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Adjudication process
At Veterans Affairs Canada (VAC), Disability benefits* decisions are made in a two-step process.
In the first step, a decision is made regarding entitlement. Entitlement can be granted when there is a diagnosed medical condition that has existed for at least six months and the medical condition is related to military and/or Royal Canadian Mounted Police (RCMP) service. The EEGs are tools used to support this step in the adjudicative process.
Once entitlement is granted, a second step in the decision-making process is to determine the disability assessment. In this step, the severity of the entitled disability is determined in accordance with the Table of Disabilities. The extent of entitlement and the assessment level are used to calculate the amount of disability benefits paid to an individual.
*A reference to “Disability benefits” in this document means the Pain and Suffering Compensation and the Disability Pension. The legal authorities for granting these disability benefits are detailed in the Effective dates and legislative authorities Section below.
Guideline use and development
VAC uses EEGs to support consistent, equitable and timely decisions on disability benefits. These guidelines are policy statements based on current information drawn from credible, peer-reviewed medical and scientific research on injuries and diseases.
The EEGs assist decision makers with entitlement decisions, by providing reliable information to consider in addition to the merits of an application. All the evidence for an application is reviewed to determine its relevance, credibility, and weight to provide a fair and unbiased decision. More information on the “Benefit of Doubt” provisions in the Acts can be found in the Benefit of Doubt policy.
Medicine is an ever-changing science. As a result, the EEGs are not considered to be full descriptions of any given medical condition or group of conditions. Comprehensive adjudicative guidelines from various disability compensation bodies in Canada and internationally, including but not limited to the Australian Statement of Principles are also reviewed during development of an EEG to identify best practice approaches. It is recommended that EEGs be reviewed on a regular basis to update content that aligns with relevant changes in science, medicine, policy and legislation. The EEGs are developed in accordance with VAC’s Policy on Assessing and Categorizing Health Related Expert Opinion(s) and Scientific Evidence.
As of 2021, Gender-based Analysis (GBA) Plus has been completed to inform development and revision of the EEGs. GBA Plus provides important considerations based on a scoping review of available health and scientific literature about how the intersectional identity factors of biological sex, service characteristics, and disability may affect the presentation or development of a medical condition. In choosing language used in the EEGs, VAC aims to be inclusive and in keeping with the Government of Canada Guide on Equity, Diversity and Inclusion Terminology.
More information about GBA Plus at VAC can be found in the VAC Policy Gender-Based Analysis Plus and direction outlined in Government of Canada guidance from Women and Gender Equality Canada (WAGE).
Effective dates and legislative authorities
The effective date of an EEG is the Date reviewed noted at the top of each EEG. Where an EEG does not have a Date reviewed, the Date created shall be used as the effective date. The Date created of an EEG, unless otherwise noted, is February 1, 2005, at which time the EEGs replaced previous departmental medical guidelines.
The following principles are to be followed with respect to EEG effective dates for claims management:
- A change to an EEG or implementation of a new guideline does not constitute grounds for a departmental review of a decision.
- All claims will be adjudicated upon using the EEG in effect on the date of the departmental decision.
For Canadian Armed Forces (CAF) members and Veterans, the Veterans Well-being Act and the Veterans Well-being Regulations, set out the authorities for granting and administering Pain and Suffering Compensation.
The Pension Act and the Award Regulations set out the authorities for granting and administering Disability Pension. (“the Acts”)
VAC adjudicates and administers disability pension claims on behalf of the RCMP. The Royal Canadian Mounted Police Superannuation Act and the Royal Canadian Mounted Police Pension Continuation Act set out the authorities for granting and administering Disability Pensions for Royal Canadian Mounted Police (RCMP), in accordance with the Pension Act.
Document sections
For VAC purposes, the accepted definition of aggravation has been the permanent worsening of a disability from disease or injury between enrolment and discharge as outlined in the VAC Policy Disability Resulting From a Non Service Related Injury or Disease.
Medical code (MC) or medical pension code (MPC)
At the beginning of each EEG, there is reference to medical code(s) (MCs). In EEGs created prior to 2008, the term medical pension code(s) (MPCs) was used. These five-digit numbers are used internally by VAC and are associated with lists of treatment and prescription benefits covered by VAC for the medical condition. These codes are also used for reporting purposes.
International Classification of Diseases (ICD)
The International Classification of Diseases (ICD) code, published by the World Health Organization (WHO) is provided for the EEG medical condition. These standardized codes and associated descriptions are used by the medical community across the world. This reference is updated on a regular basis with most recent versions referred to as ICD-9, ICD-10 and ICD-11.
Medical definition
This section identifies the commonly accepted medical definition for the EEG condition or group of medical conditions. If an EEG is written for a group of conditions, the conditions included in the EEG are listed in the definition section. Where a medical condition is listed as an included condition in the definition section, a separate entitlement decision is not necessary and the guidance provided in the Entitlement Considerations section of the EEG may be applied.
Disability benefits entitlement is granted for chronic medical conditions. For VAC entitlement purposes, a medical condition is considered chronic when it has lasted for at least six months and where signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane.
Diagnostic standard
Using the information in this section, the available medical evidence and considerations as outlined in the VAC policy Establishing the Existence of a Disability, decision-makers confirm the presence of a diagnosed disability.
This section of the EEGs along with VAC Policy Pain and Suffering Compensation and VAC reference Who can complete VAC’s medical questionnaires for the Veterans Affairs Canada Disability Benefits Program, provide details about the qualified health professionals that may diagnose and submit medical information in support of disability benefits applications for certain medical conditions.
This section also includes instruction describing evidentiary best practices for establishing a diagnosis for the medical condition in the EEG, including the supportive investigations which assist to establish the diagnosis of the EEG condition e.g., diagnostic imaging, pulmonary function tests.
Anatomy and physiology
This section describes the body structures or systems and normal function of the body system(s) addressed by the EEG. This section may include a description of how certain disorders or diseases alter the structure or functioning.
Clinical features
This section describes the common signs and symptoms associated with the EEG condition or group of conditions and may include comment on disease progression or aggravation.
In this section, EEGs may also describe other relevant medical or epidemiological information about the clinical presentation or features of a medical condition and findings of GBA Plus. For example, an EEG may include available information about rates of injury or disease in the military or Veteran population as compared to the civilian population, or clinical presentation differences in people who are male, female or receiving gender affirming care.
Entitlement considerations
Note: In EEGs published prior to 2008, this section is referred to as Pension Considerations.
The entitlement considerations are divided into three sections:
- Section A: Causes and/or aggravation
- Section B: Medical conditions which are to be included in entitlement/assessment
- Section C: Common medical conditions which may result, in whole or in part, from the EEG condition and/or its treatment
Section A: Causes and/or aggravation
Section A identifies factors which are medically accepted to cause or aggravate the EEG condition or group of conditions.
Section A is not intended to be an exhaustive list of all factors which can cause or aggravate the EEG condition and it is not meant to be rigidly, or inflexibly applied. The decision maker may consider factors other than those listed to cause or aggravate an EEG condition.
This section may identify specific timelines for expected clinical onset of a medical condition after exposure to certain causal or aggravating factors. The term "clinical onset" within an EEG refers to the first appearance of signs and/or symptoms. These timelines are to be considered by decision makers when reviewing evidnce.
A factor in this section for all EEGs includes the Inability to obtain appropriate clinical management for the EEG condition. Please refer to VAC policy Disability Benefits in Respect of Peacetime Service – The Compensation Principle for further details with respect to disability benefit applications for treatment related injuries.
Section B: Medical conditions which are to be included in entitlement/assessment
Section B provides a list of diagnosed medical conditions which are considered for VAC purposes to be included in the entitlement and assessment* of the EEG condition. Medical conditions included in Section B have similar or the same symptoms as the EEG condition. When entitlement of an EEG condition is granted, the decision includes entitlement of all medical conditions listed in Section B. For this reason, subsequent applications for Section B conditions may not require a separate entitlement decision.
The factors listed in Section A have been medically accepted to cause or aggravate the specific EEG condition(s) only. The factors listed in Section A, cannot be considered to also cause or aggravate medical conditions listed in Section B.
The list of medical conditions in Section B is not intended to be all inclusive.
* The disability assessment of the EEG condition using the Table of Disabilities includes any co-morbid entitled or non-entitled Section B conditions.
Section C: Common medical conditions which may result, in whole or in part, from EEG condition and/or its treatment
Section C is a list of conditions which can be caused or aggravated by the EEG condition and/or its treatment. Conditions listed in Section C are not included in the entitlement and assessment of the EEG condition; they require a consequential entitlement decision. Consequential entitlement is granted when the medical evidence supports a relationship between a primary medical condition and the development of a resulting condition.
Medical conditions listed in Section C may require different medical treatment than the EEG condition.
The list of Section C conditions is not intended to be all inclusive. Consequential entitlement may be considered for conditions other than those listed in Section C.
References
Each EEG includes a list of all references reviewed and considered in the development of the EEG from the date created to the last modified date. For example: References as of (month, year).