through mutual co-operation and shared responsibility that clear and wellfounded decisions are reached.
- Disabled
- In this policy, "disabled" means "disabled for Canada Pension Plan (CPP) purposes" unless otherwise stated. This is described in the Canada Pension Plan legislation under paragraph 42.
- Early Client Contact
- In accordance with Operational Directives Early Client Contact (ECC) refers to the telephone contacts that are made by CPP departmental representatives at the initial application and reconsideration stages. No less than two attempts to contact the client are to be made for each rapport and decision call. The rapport call is to inform the client of the process and the required documentation. The decision call is to explain the reasons for the decision and the appeal rights.
- Fairness
- An administrative law principle. The "duty to be fair" means the medical adjudicator keeps an open mind in reviewing the evidence in a case and carefully reviews all of the evidence to determine if the person meets or continues to meet the "severe and prolonged" criteria. This approach begins upon receipt of the first document and is observed throughout the disability determination and reassessment processes.
- Federal Court of Appeal
- Is a section of the Federal Court of Canada which reviews the PAB decisions that an applicant is not disabled according to the CPP legislation. The applicant or the Minister can request judicial review of decisions. However, the Federal Court does not have jurisdiction to make a decision on the substantive issue of eligibility for CPP benefits; but it can refer the case back to the previous decision- maker to re-hear the issue of disability. The Federal Court and the Federal Court of Appeal can only hear arguments about how the decision-maker reached its decision. Did it have the statutory authority to make the decision? Did it apply the correct law? Were the proceedings fair? Was its decision based on the evidence before it? The Angheloni, Rice and Villani decisions are Federal Court decisions that can be accessed at its Web site.
- Formal Education
- A formal education includes basic learning, elementary and high school, and post-secondary school (college, trades or technical school, or university).
- Functional Capacity Evaluation
- A functional capacity evaluation (FCE) is a series of tests used to evaluate a person's abilities and limitations in activities of daily living and activities related to work. The activities include positions and movements such as sitting, standing, walking, bending, lifting, reaching, carrying, climbing, kneeling, etc. A trained professional such as a physiotherapist, occupational therapist or kinesiologist, conduct the FCE and in many cases, it is done by a team.
- Functional Limitation
- An impairment that leads to a less than normal performance for an individual. The focus of CPP Disability is only on those functional limitations that affect the capacity to work.
- Incapable
- As a result of the continuous and uninterrupted nature of the disability, an individual would not be able to do any substantially gainful occupation. This is described in the Canada Pension Plan legislation under paragraph 60(8) and 60(9).
- Informal Education
- Informal education can contribute to learning a new job or transferring skills which were not necessarily the principal skills for a previous job. These include communication, organizational, time management skills and the ability to set priorities. Sometimes only a few weeks or a month of "on-the-job training" can assist an individual to be able to perform a new job. Informal education also includes learning and specialized skill development pursued in job-sponsored orientation courses (e.g. computer training courses, project management).
- Late Applicant Provision
- This provision is to help an applicant of a CPP disability benefit that has not worked recently enough to fulfil the CPP eligibility requirement to have contributions in four of the last six years. As long as an applicant had enough years of CPP contributions when they first became severely disabled, and as long as the medical evidence demonstrates they are continuously disabled (as defined by CPP legislation) from that date up to the present time, they may still be eligible. Please contact us for further information.
- Latest Possible Date of Onset
- The date when an applicant last meets the contributory requirements for being eligible for Canada Pension Plan disability benefits - that being, when they last made contributions.
- Medical Adjudicator
- The Department's medical adjudicators are health professionals who review applications for the Canada Pension Plan (CPP) disability benefit, except when the applicant has not made enough CPP contributions.
Social Development Canada's medical adjudicators are trained nurses with extensive knowledge of CPP legislation, regulations, policies and procedures. The medical adjudicators are drawn from all medical specialties.
- Occupation
- An occupation is work or a job/career/profession that is conducted in a competitive workforce. It is an activity in which a person might reasonably be expected to be employed because of his or her skills, education and training. It may also refer to the capacity to acquire the necessary skills, education or training in the short-term whether on the job or otherwise given the person's limitations and restrictions.
- Offer of Settlement
- In exceptional circumstances an offer of settlement is made by the Minister to an appellant prior to a Review Tribunal or Pension Appeals Board hearing. Neither the Review Tribunal nor the Pension Appeals Board is involved in any way.
- Onus of Proof
- A legal concept that refers to who bears the burden of proof.
- Onus on the Client
- At all levels of decision-making in the determination of eligibility for a CPP disability benefit, the "onus of proof" is with the individual. As such the person, or the representative acting on behalf of the person, must provide the necessary documentation to satisfy the Minister that he or she meets the "severe" and "prolonged" criteria. The person is responsible for contacting the Department to obtain assistance when he or she is unsure about what evidence is required to determine eligibility. Once contacted the Minister has an obligation to explain to the person what may be required to help meet their onus when applying for a CPP disability benefit.
- Onus on the Minister
- At reassessment, in order to cease benefits, the onus to prove that the disability benefit recipient is no longer eligible rests with CPP. The onus is on CPP to establish on "the balance of probabilities" that since the time the individual was granted a CPP disability benefit there has been:
- an adaptation to the limitations of the medical condition and/or an improvement in the medical condition;
- this adaptation to the medical condition and/or improvement in the medical condition has resulted in an increased capacity for work; and
- the increased capacity for work warrants a cease of the CPP disability benefit.
- At reassessment, in order to cease benefits, the onus to prove that the disability benefit recipient is no longer eligible rests with CPP. The onus is on CPP to establish on "the balance of probabilities" that since the time the individual was granted a CPP disability benefit there has been:
At reassessment, a statement of a physician or a qualified health professional that a beneficiary's medical condition has improved would not be sufficient evidence to cease the CPP disability benefit. The medical adjudicator must determine whether this improvement is related only to the ability to perform his/her basic activities of daily living or whether this improvement results in an increased capacity to pursue any substantially gainful occupation.
- Onus on the Client
- Pension Appeals Board
- The Pension Appeals Board is an independent body, operating separately from CPP Disability. It is the second formal level of appeal of the Canada Pension Plan appeal process. This is described in the Canada Pension Plan legislation under sections 83 and 84.
- Performance
- The actual effort that the individual undertakes in order to carry out the work. Performance relates to the person's ability to perform all of the tasks and duties required for a specific job. It is not considered in isolation but is considered based on the interrelationship with productivity and profitability.
- Personal Characteristics
- Personal characteristics are those intrinsic factors that are unique to a particular person and directly affect that person's regular capacity to pursue any substantially gainful occupation. They alone do not establish eligibility for CPP disability benefits.
The personal characteristics to be considered are:
- age,
- education,
- work experience.
- Power of Attorney
- When a person authorizes another person to act on his or her behalf in specific situations.
- Prime Indicator
- The medical condition is always the prime indicator in determining eligibility for CPP disability benefits. This determination is based on the nature of the medical condition, functional limitations, impact of treatment, and medical statements from physicians or other health care professionals.
- Productivity
- The amount of work produced in a given period of time. Productivity relates to the person's ability to produce the standard amount or number of products, services or outcomes as described in a work description. It is not considered in isolation but is considered based on the interrelationship with, performance and profitability.
- Profitability
- The amount of money an individual earns for a work activity from employment or self-employment. Profitability is always assessed in conjunction with performance and productivity.
- Prolonged
- "Prolonged" means that your disability is likely to be long term and of indefinite duration, or is likely to result in death. This is described in the Canada Pension Plan legislation under paragraphs 42(2)(a) and 42(2)(b).
- Proof
- Proof is the result of evidence; while evidence is the means by which a fact is proven or disproved. For example, a statement from an employer is considered as evidence, but this evidence alone may not be sufficient to determine that a person has a "severe" and "prolonged" disability.
- Pursuing
- Means actually doing a job. "Pursuing" is not used in the sense of seeking work.
- Reasonably Satisfied Standard for CPP Disability
- The standard of proof that must be met for a person to be eligible for a CPP disability benefit or for a CPP disability benefit to continue.
The standard of proof is established by considering all evidence that is pertinent to the person's medical condition, capacity to work and personal characteristics, and only evidence that is pertinent.
In relation to all the evidence that is before the medical adjudicator, the questions to be asked to establish a reasonably satisfied standard of proof are:
- Is this person's medical condition likely to result in death, thus supporting a finding of a severe and "prolonged" disability? Or,
- Based on the overall evidence, is it more likely than not that this person meets the CPP "severe" and "prolonged" criteria?
That is:
- Is it more likely than not that this person's disability makes him/her incapable regularly of pursuing any substantially gainful occupation?
And if so,
- Is the disability more likely than not to be long continued and of indefinite duration?
- Reassessment
- A systematic review of medical and employment information of selected CPP disability recipients. This review results in a decision to continue or stop CPP disability benefits. It can also assist to identify the services which would best support a person attempting to return to work.
- Reconsideration
- The first level of recourse for CPP claimants is an administrative review or reconsideration carried out by a staff member who was not involved in the initial decision. Claimants must request reconsideration in writing within 90 days of receiving the initial decision letter. This is described in the Canada Pension Plan legislation in paragraphs 81(1) and 81(2).
- Record of Earnings
- A record of all earnings and CPP contribution information of every working Canadian collected by Canada Revenue Agency and provided to CPP for the administration of its programs. CPP benefits are based directly on this database. Québec Pension Plan contributions are also provided for dual contributors.
It does not capture periods prior to age 18 when someone may have been working. The Record of Earnings amounts directly related to work are to be considered. Earnings which are related to severance, vacation, sick leave, etc. are not considered.
- Regularly
- The limitations associated with the disability are persistent almost to the point of being continuous or uninterrupted.
- Representative
- A person who the client has identified to the Canada Pension Plan as representing them in their Canada Pension Plan disability application or appeal processes. In these cases depending on the directions given Canada Pension Plan staff will communicate with the client and representative or directly with the representative depending on the directions given.
- Sheltered Employment
- Sheltered employment is not considered to be an "occupation" for the purposes of eligibility or continuing eligibility for a CPP disability benefit. Sheltered employment involves simple tasks performed in a closely supervised environment where performance goals are defined by the employee's capabilities. The work is therapeutic in that it gives the employee a sense of accomplishment as well as an income. The client employed in a sheltered work environment is incapable regularly of pursuing any work in the competitive workplace. Often sheltered employment is offered in co-ordination with other public programs, psychiatric or mental health organizations.
- Severe
- Severe means that you have a mental or physical disability that regularly stops you from doing any type of work, not just the work you usually do. This is described in the Canada Pension Plan legislation under sections 42(2)(a) and 42(2)(b).
- Socio-economic conditions
- Conditions, such as the unemployment rate or the availability of certain types of jobs in a particular locality, are factors that exist in society which are outside the context of the individual with the disability. They affect groups or populations living in regions or provinces, or the country as a whole, and may constitute a barrier to work.
Similarly, factors such as the lack of child care or elder care, family responsibilities or preferred working hours are also not to be considered in a CPP disability determination.
Socio-economic conditions are not considered when determining a "severe" and "prolonged" disability.
- Standard of Proof
- The "standard of proof" is a legal concept. It is the level of proof that must be met by the person who has the onus.
- Substantially Gainful Occupation
- An occupation where the remuneration for the work performed and services rendered is at a substantially gainful amount. The substantially gainful amount is a benchmark of earnings that likely indicates whether a person is showing regular capacity for work.
The substantially gainful amount is the maximum monthly CPP retirement pension. The annual amount is equal to twelve (12) times the maximum monthly CPP retirement pension. CPP payment rates are adjusted every January.
- Work Capacity
- The capacity to perform physical and/or mental work-related activities despite certain functional limitations and restrictions resulting from a medical condition(s).