Entitlement Eligibility Guidelines (EEGs)
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1.0 Alphabetical Listing of Entitlement Eligibility Guidelines
1.01 Adjudication Process
At Veterans Affairs Canada (VAC), Disability Benefits* decisions are made in two-steps. In the first step, a decision is made about granting of Entitlement; in other words, whether or not the application will be approved. When entitlement is granted, a second step in the decision making process is then needed to determine the disability assessment. In this step, the severity of the entitled disability is determined in accordance with the Table of Disabilities to assign an assessment level. Both the extent of entitlement and the assessment level are used to calculate the amount of disability benefits paid to an individual.
* A reference to “Disability Benefits” in this document means the Pain and Suffering Compensation and the Disability Pension. The legal authorities for granting these Disability Benefits are detailed in Section 1.02 below.
1.02 Disability Benefits Legislative Authorities
For Canadian Armed Forces members and Veterans, the Veterans Well-being Act and the Veterans Well-being Regulations, set out the authorities for granting and administering Pain and Suffering Compensation. The Pension Act and the Award Regulations set out the authorities for granting and administering Disability Pension. (“the Acts”)
Veterans Affairs Canada (VAC) adjudicates and administers Disability Pension claims on behalf of the RCMP. The Royal Canadian Mounted Police Superannuation Act and the Royal Canadian Mounted Police Pension Continuation Act set out the authorities for granting and administering Disability Pensions for Royal Canadian Mounted Police (RCMP), in accordance with the Pension Act.
1.03 EEG Use and Application
VAC uses Entitlement Eligibility Guidelines (EEGs) as tools to support the first step in decision making; entitlement. The EEGs are medical and scientific evidence-based policy statements which compile current medical and scientific descriptions about certain injuries and disease. They provide for consistent, equitable, and swift Disability Benefits entitlement decisions.
The EEGs are developed in accordance with VAC’s Policy on Assessing and Categorizing Health Related Expert Opinion(s) and Scientific Evidence.
The EEGs are intended to provide guidance as opposed to direction to decision-makers about entitlement decisions for certain medical conditions. They are not a substitute for careful analysis of any given case by decision-makers and are not mandatory or binding. They allow for use of judgement by the adjudicator as they review all evidence of an application to determine its relevance and credibility, weigh the evidence, and provide a fair and unbiased decision. More information on the “Benefit of Doubt” provisions in the Acts can be found in the Benefit of Doubt policy.
1.04 EEG Effective Dates
The effective date of an EEG is the Last Revised date noted at the top of each EEG. Where an EEG does not have a Last Revised date, the Initial Publishing Date shall be used as the effective date. The Initial Publishing Date of an Entitlement Eligibility Guideline unless otherwise noted is February 1, 2005. On that date, the EEGs replaced various guidelines contained within a Departmental Medical Guidelines publication.
The following principles are to be followed with respect to EEG effective dates for claims management:
- A change to an Entitlement Eligibility Guideline or implementation of a new guideline does not constitute grounds for a Departmental Review of a decision.
- On and after the effective date of an Entitlement Eligibility Guideline, all claims will be adjudicated upon using the Entitlement Eligibility Guideline.
- Claims awaiting adjudication prior to the effective date of an Entitlement Eligibility Guideline will be adjudicated upon using the entitlement guideline in effect on the date of the Departmental decision.
1.05 EEG Definitions
The Entitlement Eligibility Guidelines provide medical and administrative knowledge for the Title EEG condition, or group of conditions. A Title EEG condition is the medical condition addressed by the EEG. Note that where the term aggravation is used, we mean the permanent worsening of a disability from disease or injury between enrolment and discharge as outlined in the VAC Policy Disability Resulting From a Non Service Related Injury or Disease.
MPC or MC
At the beginning of each EEG, there is reference to Medical Code(s) (MCs). In EEGs published or last revised prior to 2008, this section refers to Medical Pension Code(s) (MPCs).These five-digit numbers are used internally by VAC and are associated with lists of treatment and prescription benefits covered by VAC for the Title EEG condition or group of conditions. These codes are also used for reporting purposes.
ICD
This is the International Classification of Diseases (ICD) code published by the World Health Organization (WHO). The ICD is updated on a regular basis with most recent versions referenced such as ICD-9, ICD-10 and ICD-11.
Definition
This section identifies commonly accepted medical descriptions of the Title EEG or group of medical conditions. If an EEG is written for a group of conditions, the conditions included in the EEG are listed in the Definition Section.
Diagnostic Standard
This Section identifies the supportive investigations which help establish the diagnosis of the Title EEG condition e.g., diagnostic imaging, pulmonary function tests.
This section may describe statements about the qualified medical practitioners from whom VAC will accept diagnosis of the Title EEG condition or group of conditions. The EEGs may identify any circumstances where diagnoses from certain types of health care professionals may not be accepted.
Using the information in this section, the available medical evidence and considerations as outlined in the VAC policy Establishing the Existence of a Disability, decision makers confirm the presence of a disability and assign the most accurate diagnosis for the entitlement decision.
Anatomy and Physiology
This section defines the structure and functioning of the body system(s) addressed by the EEG. This section may include a description of how certain disorders or diseases alter the structure or functioning of the body system(s).
Clinical Features
This section describes the common signs and symptoms associated with the Title EEG condition or group of conditions, and may include comment on disease progression or aggravation.
In this section, EEGs may also describe other relevant medical or epidemiological information about the clinical presentation or features of a medical condition. For example, an EEG may include information about rates of injury or disease in the military or Veteran population as compared to the civilian population, or clinical presentation differences in people who identify as male, female or sex/gender diverse.
Entitlement Considerations
Note: In EEGs published or last revised prior to 2008, this section is referred to as Pension Considerations.
The Entitlement Considerations are divided into three sections: Section A, Section B and Section C as follows:
Subsections
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Section A: Causes and/or Aggravation
Section A identifies factors which are medically accepted to cause or aggravate the Title EEG condition or group of conditions.
Section A is not intended to be an exhaustive list of all factors which can cause or aggravate the Title EEG condition and it is not meant to be rigidly, or inflexibly applied. The entitlement decision maker may consider factors other than those listed to cause or aggravate a Title EEG condition.
This section may identify specific timelines for expected clinical onset of a medical condition after exposure to certain causal or aggravating factors. The term "clinical onset" within an EEG refers to the first appearance of signs and/or symptoms. These timelines are to be considered by decision-makers when reviewing evidence.
Section B: Medical conditions which are to be included in Entitlement/Assessment
Section B provides a list of diagnosed medical conditions which are considered for VAC purposes to be included in the entitlement and assessment* of the Title EEG condition. Medical conditions are included in Section B because they have similar or the same symptoms as the Title EEG condition and therefore cannot be differentiated from each other. When entitlement of a Title EEG condition is granted, the decision includes entitlement of all medical conditions listed in Section B. For this reason subsequent applications for Section B conditions may not require a separate entitlement decision.
The factors listed in Section A have been determined based on a review of medical evidence to cause or aggravate the Title EEG condition only. These factors cannot be considered to also cause or aggravate medical conditions listed in Section B.
The list of medical conditions in Section B is not intended to be all inclusive.
* The Disability Assessment of the Title EEG condition using the Table of Disabilities includes any co-morbid entitled or non-entitled Section B conditions.
Section C: Common medical conditions which may result in whole or in part from Title EEG condition and/or its treatment
Section C is a list of conditions which can be caused or aggravated by the Title EEG condition and/or it’s treatment. By aggravated, we mean permanently worsened. Conditions listed in Section C are not included in the entitlement and assessment of the Title EEG condition; they require a consequential entitlement decision. Consequential entitlement is granted when the medical evidence supports a relationship between a primary medical condition and the development of a resulting condition.
Medical conditions listed in Section C may require different treatment than the Title EEG condition.
The list of Section C conditions is not intended to be all inclusive. Consequential entitlement may be considered for conditions other than those listed in Section C.
1.06 References and Acknowledgement
The EEGs are based on evidence from credible and peer-reviewed medical research and literature. Comprehensive adjudicative guidelines from various disability compensation bodies in Canada and internationally, including the Australian Statement of Principles are reviewed during development of an EEG.
A Sex and Gender Based Analysis Plus (SGBA+) lens is applied during the revision of VAC’s existing EEGs and development of new EEGs. Where available, relevant research about the health-related experience of diverse Canadian members and Veterans is considered. VAC aims to use language that is inclusive and in keeping with Government of Canada Guide on Equity, Diversity and Inclusion Terminology.
Medicine is an ever-changing science. As a result, the EEGs are not considered to be full descriptions of any given Title EEG condition or group of conditions. It is recommended that the EEGs are reviewed on a regular basis to update content that aligns with relevant changes in medicine, policy and legislation.
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