Payment Time Limits for Benefits, Services or Care

Purpose

This policy provides direction on the time limit within which a person must submit a claim for payment or reimbursement of an expenditure incurred to acquire the following services under the Veterans Health Care Regulations:

1. treatment benefits, supplementary (travel) benefits, treatment allowance or miscellaneous (examination and travel) benefits;
2. Veterans Independence Program services; and
3. Long Term Care services.

Policy

1. The Veterans Health Care Regulations (section 34.1) state the time limits for an eligible person to obtain reimbursement or payment of expenditures incurred to meet a health need.
2. The general requirements governing reimbursement or payment of expenditures incurred by an eligible person are:
   1. a claim for reimbursement or payment must be made by or on behalf of the person within 18 months of the day on which the expenditure was incurred;
   2. proof of the expenditure must be provided by the person or on the person’s behalf; and
   3. reimbursement or payment must not exceed the maximum amount payable under the Veterans Health Care Regulations at the time the expenditure was incurred, unless payment at a higher rate is authorized by the Minister under subsection 34(1) of the Veterans Health Care Regulations. (See Exceeding Rates for Veterans Independence Program (VIP) and Long Term Care (LTC) policy.)
3. Subject to paragraph 2, reimbursement or payment shall be made if the person was eligible to receive benefits, services or care under these Regulations for that health need at the time that the expenditure was incurred.
4. Subject to paragraph 2, reimbursement or payment shall be made if the person, within 90 days after incurring the expenditure, applies for a pension and:
   1. the person is awarded the pension for the condition in respect of which the expenditure was incurred and would have been eligible to receive benefits, services or care in respect of that condition if the person had been entitled to the pension at the time the expenditure was incurred;
   2. the person is awarded the pension and, as a result, qualifies as a seriously disabled veteran pensioner or seriously disabled civilian pensioner; or
   3. the person is awarded the pension and, as a result, qualifies as a medium-disabled veteran pensioner or medium disabled civilian pensioner.
5. In cases where an eligible person is not able to meet the 18-month time limit due to certain actions or inactions by the Department, the decision-maker will base his or her decision on a review of the circumstances to ensure consistency and fairness.

Disability Award Recipients

6. Disability award recipients are entitled to reimbursement or payment of an eligible health need expenditure that is incurred on or after the effective date of their disability award entitlement decision.
7. Where a person has received a disability award entitlement decision before April 1, 2019, but has not yet recieved an assessment decision by that date, he or she will be paid pain and suffering compensation. In such case, the person would be entitled to reimbursement or payment for eligible health need expenditures that are incurred on or after the date of their disability award entitlement decision.

Pain and Suffering Compensation Recipients

8. Pain and suffering compensation recipients are entitled to reimbursement or payment of an eligible health need expenditure that is incurred on or after the effective date of their entitlement, which is the date the compensation begins to be payable from.
9. Where a person has applied for a disability award before April 1, 2019, but has not yet received an entitlement decision for a disability award, he or she will will receive an entitlement decision for pain and suffering compensation. In such case, the person would be entitled to reimbursement or payment for eligible health need expenditures that are incurred on or after April 1, 2019.

Reimbursement or Payment after Eligibility Ceases

10. Where a person in receipt of any benefit, service or care under the Veterans Health Care Regulations ceases to be eligible for it, the benefit, service or care shall be continued for a reasonable period in order to allow the individual to make alternate arrangements (see Termination of Benefits, Services and Care policy). Claims for reimbursement or payment of such expenditures incurred for a health need during that reasonable period must be made within 18 months of the date the expenditure was incurred.

Exception to the 18-Month Time Limit for Filing Claim

11. A claim may be approved beyond the 18-month time limit only when there is clear evidence that the person was unable to make the claim due to medical or psychological incapacity.
12. “Medical or psychological incapacity” may be defined as the inability of a person to manage their own affairs, as a result of:
    1. a) any damage to or any illness, disorder, imperfect or delayed development, impairment or deterioration of the brain or mind (i.e. brain damage or neurological disease); or
    2. any physical illness or condition that renders the person unable to communicate his or her intentions or wishes in any way or take necessary action (e.g. multiple physical disabilities like hearing, speech and sight impairments and stroke.

References

Veterans Health Care Regulations

Exceeding Rates for Veterans Independence Program (VIP) and Long Term Care (LTC)

Termination of Benefits, Services and Care