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CPP Disability - I am a health professional
- How can I help my patient qualify for a CPP disability benefit?
- How does SDC decide if my patient is eligible?
- What type of medical information do you need from me?
- Do I have to send in any follow-up medical information about my patient who is already receiving a CPP disability benefit?
- Will my patient see my medical report about him or her?
- How will I be paid for my medical reports?
How can I help my patient qualify for a CPP disability benefit?
You may be requested to provide medical information about your patient who has submitted an application for a Canada Pension Plan (CPP) disability benefit. As a health professional, you play a key role in our process. This information is important to Social Development Canada (SDC) staff to assess your patient's eligibility or continued eligibility. If required, SDC staff may also seek information from specialists or obtain a second opinion from an independent medical examiner.
The medical information you submit about your patient's capacity to work is essential, not only at the initial eligibility application level, but also during appeals, follow-up reviews or reassessments or vocational rehabilitation. This ensures that SDC staff have enough information to be reasonably satisfied that your patient meets eligibility requirements for a CPP disability benefit.
The information we need from you is a clear and comprehensive medical assessment of your patient's disabling condition(s) together with information on any limitations imposed on his or her capacity to function. Please note that it is not necessary for you to include any particular statements or phrases to ensure that your patient qualifies for a benefit. We assess the totality of the evidence, medical and non-medical, to reach our decision and do not base it on whether the physician includes or omits a statement such as that the patient has a severe and prolonged disability.
One thing you can do to help your patient is to submit the medical report promptly. The application cannot be adjudicated until this is received.
Who in SDC makes the medical decision to grant or deny my patient?
SDC's medical adjudicators (Service Delivery Specialists) are responsible for making a decision on applications for a CPP disability benefit. They are trained nurses who have extensive knowledge of CPP legislation, regulations, policies and procedures. They receive ongoing education on current medical developments to ensure that they are aware of, and sensitive to, the complexities of new medical conditions. They are supported by a group of CPP physicians and specialists who provide advice on complex medical issues.
How does SDC decide if my patient is eligible?
The CPP legislation has strict eligibility criteria. To qualify for a CPP disability benefit, your patient must:
- be under 65 years of age;
- have made contributions to the CPP in at least four of the last six years (although there may be exceptions which allow us to examine more of your patient's working years to help him or her qualify); and,
- have a "severe" and "prolonged" disability that prevents your patient from working at any job on a regular basis.
Medical Eligibility
To be eligible for a CPP disability benefit, your patient must have a physical and/or mental impairment that is both severe and prolonged, as defined by CPP legislation.
"Severe" means that a person is incapable of regularly pursuing any substantially gainful occupation. This is different from most other long-term disability insurance systems in that they may base eligibility for benefits on incapacity to return to the person's former job. The CPP bases eligibility on the applicant's incapacity to do any type of paid work on a regular basis.
Does SDC consider other factors when making a decision?
Yes, SDC considers other factors as well as the medical diagnosis. Eligibility is determined by considering the entire individual, taking into consideration:
- the nature and severity of their medical condition;
- the impact of the medical condition and treatment on his or her capacity to work;
- his or her prognosis;
- personal characteristics such as age, education, and work history; and,
- the applicant's work performance and productivity.
The availability of suitable employment in the applicant's geographical location is not considered in determining eligibility. This policy has been confirmed by a recent court decision (Federal Court of Appeals decision on Milford Rice, FCA, Jan. 29, 2002).
What type of medical information do you need from me?
The medical information you provide is critical to the adjudication decision. SDC staff do not need your patient's entire medical file.
You will be requested to provide only the medical information relevant to your patient's ability to work, including supporting documents, such as:
- consultants' reports;
- investigative reports; and,
- hospital notes.
If your patient can still work on a regular basis, he or she will be unlikely to qualify for a CPP disability benefit.
If your clinical notes address all questions in the medical report, you may send those notes instead of completing the entire medical report (which will be sent to you to fill out). However, you must complete the prognosis section of the report and sign the form. Sending in your clinical notes is only appropriate for patients you are following closely and for whom you are keeping detailed clinical notes.
You will be asked to provide comments on psycho-social impacts of the disability on your patient's ability to work. Please provide supporting documents for your comments as this will greatly assist CPP in making its decision.
We may ask you for information going back a number of years. This is done because of the "Late Applicant" legislative provision, an exception which may help your patient qualify for a CPP disability benefit. This provision allows an application to be treated as if submitted at an earlier date, when the applicant still met the contributory requirements. Under this provision, SDC staff need to determine whether your patient was medically eligible at that date and continuously up until the present.
Please contact SDC if you are unable to provide the medical information requested. This will help prevent delays in determining eligibility for your patient. HRDC medical adjudicators may be able to get information from your patient or from other sources, or may decide to send your patient for an independent medical consultation.
Do I have to send in any follow-up medical information about my patient who is already receiving a CPP disability benefit?
Yes, as the treating health professional, you are very important in helping SDC staff determine if your patient should continue to receive a disability benefit, or if he or she might be eligible for a work-related retraining program under our vocational rehabilitation services. SDC staff periodically review or reassess a client's case to ensure continuing eligibility, and we may ask you for up-to-date medical information on your patient's condition. If so, you may be asked to complete either a short medical report or a "scannable evaluation form". We ask that you answer all the questions on any forms you are asked to fill out to avoid a delay in making a decision.
A review is one of the ways SDC follows up with its clients. It gives us the opportunity to make contact and identify what services they can receive that would best suit them. If your patient's case is being reassessed, he or she will be asked to provide medical and non medical information to SDC to help complete the reassessment. Because everyone's medical condition and capacity to work is unique, each case is looked at individually. Once all necessary information has been collected, a decision to continue or stop disability benefits is made.
Will my patient see my medical report about him or her?
Your patient has the right to see and to receive a copy of all the information included in his or her CPP disability file, including the medical report that you fill out and any supporting documents that you include, if the patient makes such a request under the Privacy Act. Please indicate in your report if you feel it would be detrimental to your patient to be given particular information about his or her medical condition. SDC will contact you directly to determine whether this information can be withheld under Section 25 of the Privacy Act, which states that:
- "personal information can be withheld if the disclosure of information may threaten the safety of an individual."
How will I be paid for my medical reports?
You must send your bill for services to SDC. Please include your patient's name on the bill, as well as the patient's address, or date of birth or social insurance number. This will help us match your invoice to your patient's file. Please note that proper identification of the invoice is also required by the Canada Revenue Agency (CRA). Your invoice must include one of the following:
- your business number or
- your GST/HST number or
- your Social Insurance Number
Please check our offices for the closest address in your area. Upon receipt of your invoice and confirmation that the individual concerned has submitted an application, SDC will reimburse you:
- Up to $65 for the initial medical report;
- Up to $25 for the reassessment medical report;
- Up to $50 for the "Scannable Impairment Evaluation";
- $25 for the "Medical Report - Recurrence of the Same Medical Problem"); and,
- Up to $150 (depending on the complexity and the time required for completion) if SDC medical adjudicators ask you to provide other information in the form of a narrative report.
Your patient is responsible for covering any extra costs. If your fees are higher than these amounts, please bill your patients directly. Fees outlined in this section are set in consultation with the Canadian Medical Association, and are subject to change.
Occasionally, SDC medical adjudicators may request independent medical consultations or functional capacity evaluations during the application process, or when determining continuing eligibility. SDC pays the specialist or functional capacity evaluation facility directly for these examinations.
