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The Canada Pension Plan Disability Adjudication Framework
The Reasonably Satisfied Standard of Review for Determining Eligibility and/or Continuing Eligibility for Canada Pension Plan Disability Benefits
Purpose
The purpose of this section of the adjudication framework is to assist the medical adjudicator to apply a "reasonably satisfied" standard of proof when determining eligibility or continuing eligibility for Canada Pension Plan (CPP) disability benefits.
Table of Contents
1. Policy
1.1 Reasonably Satisfied: Legal Concepts and an Administrative Law Principle
The legal concepts of onus of proof and standard of proof, and the administrative law principle of fairness form the basis of a "reasonably satisfied" standard of decision-making.
Diligence is a principle of good adjudication that assists the Department to fulfill its obligations to make an informed decision under the "reasonably satisfied" standard.
1.2 The Reasonably Satisfied Standard
The "reasonably satisfied" standard, as defined in this document, is the standard to be applied in determining a person’s eligibility or continuing eligibility for disability benefits under the CPP. It is an adaptation of the civil standard of proof of "on a balance of probabilities," or "on the preponderance of the evidence" and is synonymous with the phrase "more likely than not." In this policy the phrase that is most often used is "more likely than not."
The standard is not whether the disability would cause "any person" or "most people" to be incapable, but whether it causes a "particular person" to be incapable regularly of pursuing any substantially gainful occupation.
It is not a decision based solely on medical facts. The reasonably satisfied standard of proof requires a medical adjudicator to consider not only the medical condition(s), but also work capacity and personal characteristics and how they affect the individual.
The medical condition is the prime indicator of a disability. The analysis includes an evaluation of the "severe" and "prolonged" criteria related to the nature of the medical condition, progressive nature of the medical condition, functional limitations, impact of treatment, medical statements, and multiple medical conditions as defined in this guideline.
Work Capacity is the capacity to perform physical and/or mental work-related activities despite certain functional limitations and restrictions resulting from the medical condition(s). Assessment is based on pertinent medical and work capacity evidence, vocational findings and personal characteristics. When considered together, these facts provide evidence to support the necessary judgment(s) related to the person’s capacity to pursue any substantially gainful occupation.
Personal characteristics to be considered are age, education, and work experience. The reference to "the person in respect of whom the determination is made" means that a "severe" and "prolonged" disability must be evaluated within the context of the whole person.
1.3 Evidence
The person’s description of his or her disability is the starting point for the determination of whether that person meets or continues to meet the "severe" and "prolonged" criteria. All pertinent evidence related to the disability issue(s) identified in the application is considered.
1.3.1 Pertinent Evidence
Pertinent evidence is all the evidence required to make an informed decision in a case. This decision is based on any evidence about the person’s medical condition(s), work impairments, or work capacity. In addition, the medical adjudicator’s knowledge of the health sciences and of the CPP legislation must be applied to the evidence under consideration.
Pertinent evidence includes evidence obtained from Early Client Contact calls to the client, phone calls to physicians, medical reports by family physicians, specialists and/or other health care professionals, reports of diagnostic investigations, employer reports and functional capacity assessments. It also includes information obtained from federal and provincial government on Employment Insurance benefits, Workers Compensation benefits etc. Pertinent evidence must always relate to the time period in question.
Pertinent evidence based on objective evidence linked directly to the medical condition(s), affords a greater degree of certainty as to the level of capacity and/or disability experienced by the person.
Pertinent evidence resulting from subjective evidence can afford a lesser degree of certainty as to the level of capacity and/or disability experienced by the person and must be evaluated within the context of all the evidence.
Pertinent evidence includes both medical and work capacity evidence as defined in this document.
1.3.2. Medical Evidence
Medical evidence may be subjective or objective:
1.3.2.1 Subjective medical evidence
- Any evidence that cannot be observed or measured objectively through diagnostic testing. This includes the person’s or physician’s description of symptoms or complaints (e.g. pain, weakness, etc.).
1.3.2.2 Objective medical evidence
- A sign, deficit or impairment that can be observed and described or measured and may validate subjective symptoms. Examples include diagnostic test results, observation of function (can lift X kilos, can sit X minutes, walks with a limp, measured lack of short-term memory, etc.).
Medical evidence includes reports by qualified family physicians, specialists, and other health professionals, and results from physical examination(s), diagnostic and investigative tests etc.
1.3.3 Evidence of Capacity to Work
Capacity for any type of substantially gainful occupation is based on all the evidence concerning the person’s physical and mental abilities, restrictions and limitations. Work capacity evidence includes reports from psychologists, neuropsychologists, physiotherapists, occupational therapists, vocational rehabilitation professionals, functional capacity assessments, statements from educational institutions and employers, power of attorney documents, certificates of incapacity and other sworn affidavits which validate mental incapacity, etc.
1.4 Considering All the Evidence
The medical adjudicator, using his or her health sciences knowledge and knowledge of CPP legislation and policy, considers all evidence and decides whether he or she is reasonably satisfied that the person meets or continues to meet the "severe" and "prolonged" criteria.
While many medical conditions can be readily recognized and evaluated based on objective medical evidence, some conditions, such as Fibromyalgia, Chronic Pain Syndrome and Chronic Fatigue Syndrome will not have the traditional objective tests available to determine whether the person meets or continues to meet the "severe and prolonged" criteria. The adjudication of these cases can be a challenge.
In these conditions, evidence can be obtained from other sources, such as a vocational rehabilitation consultant, an occupational therapist, a physiotherapist, an employer, etc. For particularly difficult/complex cases, CPP will request evidence from a wide variety of sources and may request an examination by an independent physician who specializes in the medical condition.
The objective medical findings may not indicate any pathology. However, the residual effects of a medical condition, injury or medical treatment(s) may have a significant impact on the individual’s ability to function in the workplace. In some instances, an individual may develop a condition such as depression or chronic pain related to the primary medical condition resulting in the regular inability to pursue any substantially gainful occupation. It may be reported or described, but no clear documentation or test results can be provided. Consistent references and opinions in the overall evidence must be accepted as valid and substantive when provided by duly qualified professionals.
Opinions provided by all of the professionals must be compared and evaluated with the statements made by the person in order to obtain a total picture of the individual. Where the overall available evidence supports that the person meets the "severe" and "prolonged" criteria, the benefit is granted.
The medical adjudicator therefore does not require absolute proof that the person has or continues to have a "severe" and "prolonged" disability. The medical adjudicator must only conclude that based on the overall evidence, it is more likely than not that the person meets or continues to meet these criteria.
1.5 Making an Eligibility Decision
1.5.1 Determining Eligibility
When determining eligibility for disability benefits, two possible decisions can be made:
- If, after reviewing a file, the medical adjudicator is reasonably satisfied that the person meets the "severe" and "prolonged" criteria, grant.
- Otherwise, the medical adjudicator will deny.
1.5.2 Reassessing Eligibility
When reassessing eligibility for disability benefits, two possible decisions can be made:
- If, after reviewing a file, the medical adjudicator is reasonably satisfied that the person continues to meet the "severe" criteria, continue disability benefits.
- Otherwise, the medical adjudicator will cease disability benefits.
1.6 When a Decision Cannot be Made
If, after reviewing a file, the medical adjudicator cannot make a decision, further assessment and/or consultation may be needed.