Changes in Canada Pension Plan disability rules hold implications for physicians

Dr. Alex Romaniuk is senior medical adviser with the Canada Pension Plan.

Canadian Medical Association Journal 1995; 153: 1777-1778

[résumé]

Abstract

When a Canadian company commissioned market research in Great Britain to see what images came to mind when Britons thought about Canada, the top three responses were moose, snow and Mounties.

If one asked Canadians what images come to mind when they think of the Canada Pension Plan (CPP), it wouldn't surprise me if most responded: Isn't that a retirement scheme? And isn't it going broke?

CPP is not just a retirement scheme -- it also provides disability benefits. And since it is based on contributions that increase annually, it cannot go broke. But CPP financing is not the subject of this article. I want to provide information about the CPP disability pension and recent legislative changes that have significantly altered eligibility requirements. I will also deal with the definition of disability under CPP legislation, because in my experience this causes much confusion, both for claimants and their physicians.

Starting at age 18, all Canadians with employment income above a threshold amount -- currently $3400 -- contribute to the CPP. People are eligible for a disability pension only if they have contributed to the plan in 2 of the last 3 years, or 5 of the last 10 years. CPP contributions are the equivalent of premiums paid to a private insurance company.

In 1992, legislative changes addressed two eligibility problems. The first was the catch-22 situation involving people who were rendered incapable of forming the intent to apply for a disability pension, usually because of mental illness or brain injury. If no relative or agent applied for them during the 5-year window of opportunity, they were out of luck. Bill C-39 allows the CPP to pay full retroactive benefits regardless of when the application is received, provided there is medical evidence the person really was incapable of forming the intent to apply.

The second eligibility problem concerned a person who could have applied during the 5-year window of opportunity, but did not because of inadequate information or lack of awareness related to illiteracy or language difficulty. Bill C-57 allows disability benefits to be paid -- with limited retroactivity -- if it can be established that people were disabled (within the meaning of CPP legislation) at the time they last met the earnings requirement, and have remained disabled.

These legislative changes may require CPP officials to solicit medical information that is 10 or 20 years old. Consequently, we find ourselves asking physicians to look for charts that, assuming they have not been destroyed, have been relegated to dark basement corners. We understand it is not easy to meet requests for old medical records, but we do have reasons for asking -- if the medical information can be provided, it can be the missing link that allows a disabled person to qualify for a disability pension.

Although applicants may be eligible for such a pension on the basis of contributions, they must also have a disability that is "severe and prolonged" within the meaning of CPP legislation. A disability is severe "only if by reason thereof the person in respect of whom the determination is made is incapable regularly of pursuing any substantially gainful occupation." A disability is prolonged "only if it is determined in [a] prescribed manner that such a disability is likely to be long continued and of indefinite duration or is likely to result in death."

These ostensibly simple definitions are not as simple as they appear.

• The definition of "severe" is not expressed in terms of medical diagnoses or disease descriptions, only in terms of the person's capacity for activity in the workforce. A quadriplegic employed full time as a computer programmer would not meet the "severe" definition.
• A disability is not "severe" because it prevents a person from doing his or her usual job. It is only considered "severe" if it prevents a person from having any substantially gainful occupation. Consequently, a letter carrier whose varicose veins prevent ambulatory work but do not prevent sedentary work would not meet the definition of "severe."
• The definition of "prolonged" varies quite substantially from the normal meaning of that word. Normally "prolonged" means "longer than expected" or "longer than normal." "Prolonged" in the CPP sense does not refer to a past prolongation, but to a potential prolongation into the future -- the likelihood that a severe disability will be long lasting and indefinite, or result in death. Consequently, people who have been off work for 2 years because of heart problems would not meet the "prolonged" criteria if they have just had successful bypass surgery and expect to return to work soon. When considering "prolonged," it is what is likely to happen, not what has happened, that is important.
• To qualify, a disability must be "severe and prolonged." This means both criteria must be met simultaneously. You cannot have one without the other.

Or: "He's had that clubfoot all his life? How can you possibly say the disability is not prolonged?"

I hope the foregoing explanations and definitions show why neither of these situations would necessarily meet CPP disability pension criteria.

Our criteria have been called "stringent" -- and worse than that by lawyers at appeal hearings -- but they have been the same since the inception of the CPP in 1966. Until Parliament decides to change them, those are the criteria we must use when adjudicating disability cases.

CPP disability pensions were never designed to be a substitute for short-term disability insurance, a supplement for partially disabled workers, or an income supplement for aging workers in economically deprived regions.

We are aware that physicians in general, and general practitioners in particular, can feel pressured by patients to provide medical reports that will support their applications. Consequently, in the preformatted reports we provide to physicians we solicit objective medical information about your patient. We do not actively ask whether you think the patient meets the "severe and prolonged" criteria.

You are, of course, free to provide such opinion if you wish, but providing us with solid clinical information is more likely to get your patient a speedy and accurate decision than providing opinion in the absence of supporting clinical data. In the latter case we have no recourse but to solicit information from consultants to see if the opinion has a clinical basis, and if there are no other treating doctors we have to arrange a consultation ourselves. All of this takes time. If the clinical evidence of a significant disability is ultimately not forthcoming, then the whole exercise has been a waste of everyone's time -- yours, ours and the patient's.

For more information about CPP disability benefits or for copies of the Disability Benefits brochure, contact CPP client service centres or Human Resources Development Canada; fax: 819 953-7260. Cite catalogue number ISPB-153-01-95E.

If you have specific medical questions, telephone 800 267-3391 and ask to speak to a physician; (fax) 800 267-1540.