How we review a disability benefit claim

Do we have everything?

A complete application for a disability benefit (form #PEN923AP) will have all the information needed to determine that you have a diagnosed medical condition related to your service. In this first step, we will review your:

1. Disability benefit application (form #PEN923);
2. Medical reports or CAF/RCMP health reports;
3. Medical questionnaire(s);
4. Your service health records; and if needed one or all of the following,
5. Your profile (form #VAC1055) including your proof of identify, third-party consent, and direct deposit form (form #VAC441).

Learn more about how to complete an application for a disability benefit.

Who reviews the claim?

Once your application package is complete, it is assigned to an adjudicator.

Every application for a disability benefit is reviewed by an adjudicator – who are specially-trained to review and make decisions on claims for a disability benefit. The adjudicator must base their decision on the evidence they receive. To ensure they review your claim accurately and quickly, it is very important to provide only information that clearly shows that you have a diagnosed medical condition. Your service records will confirm if that diagnosed condition is related to your service.

How is my service covered?

If your service records show that you were serving in a Special Duty Area (SDA) or Special Duty Operation (SDO) when you became ill or were injured, any disability from that service is covered by the Insurance Principle, which provides 24-hour coverage.

If you were serving outside an SDA or SDO, you will be covered through the Compensation Principle, which provides coverage for an illness or injury that occurred while you were on duty.

Assessment tools used to review the claim

If the adjudicator determines that there is clear medical evidence of a chronic or permanent disability, they must then determine:

1. Your entitlement – is the disability directly or partially-related to service?
   
   and
   
2. Your assessment – what is the severity or extent of the disability and its impact on your quality of life?

To ensure that all decisions are fair and consistent, adjudicators always use the following tools to review your entitlement and assessment:

• Entitlement Eligibility Guidelines - These policy statements are based on evidence from peer-reviewed medical research and literature both in Canada and abroad. They help to ensure the consistency, equity and quality of decisions made regarding the relationship between your service and your disability.
• Table of Disabilities - The table is used by an adjudicator to assess the extent of a disability for the purposes of determining disability benefits. Specifically, to assess the level of an impairment and the impact that impairment has on your quality of life.
• Medical questionnaires - The purpose of a questionnaire is to support your diagnosis and supplement the information found in the Table of Disabilities.

The decision letter

Once the adjudicator reaches a decision on your claim, you will receive a decision letter. The letter will let you know the decision and what evidence the adjudicator used to reach their decision. If they confirmed you have a service-related disability, the letter will also show your entitlement and your assessment.

If you receive an unfavourable decision, the letter will explain the reasons why your claim was not accepted. It will also provide the name and telephone number to call if you wish to discuss this decision further or to identify what evidence your claim requires to be approved. The letter will also explain your appeal rights if you believe the adjudicator has made an error in reviewing your application and supporting evidence.

Additional information

Learn more about how to provide all the components of a complete application for a disability benefit.

How long does it take to be approved for a disability benefit?

We are committed to providing a decision as quickly as possible. To make their decisions, adjudicators must use only the evidence they received. Once adjudicators have received all the information they require - complete and signed form(s), service records, medical reports and questionnaire(s) - they can usually make a decision within 15-41 weeks.

This timeframe will vary depending on several factors such as:

• the complexity of your condition,
• the complexity of the medical reports and questionnaires explaining that condition,
• how long it takes to receive service health records from DND or Library and Archives Canada,
• the level of detail (or lack of detail) in those service health records, and
• any challenges in getting other needed evidence to support your claim.

The Wait time tool provides current average wait times for receiving a decision on certain applications.