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The Prolonged Criterion
Purpose
The purpose of this policy is to assist the medical adjudicator determine if the "prolonged" criterion of the Canada Pension Plan (CPP) legislation is met.
Table of Contents
- 1. Introduction
- 2. Policy
1. Introduction
"Prolonged" applies only at initial determination and is assessed at the date the medical adjudicator is making a decision on an application. The "prolonged" criterion is only considered after the "severe" criterion is met. It refers to the length of time a person is expected to be unable to do any work because of their severe disability.
"Prolonged" requires an assessment of the likelihood that the severe disability will continue into the future and whether or not it is likely that a person will go back to any work. In determining "prolonged," the medical adjudicator reviews the interrelationship among factors related to the medical condition (prime indicator) that could affect a particular person's recovery period.
At reassessment, as long as the "severe" criterion continues to be met, the "prolonged" criterion is met. When a reassessment determines that a beneficiary no longer meets the severe criteria, this means there is now capacity for work and the beneficiary is no longer eligible for CPP disability benefits.
2. Policy
"Prolonged" does not refer to past duration. "Prolonged" is only considered after the "severe" criterion is met; that is, only after it has been determined that a person has a severe disability.
To be eligible for CPP disability benefits, an applicant must demonstrate that both the "severe" and "prolonged" criteria are simultaneously met. The point at which the disability became "prolonged" may be important in determining the date of onset.
In looking at a "severe" disability, it is the expectation that the "severe" disability will prevent a person from returning to any work for a period of time that must be demonstrated.
"Prolonged" has two components. These are:
- "likely to result in death," or
- "likely to be long continued" and "of indefinite duration."
Only one of these components must be met to establish "prolonged."
2.1 Component: Likely to Result in Death
When the evidence is conclusive that the disability is likely to result in death in the near future and there is no work activity at the Date of Application the "prolonged" criterion is met.
The evidence related to the nature of the medical condition supports that no recovery is expected and the prognosis supports that death is likely to occur in the near future. In these cases, the second component, "likely to be long continued and of indefinite duration" is not relevant. The person is eligible for CPP disability benefits.
2.2 Component: "Likely to be Long Continued" and "of Indefinite Duration"
Under this requirement "prolonged" is only met when the "likely to be long continued" and of "indefinite duration" components are simultaneously met. The individual must demonstrate that both components are met at the same time to be eligible for CPP disability benefits.
There is no reference in the CPP legislation or regulations to a numerical timeframe for "prolonged." However, one year is considered to be a reasonable period of time from which to predict the likelihood of whether the severe disability will improve enough so that the person may return to any work. The prediction of the likelihood of improvement is based on a more likely than not basis which is the reasonably satisfied standard.
These components assess whether there is uncertainty and/or unpredictability with respect to the length of time a severe disability is expected to continue into the future. The medical adjudicator makes this determination based on a combination of evidence and health science knowledge as to whether it is likely that:
- the severe disability will last for at least the next 12 months (can also be more than 12 months if the expected date of return to work is given in the evidence); and
- the capacity to do any work can be predicted with a definitive degree of certainty.
2.2.1 Component: Likely to be Long Continued
To meet the "likely to be long continued," the combination of evidence and health science knowledge related to the disabling medical condition(s) must support that there is no possibility of a return to any work within one year. The possibility of a return to any work must be considered into the future.
The onset of the disability may have been months or years prior to the application; nevertheless, it must be determined that the disability will also continue into the future, for at least a year and prevent the individual from doing any work.
If the capacity to do any work can be predicted in the future the individual does not meet the component of "likely to be long continued" and is not eligible for CPP disability benefits.
2.2.2 Component: Likely to be of Indefinite Duration
The second legislative requirement to be considered is "likely to be of indefinite duration"; that is, there must be no definite end in sight for the period of disability.
Generally when there is a definite end in sight to the disability such as a fixed return to work date, medical intervention, medical treatment or the completion of retraining or upgrading this component is considered not to be met. If it can be predicted based on a planned return to work, medical treatment or intervention that the capacity to do any work will be beyond 12 months the "likely to be of indefinite duration" would not be met.
Where there is uncertainty and unpredictability with respect to the time that a person will take to recover sufficiently in order to resume some kind of substantially gainful employment, the person will be granted disability benefits. A reassessment date will be scheduled for a time when potentially the client may be able to go back to work.
2.3 Recurrent Medical Conditions/Episodic and Cyclical Medical Conditions
Medical conditions such as cancer can recur given the nature of the medical condition. Recurrent medical conditions tend to be more severe with complications and can have an increased impact on an individual's ability to function. Each recurrence has an impact in terms of treatment, recovery and likelihood of deterioration. Recurrence generally results in shorter intervals between relapses, more aggressive treatment and medical interventions and longer absences from the workplace. Functional limitations may be more significantly affected with each recurrence. The individual's ability to function as a result of a long-term medical condition that recurs may be reduced with each recurrence. The cumulative effect of recurrences may result in a "prolonged" disability.
Episodic and cyclical medical conditions can result in deterioration of the individual's ability to function with each exacerbation. Examples of such conditions are schizophrenia and multiple sclerosis. Each exacerbation can result in a decreased likelihood of improvement or recovery. The cumulative effects of exacerbations can result in a significant decrease in function over a period of years. Each exacerbation has an impact in terms of treatment, recovery and likelihood of deterioration. Long-term medical conditions that are recurrent, episodic or cyclical may not meet the "prolonged" criterion looking back on the person's history; however, with a new exacerbation it may be predicted that it is more likely than not that the "prolonged" criterion is met into the future.