Treatment for a Disability Benefits Entitled Condition

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Issuing Authority

Director General, Policy and Research

Effective Date

April 01, 2019

Document ID

1915

Purpose Policy General Guiding Principles Considerations References

Purpose

The purpose of this document is to provide policy direction regarding the interpretation of the phrase “in respect of” in relation to a disability benefits entitled condition.

Policy

General

For the purpose of this policy, the term “Veteran” is interpreted to include all individuals eligible for treatment for a disability benefits entitled condition.
This policy sets out principles to be applied in decision-making when determining if a relationship exists between a treatment benefit and a Veteran’s disability benefits entitled condition. This policy is intended to complement the exercise of decision-making, as it is conducted in accordance with the legislation and the principles of administrative law.
The objective of providing any benefit or service under the Veterans Health Care Regulations shall be to achieve a positive treatment outcome for the Veteran’s entitled condition.
A practical approach to providing health care benefits to eligible Veterans requires that requests for treatment benefits be considered in a broad and inclusive manner so as to successfully treat the entitled condition.

Guiding Principles

When determining whether a particular benefit or service is for a disability benefits entitled condition, the following guiding principles shall be considered:
1. the requested treatment should be expected to produce a positive treatment outcome for the entitled condition; or
2. the requested treatment addresses, or is reasonably expected to address, symptoms and/or effects that are caused in whole or in part by the entitled condition.

Considerations

The following statements and examples are intended to more clearly articulate how the guiding principles are intended to be applied.
1. Degrees of Separation
  
  Paragraph 5(b) above may be reasonably interpreted by limiting the linkage between the proposed treatment and the symptoms and/or effects caused wholly or partly by the entitled condition to one degree of separation. In other words, the treatment may be provided to address a symptom and/or effect which is a direct result of the entitled condition.
  1. Examples:
    
    An A-line Veteran diagnosed with tinnitus is bothered by a distracting ringing noise that impairs his ability to sleep. This is one degree of separation, and it would be legitimate for the Department to provide for the sleep disturbance in these circumstances.
  2. A Veteran has been diagnosed with osteoarthritis of the knees. This in turn causes pain. The pain makes it difficult to exercise. Consequently, the Veteran burns fewer calories. This results in weight gain, which leads to the Veteran being a type 2 diabetic. The Veteran’s diabetes represents about four degrees of separation from the original pain caused by the osteoarthritis. Therefore, it would not be appropriate for the Department to pay for diabetes medications on the basis of osteoarthritis of the knee.
2. Different Conditions with Similar Symptoms
  
  If a requested treatment is going to address the signs and symptoms of a entitled condition, treatment may be approved even if the treatment is targeted to a
  non-entitled condition. This can occur in circumstances where a pensioned/awarded condition and a non-entitled condition have similar symptoms and effects which cannot be separated. For example, if a symptom (e.g. anxiety) is usually a feature of the
  entitled condition as well as of another non-entitled condition, it may be appropriate to approve treatment that is targeted at the non-entitled condition to the extent that it will reasonably have a positive effect for the entitled condition.
  1. Example:
    
    An A-line Veteran has a disability benefit for Chronic Adjustment Disorder with anxiety and is now requesting an extension of treatment. Based on a review of the available evidence, it is clear that the proposed treatment extension is necessary and appropriate given the severity of the Veteran’s symptoms. However, the treating psychologist has noted that Post Traumatic Stress Disorder and depression and social phobia are being treated. Therefore, in considering approval of the extension of treatment, questions arise with respect to the link between the treatment and the entitled condition. As the entitled condition and the non-entitled conditions which are being targeted by the treatment have similar symptoms and effects which cannot be separated, approval of the request could be granted.
3. Consequential Conditions
  
  In circumstances where the Veteran is suffering from an additional disability that is in whole or in part a consequence of the entitled condition, treatment required for the additional disability will not normally be considered to be for the entitled condition. Therefore, if treatment needs arise for the additional disability, Veterans should be counselled to seek a consequential entitlement decision under section 21(5) of the Pension Act or under sections 45 and 46 of the Veterans Well-being Act.
  1. Example:
    
    The treatment required by a Veteran for osteoarthritis of the left knee that is wholly or partly a consequence of an entitled condition, fracture of the left knee, would not be considered to be for the entitled condition. In this case, the Veteran should seek a consequential entitlement decision under the applicable legislation above.
4. Anatomical Proximity
  
  Determining a disability benefits relationship is not to be limited to approving interventions which are applied in direct anatomical proximity to the entitled condition. Treatment benefits may also be approved in cases where the requested benefit is applied on an area which is anatomically distant from the pensioned/awarded condition but is reasonably expected to help achieve the desired treatment outcome for the entitled condition.
  1. Example:
    
    A Veteran's physician has prescribed foot orthotics. The physician has indicated that this has been prescribed to reduce pain and provide relief for the Veteran's entitled back condition. As the Veteran does not hold entitlement for a foot condition - which is where the intervention is being applied - declining the request is being considered. However, the intervention is prescribed to provide a treatment benefit to the Veteran's entitled back condition so the orthotics should be approved.
  In contrast, consider the case of requested treatment which is being applied in anatomical proximity to the entitled condition but for a separate and distinct condition.
  1. Example:
    
    An A-line Veteran has applied for treatment for left ulnar neuropathy. The entitled condition is osteoarthritis of the left elbow. While the ulnar neuropathy is an inflammation of the ulnar nerve, osteoarthritis is a non-inflammatory joint disease characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. Normally, ulnar neuropathy will not be related to osteoarthritis. Therefore, in most circumstances, any treatment required for the ulnar neuropathy would not be considered to be for the entitled osteoarthritis even though the two conditions may share an anatomical proximity.
5. Programs of Choice (POCs) Linkages
  
  For Veterans with A-coverage, the relationship between the entitled condition and the benefit requested must be thoroughly considered. Although Benefit Grid prerequisites and/or POC linkages to Medical Pension Codes have been established, these non-Veteran specific edits are not meant to replace the professional judgment of the decision-maker when special circumstances of an individual case provide a clear indication of a need for a treatment benefit that is for a entitled condition.
  1. Example:
    
    A request was received for custom made orthotics for an A-line Veteran who is entitled for Chronic Pain Syndrome. This condition is not mapped to link with POC 11 (Prostheses and Orthotics) therefore an assumption is made that the Veteran is “not eligible” for this benefit. Nevertheless, eligibility is derived from the Veterans Health Care Regulations, which indicate that Veterans are eligible to receive treatment benefits that are for their entitled condition. In this particular case, there is credible and persuasive medical documentation which indicates that the chronic pain syndrome is affecting the Veteran's feet. Custom made orthotics were prescribed for relief of pain caused by the entitled condition. As this treatment was determined to be for the entitled condition, approval was granted.
  2. Example:
    
    A Veteran is entitled for a left foot condition and was prescribed bilateral orthotics. As the Veteran does not hold entitlement for a right foot condition, only approval for the left orthotics was considered. Although the Veteran is entitled for only a left foot condition, it is necessary to provide orthotics for both the right and left foot in order to treat the entitled condition, therefore approving both orthotics would be appropriate. As the left foot can’t benefit from treatment without the pair, not providing the two orthotics would result in not providing the Veteran with the treatment benefit to which he is entitled.
6. Scope of Disability Condition
  
  An understanding of the scope of the entitled disability is important when determining if there are links between the entitled condition and the treatment benefit. When considering eligibility for treatment benefits, the full scope of the entitled disability must be taken into consideration. In addition to the considerations included above, decision-makers may also refer to VAC’s Entitlement Eligibility Guidelines, which consist of current medical and scientific descriptions of injuries and diseases.
  
  For Veterans with A-coverage, the relationship between the entitled condition and the benefit requested must be thoroughly examined. It may be necessary to review the benefits decision letter, recent benefits medical exams, VAC area counsellor and/or nursing assessments, other professional assessments, consultant reports, prescriptions, etc.
  
  In many cases, it may be necessary to obtain an opinion from a departmental health professional (medical officer, dental officer, nursing officer, mental health officer, etc.) regarding the relationship between the requested treatment and the entitled condition.