Eligibility for Health Care Programs - Entitled to a Disability Award or Pain and Suffering Compensation (Regular and Reserve Force Services)

Purpose

This policy provides direction on health care eligibility under the Veterans Health Care Regulations for those individuals who are entitled to a disability award or entitled to pain and suffering compensation.

Policy

General

1. Under the Veterans Health Care Regulations, entitled to a disability award means, in relation to a member or former member, that the member or former member:
   1. has received a disability award under the Veterans Well-being Act;
   2. has not received a disability award under that Act, as of April 1, 2019, but has been granted entitlement to a disability award before that date; or,
   3. would have received a disability award under that Act, except that the combined total of a disability benefits entitled conditions cannot be payable at a rate higher than 100% (see subsection 54(1) of the Veterans Well-being Act).
2. Under the Veterans Health Care Regulations, entitled to pain and suffering compensation means, in relation to a member or former member, that the member or former member:
   1. has received pain and suffering compensation under the Veterans Well-being Act;
   2. has been granted disability entitlement under that Act, but the extent of his or her disabilty has not been assesssed; or
   3. would have received pain and suffering compensation under that Act, except that the combined total of a disability pension, a disability award, or pain and suffering compensation cannot be payable at a rate higher than 100%.

Treatment Benefits - Disability Award or Pain and Suffering Compensation

3. Former members or reserve force members are eligible to receive treatment benefits, in Canada or elsewhere, for the injury or disease for which they are entitled to a disability award or pain and suffering compensation (see policy entitled Treatment for a Disability Benefits Entitled Condition), to the extent that the treatment benefits are not available to them as former members or reserve force members of the Canadian Armed Forces.

Supplementary Benefits

4. Former members or reserve force members of the Canadian Armed Forces who are entitled to a disability award or pain and suffering compensation are eligible to receive supplementary benefits, including the cost of travel and escort fees (see policy entitled Health-related Travel) if they receive the following treatment benefits authorized by Veterans Affairs Canada:
   1. any medical, surgical or dental examination or treatment provided by a health professional; or
   2. the provision or maintenance of any surgical or prosthetic device or aid, or any home adaptations to accommodate the use of such a device or aid.

Miscellaneous Benefits

5. Former members or reserve force members of the Canadian Armed Forces who are entitled to a disability award or pain and suffering compensation and are transferred from one health care facility to another are eligible to receive the costs of transportation incurred in Canada, if they are:
   1. eligible to receive any part of the cost of intermediate care under the Veterans Independence Program; or
   2. eligible to receive any part of the cost of chronic care under the Long Term Care Program.
6. When a critically-ill former member or reserve force member of the Canadian Armed Forces who is entitled to a disability award or pain and suffering compensation receives intermediate care, chronic care, or acute care in a hospital and, in the attending physician's opinion, a visit by a family member or other designated person would be beneficial to the health of the former member or reserve force member; that family member or other designated person is eligible to receive the transportation costs incurred, in Canada, for the visit (see Health-related Travel policy).

Veterans Independence Program

7. Former members or reserve force members of the Canadian Armed Forces who are entitled to a disability award or pain and suffering compensation are eligible to receive Veterans Independence Program services of home care, ambulatory health care, and home adaptations, or intermediate care in a community bed, if:
   1. the services or care are not available to them as former members or reserve force members of the Canadian Armed Forces or, as an insured service under a provincial health care system, or if the cost of such services or care is not recoverable from a third party (see policies entitled Requirement to Access Provincial Programs and Costs Recoverable from Third Parties);
   2. they are resident in Canada;
   3. they undergo an assessment which indicates one of the following:
      1. the disability for which they are entitled to a disability award or pain and suffering compensation impairs their ability to remain self-sufficient at their principal residence; or
      2. they meet the criteria of a frail pensioner (Veterans Independence Program - Benefits at Home Policy for more information); and
   4. the provision of these services will assist them to remain self-sufficient at their principal residence or the provision of intermediate care is necessary for health reasons.

Long Term Care - Disability Award or Pain and Suffering Compensation (Community Bed)

8. Members or former members who are entitled to a disability award or pain and suffering compensation are eligible to receive the cost to them of chronic care for a disability for which they are entitled to a disability award or pain and suffering compensation, if:
   1. the care is received in Canada in a community bed;
   2. the care is received in a health care facility outside Canada that is of a standard equivalent to the care that would have been provided under 8.a) provided that the cost of such care does not exceed the usual cost of chronic are in the jurisdiction in which the care is received; and
   3. an assessment shows that the care is an appropriate response to their health needs.

Long Term Care - Frail Pensioner

9. A member or former member who is entitled to a disability award or pain and suffering compensation who requires chronic care under the Long Term Care program for a non-awarded condition (i.e. does not meet the eligibility outlined in paragraph 8 of this policy) may be eligible for financial support toward the cost of care if they meet the criteria of a frail pensioner as outlined in the Veterans Independence Program - Benefits at Home Policy. Those members or former members who are entitled to a disability award or pain and suffering compensation, who are approved for Veterans Independence Program intermediate care (type II health needs) and whose health needs increase to chronic care (type III health needs) continue to be eligible to receive reimbursement for Veterans Independence Program intermediate care, as type III health care needs encompasses type II needs (see paragraph 9 of the Community Facilities (Veterans Independence Program - Intermediate Care and Long-term Care).
10. A member or former member who is entitled to a disability award or pain and suffering compensation, as referred to in paragraph 9 of this policy, is responsible for the cost of chronic care beyond the limit established for Veterans Independence Program intermediate care. If applicable, they are also required to pay up to the maximum accommodation and meal rate (see policy entitled Accommodation and Meals Contribution).

References

Veterans Well-being Act

Veterans Health Care Regulations

Treatment for a Disability Benefits Entitled Condition policy

Health-related Travel policy

Requirement to Access Provincial Programs policy

Costs Recoverable from Third Parties policy

Veterans Independence Program - Benefits at Home Policy

Community Facilities (Veterans Independence Program - Intermediate Care and Long-term Care) policy

Accommodation and Meals Contribution policy