Creating a New Standard in Veterans Health Care : Part Three

It is difficult to overstate the importance of pensions and allowances to veterans. A pension represents more than simple compensation for disability; it is a tangible recognition of service and sacrifice for the sake of country. As veterans age, pension entitlements become even more important because survivors benefits are based on a percentage of the pension being paid at the time of death. Thus it is natural for veterans in their late 70s to worry that when they die, their pensions will be inadequate to meet the needs of the spouses who have looked after them for 50 years and more.

Veterans have reason to worry: of an estimated 400,000 service veterans only 68,000 or 17% receive a disability pension. The vast majority of pensioned veterans receive very small pensions and will not leave much in the way of survivors benefits to their spouses. This factor weighs heavily on their minds and effects their quality of life.

The following chart, taken from the December 1998 Report of the Auditor General of Canada on veterans disability pensions presents a visual analysis of the distribution of disability pensioners by the degree of their assessed disability. The solid line represents war veterans from World War I, World War II, and the Korean War and the broken line represents Canadian Forces pensioners.

Source: Report of the Auditor General of Canada, Chapter 23 Veterans Affairs Canada - Disability Pensions, December 1998.

The chart shows that the overwhelming majority of war veterans and Canadian Forces pensioners are assessed at a very low level of disability; almost two-thirds of veterans are assessed at a disability rate of 25% or less. The sharp peak between 45% and 55% disability is due to the fact that the surviving spouse of a veteran assessed at 48% and above is entitled to a full survivors pension while survivors of veterans assessed at 47% and less receive a proportionate pension equal to one-half of the degree of disability. The second peak at 95% disability is explained by the additional benefits available to those judged to be exceptionally incapacitated.

The Subcommittee finds the chart both upsetting and suggestive. It is upsetting because, although there is a large age difference between war service veterans and Canadian Forces pensioners, the disability curve of the younger pensioners almost exactly duplicates the curve of the older service veterans. Yet, many pensionable conditions worsen with time and the assessed degree of disability should increase as the pensioner ages. According to the chart, however, veterans in their late 70s are not being assessed at significantly higher levels of disability than Canadian Forces veterans. Why not? Some service veterans are beginning to believe that the pension adjudication system as a whole discriminates against them.

The Subcommittee has explored two possibilities: unwitting discrimination against war service veterans because they are less inclined to press for a higher assessment and have more difficulty relating their conditions to their service because of poor record keeping; and, the tendency to attribute the aggravation of their injuries to old age rather than to service.

Service veterans come from a generation marked by deference to authority and a reluctance to ask for "more than their fair share". They served during national emergencies when reporting every injury and keeping good records were very low priorities. Injuries that were not life threatening could go unreported on the front lines, and, in the rush to demobilise tens of thousands of soldiers, unreported on discharge. As a result, service veterans have found it difficult to relate many of their medical conditions to their service. This contrasts with the situation of service personnel in the post-Korean War era. Younger personnel were brought up in a culture that prided itself on challenging authority and have the education and sophistication necessary to press for their full entitlements. Knowing the importance of being able to relate medical conditions to service long after the event, record keeping has become much more accurate and comprehensive over the past fifty years.

The Subcommittee has compiled the following table from information it requested: approval rates for First Applications by Service from Veterans Affairs Canada; and, approval rates for Review and Appeal decisions from Veterans Review and Appeal Board Canada.

Approval Rates by Service and by Level of Adjudication:
First Application, Review and Appeal

Condition

Service Veterans
1^st Applic. Review Appeal

Canadian Forces
1^st Applic. Review Appeal

All Conditions

Hearing Loss

Arthritis

Spinal Conditions
(excl. spinal cord)

Psychological Conditions (incl. PTSD and Psycho-neurosis)

58%

77%

20%

19%

49%

52%

55%

38%

43%

59%

22%

27%

19%

11%

27%

35%

42%

18%

20%

10%

54%

41%

53%

56%

42%

19%

15%

19%

16%

23%

The table shows that war service veterans have a better chance of a favourable decision on First Application than Canadian Forces personnel, but that thereafter their rates are similar through the review and appeal levels of pension adjudication.

Rates of approval for some conditions that time can be expected to aggravate follow the expected pattern. Service veterans claiming for hearing loss have a much better chance of having their claim approved at all levels than do Canadian Forces personnel. The same is true of claims for Psychological Conditions (most of which are for Post-traumatic Stress Disorder and Psychoneurosis). But the opposite holds true for conditions such as arthritis and spinal conditions (excluding spinal cord conditions). In adjudication of the latter conditions the younger applicants actually have a better chance of having their claims approved than do the service veterans.

The Subcommittee believes that the apparent anomaly in the rates of disability for service veterans and for Canadian Forces personnel, and in the approval rates for certain conditions deserves careful study, and that representatives of veterans organizations should participate.

The Subcommittee believes that it is time to stop partially attributing the deterioration in pensioned conditions to age. Under current practices, a veteran assessed at a 50% disability does not necessarily receive a 50% disability pension. All too frequently, much of the disability is attributed to "old age" and the veteran is awarded a smaller pension, perhaps 20%. This, in the opinion of the Subcommittee, is one reason for the relatively low levels of pension granted the majority of service veterans.

Veterans organizations and the Subcommittee have been critical of the role of the Headquarters Medical Advisors in pension adjudication for many years: the latter's interventions always seem to prejudice the interests of veterans. Supposedly, one of their responsibilities is to ensure that disability assessments for similar conditions are the same in all parts of the country. The reality that veterans experience, however, is that these Medical Advisors exist to maintain assessments at the lowest common denominator. Veterans and veterans organizations believe that the reputation of the Medical Advisors has an impact on the preliminary assessment of disability. In deciding at what level to assess the disability arising from a medical condition, District Medical Officers are reluctant to follow their own professional instincts, or the opinion of a family doctor. Instead, they try to anticipate the decision of the Medical Advisors by suggesting a low level of assessment or an incremental increase in the level of assessment.

The Subcommittee believes that the role of Headquarters Medical Advisors should be restricted to advising what the national trends in assessment for a particular condition are. The District Medical Officer, in consultation with the family doctor or specialist, should make the final decision about assessment. Individual assessments which diverge substantially from the national trend should be clearly justified.

The Report of the Auditor General on the adjudication of disability pensions has confirmed that together Veterans Affairs Canada and the Veterans Review and Appeal Board have drastically reduced the length of time it takes to adjudicate a claim at all levels of the process. By September 1997 they had more than met the Minister’s promise to halve turnaround times, reducing them by more than two-thirds at the First Application and Review levels of adjudication. The Subcommittee congratulates Veterans Affairs Canada and the Veterans Review and Appeal Board for this breakthrough in turnaround times.

In its April 1997 Report, "Steadying the Course", the Subcommittee first expressed its concern that the price of speedier decisions was less considered decisions that fail to take into account individual circumstances. The Subcommittee thus notes the recommendation by the Auditor-General that Veterans Affairs Canada improve the services offered first applicants in the preparation of their claims by

The Bureau of Pensions Advocates is responsible for preparing almost all cases for review and appeal. Members of the Subcommittee have received many complaints that the pressure to reduce turnaround times is not leaving the available lawyers enough time to thoroughly prepare the veteran’s case for submission and themselves for the hearing. Rather than slow down the adjudication process, the Subcommittee believes Veterans Affairs Canada should hire more lawyers.

The Subcommittee is concerned that the dramatic improvement in favourable rulings and turnaround times not distract attention from the very low disability assessments being granted veterans across the board. Veterans themselves and veterans organizations do not believe that applicants, whether at the first level or at the review and appeal levels, are always given the benefit of the doubt. The Subcommittee believes the time has come to arrange for a representative of the veterans and Canadian Forces personnel to sit on veteran’s review and appeal boards.

When veterans on War Veterans Allowance reach retirement age and become eligible for Old Age Security and Guaranteed Income Supplement payments, it is very easy for their incomes to exceed the maximum permitted. As a result, they no longer qualify for War Veterans Allowance payments. They or their spouses, however, may have substantial expenses for prescription and non-prescription drugs, medical supplies, etc., all of which have been recommended by a doctor to treat a medical condition, but whose costs are not taken into consideration when calculating income. The Subcommittee believes that this kind of medical expense should be excluded from income when calculating continuing entitlement to payments under the War Veterans Allowance.

Some veterans of peacekeeping missions are not getting treatment for their service-related conditions. Their conditions of military service, and perhaps their reasons for leaving it, have left them so distrustful of governmental authority that they will not seek help from government organizations in general, and the Department of National Defence and Veterans Affairs Canada in particular. These service men and women must be able to discuss their medical symptoms and the treatment options open to them, in complete confidence, with knowledgeable and sympathetic persons that they trust.

Veterans Affairs Canada must provide a counselling service delivered at arms length by a non-governmental organization. The counsellors of the service should know about the availability of treatment centres not connected to the federal government as well as about Veterans Affairs treatment and disability programs. The Subcommittee believes that a national organization of veterans of peacekeeping missions would be a logical choice to run such a service and to represent the interests of these veterans before departmental bodies.

Veterans Affairs Canada should offer a toll-free, at home counselling service for all veterans and their spouses. This service would not only offer information about benefits and entitlements, but also offer emotional and social support for home-based veterans.

The Subcommittee has found the work of its fact-finding task force immensely effective. Their visits to individual hospitals and long-term care facilities were appreciated by the veterans living there, by the management of the institutions, and by the local officials of Veterans Affairs Canada. The reports on individual facilities gave the Subcommittee an excellent insight into the health care of institutionalised veterans. These visits should be continued.

Follow-up visits should be paid to those institutions already visited to monitor the implementation of the recommendations of the Subcommittee. The remaining institutions with 50 and more veterans must also be visited.

Increasingly, veterans are choosing to enter institutions close to home and Veterans Affairs Canada is responding by decentralizing veterans priority beds into smaller communities. More than 60 facilities have fewer than 50 veterans. Not all of these facilities can be visited, but a cross-section should be to evaluate the ability of Veterans Affairs Canada to ensure that veterans in smaller centres receive the same level of care and have access to the same programs as veterans in facilities with large numbers of veterans.