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Severe Criterion for the Prime Indicator (Medical Condition)
Purpose
This guideline provides a framework for evaluating medical conditions to determine eligibility for Canada Pension Plan (CPP) disability benefits.
Table of Contents
- 1. Introduction
- 2. Policy
1. Introduction
The medical condition is considered the prime indicator. That is, a person must first have a medical condition and secondly, that medical condition must result in a "severe" and "prolonged" disability in order for a person to be eligible for CPP disability benefits.
The importance of the medical condition was confirmed in the Federal Court of Appeals (FCA) decision in Villani v. Canada (2001). In this case the FCA said that a person applying for a CPP disability benefit must be able to demonstrate that they have "a serious and "prolonged" disability". Medical evidence will still be needed as will evidence of employment efforts and possibilities.
2. Policy
Prime Indicator: Medical Condition
The medical condition is always the prime indicator in determining a "severe" and "prolonged" CPP disability. There are a number of factors to consider in assessing the medical condition:
- The nature of the medical condition, and whether it is progressive;
- Functional limitations imposed by the medical condition;
- Impact of treatment(s);
- Statements/opinions expressed by medical practitioners and/or other health professionals, and by the client;
- Existence of multiple medical conditions; and
- Personal characteristics.
The medical adjudicator must determine if the medical condition regularly prevents a particular person from working.
2.1 Factor: Nature of the Medical Condition
A medical condition can be evaluated as mild, mild to moderate, moderate, moderately-severe or severe in nature. Certain conditions can be described as cyclic, acute, slowly progressive, rapidly deteriorating, chronic or terminal. Certain medical conditions can have periods of exacerbations, remissions, stability and deterioration.
In some cases there will be conclusive evidence that the medical condition alone supports the "severe" and "prolonged" criteria for CPP purposes. In these cases no additional determination is required.
These medical conditions can include: AIDS, aneurysm, brain tumor, cancer, carcinoma, cerebral hemorrhage, cerebral infarction, cerebrovascular accident (CVA), coma, end stage amyotrophic lateral sclerosis (ALS), end stage degenerative neuromuscular disorders, glioma, Guillain-Barré syndrome, Hodgkin's disease, leukemia, liver failure, lymphoma, massive stroke, melanoma, muscular dystrophy, myeloma, neoplastic disease, renal failure, and sarcoma.
In most cases the medical adjudicator uses his or her health science knowledge, the CPP legislation and the medical information provided by the individual and health professionals, to determine whether the nature of a medical condition could be "severely" disabling and lead to an inability to work. The medical adjudicator must also consider any other pertinent factors and/or sub-factors, personal characteristics, and work capacity evidence that influence the determination of a "severe" and "prolonged" disability.
2.1.1 Sub-factor: Progressive Nature of the Medical Condition
Many medical conditions are cyclic, and/or slowly or rapidly progressive in nature. They require evaluation over time to determine when a person is eligible for CPP disability benefits.
Consideration of the progressive nature of the medical condition is particularly pertinent when adjudicating under the late applicant provision. This is because sometimes the signs and symptoms of a disability can occur before the medical condition has been diagnosed and/or before the person has insufficient earnings and contributions to support their disability entitlement.
The medical adjudicator therefore evaluates these signs and symptoms in conjunction with his or her knowledge of disease processes, the entire history and all the evidence in a case.
The goal of this evaluation is to determine whether the signs and symptoms, which were present and could be identified by the medical history, support on "a more likely than not" basis a "severe" and "prolonged" disability prior to the date of diagnosis or the Latest Possible Date of Onset.
2.2 Factor: Functional Limitations
A functional limitation is an impairment that leads to less than normal performance for an individual. The focus of CPP disability is only on those functional limitations that affect the capacity to work.
2.3 Factor: Impact of Treatment
For Canada Pension Plan purposes treatment can be defined as what is needed to restore or improve the health and function of a particular person, or what is needed to prevent or delay deterioration.
Treatments can vary depending on the nature, and severity of the medical condition or conditions, and the person's response to those treatments. In some cases the goal of treatment or treatments is to cure or remove the cause of the medical condition. In other cases the goal of treatment or treatments is to control the progression of the medical condition, and/or provide relief of symptoms, and/or provide insight and necessary coping mechanisms for adapting to the person's identified limitations.
The medical adjudicator must determine how ongoing medical treatments are likely to affect the medical condition and a person's ability to work in the short term and/or in the future. Short term in this context means within one year.
2.4 Factor: Medical Statements
Medical statements contained in reports form part of the medical evidence in a case. The medical statements must be evaluated in terms of what is consistent and logical in relation to all of the evidence in a case and the way CPP determines a "severe" and "prolonged" disability.
2.5 Factor: Multiple Medical Conditions
For CPP purposes, a person who has been diagnosed with two or more medical conditions has multiple medical conditions.
The medical adjudicator must determine if this is a case in which consideration of one medical condition might not indicate incapacity for any work, but when two or more medical conditions are considered together they would indicate such incapacity.
2.6 Factor: Personal Characteristics
These are described in the Personal Characteristics and Socio-Economic Factors policy.