Payment of Medical Fees

Purpose

The purpose of this policy is to provide guidance on the payment of medical fees and the payment of travel and living expenses when Veterans Affairs Canada (VAC) requires a person to undergo a medical examination or assessment.

Policy

Disability Pension, Disability Award, Pain and Suffering Compensation, and Critical Injury Benefit

1. Individuals who apply for a disability benefit may be required to undergo a medical examination by a qualified medical practitioner and/or testing by other qualified health care professionals to establish current medical diagnoses and to provide up-to-date clinical information on their health status.
2. Individuals who undergo reassessment of a medical condition for which they hold a Disability Pension, Disability Award, Critical Injury Benefit, Pain and Suffering Compensation or Additional Pain and Suffering Compensation are required to be medically examined by a qualified medical practitioner and/or tested by other qualified health care professionals to obtain necessary up-to-date medical information for assessment purposes.
3. For the purposes of disability benefit applications and reassessments, VAC Medical Questionnaire forms, which have been developed on the basis of body systems, may be used for the collection and reporting of required information.
4. Costs incurred for examination or testing and costs related to travel and living expenses will be reimbursed by the Department as follows:
   1. Costs incurred for medical examinations and testing for Disability Pension, Disability Award, Critical Injury Benefit, Pain and Suffering Compensation and Additional Pain and Suffering Compensation applications and reassessments will be reimbursed based on this policy.
   2. For Disability Pension claims, travel costs and living expenses will be paid in accordance with the Health-related Travel policy.
   3. For Disability Award claims, Critical Injury Benefit claims, Pain and Suffering Compensation and or Additional pain and Suffering Compensation, travel costs and living expenses will be paid in accordance with sections 66 and 67 of the Veterans Well-being Regulations.
5. Survivors and other dependents who apply for a Disability Pension, Disability Award, Critical Injury Benefit, Pain and Suffering Compensation, Additonal Pain and Suffering Compensation or request a reassessment after the death of an individual may be required to submit medical reports. Costs incurred for such reports will be reimbursed in accordance with this policy.
6. Costs incurred for the medical examination or testing for a disability pension application or reassessment and resultant costs related to travel and living expenses for serving Royal Canadian Mounted Police (RCMP) members are the responsibility of the RCMP.

Providers

7. See the Establishing the Existence of a Disability policy for more information on qualified medical practitioners and other qualified health care professionals.

Payment of Fees

8. When a medical examination and/or testing is requested by VAC, both the specific testing and/or the examination requirements in addition to the reporting expectations will be clearly articulated to the qualified medical practitioner or other qualified health professional providing the report. This is to prevent billing of unnecessary services.
9. Pursuant to the provisions outlined in this policy, VAC will reimburse an applicant or provider at a reasonable rate in accordance with the provincially recommended fee for uninsured third party requests for each completed VAC medical questionnaire form in support of a disability benefit application or reassessment.
10. Medical examinations other than VAC medical questionnaires which have been provided in support of a disability benefit application, reassessment or rehabilitation program applications will be reimbursed at a reasonable rate in accordance with the provincially recommended fee for uninsured third party requests.
11. Costs incurred for any testing which is a provincially insured service, i.e. pulmonary function studies, x-rays, and audiograms, will be reimbursed in accordance with the provincial rate for the insured service.
12. In exceptional cases where a specialist report has been requested, a reasonable fee may be considered based on the content of the report and in accordance with the recommended provincial fee guide.
13. Medical fees associated with examination and/or testing which has not been requested by the Department or which is in excess of the services which VAC has requested will not be reimbursed as billed. VAC will reimburse medical fees in accordance with this policy and any charge above this rate will be the responsibility of the applicant and/or client.
14. Medical exams in support of applications for disability benefits on behalf of an incapacitated child will be reimbursed at a reasonable rate in accordance with the provincially recommended fee for uninsured third party requests.
15. The Department does not generally require an Independent Medical Examiner’s Report or a Medical-Legal Report to support entitlement and assessment adjudication at the first level. If, however, reports of this nature are ever required to support a first level or a departmental review application, the report will be requested from the qualified medical practitioners and/or the other health care professional. The associated medical fee will be reimbursed in accordance with the recommended provincial fee guide. If VAC has not made the request for such reports, any associated billing will not be reimbursed.

References

Pension Act, section 90; subsections 89(1)

Veterans Well-being Act, sections 73, 74 and 75

Veterans Well-being Regulations, sections 66 and 67

Health-related Travel

Establishing the Existence of a Disability

Pain and Suffering Compensation

Additional Pain and Suffering Compensation