Although not 100% successful in our approach with the Department, we do obtain very good results in many of our interventions.
Treatment Matters: Assisting a Veteran With Medication Coverage
Those who rely on medication to keep health issues in check understand how vital daily treatment is. Treatment can also be costly if an individual does not have the appropriate coverage.
For one Veteran who contacted our office, medication and coverage were at the center of their worries.
The Veteran suffered from an uncomfortable condition that causes areas of the body to go numb and feel cold in response to cold temperatures or emotional stress. Over time, the condition can cause small arteries to thicken slightly, further limiting blood flow.
For 50 years, the Veteran managed the pensioned condition with medication covered by Veterans Affairs Canada (VAC.) However, when their physician changed the prescription from a pill form to a liquid form, VAC stated that they could not link it to the Veteran’s pensioned condition and would not pay.
When the Veteran reached out to the OVO for help, they had been trying, unsuccessfully, to get the drug reapproved by VAC for many months.
Upon assessing the situation, The OVO noted that the Veteran’s medication had been covered for decades prior to the switch from pill to liquid. Veterans are entitled to treatment for their pensioned conditions.
An OVO Intervention Officer sent the file to a VAC and requested they coordinate with the Veteran’s physician to get the necessary medical information for an approval.
VAC contacted the pharmacy unit within Medavie Blue Cross (MBC,) who informed them that no one from VAC had actually reached out on the Veteran’s behalf to discuss the coverage issue.
A medical consultant at MBC approved the medication with a retroactive reimbursement for 18 months.
After a year and a half trying to get the medication paid for, the Veteran could finally receive the medication they were entitled to.
Sometimes, our job is to create action where there has been inaction. This story illustrates the impact that action can have.
Assisting a Veteran with Their Case Manager
A Veteran battling anxiety needed a doctor to complete a questionnaire for a totally and permanently incapacitated (TPI) Earning Capacity Assessment, but after moving to a new city, the Veteran had a hard time finding a doctor. The Veteran tried to contact their case manager many times to discuss the situation, but there was a breakdown in communication. When the Veteran contacted my Office, we investigated and discovered that it had been a while since the Veteran was last contacted. After speaking to the Department, the Veteran was finally contacted and satisfied with the outcome.
Helping a Veteran Dependent Benefits
A Veteran had been paying child support for two years. Originally denied Dependent Benefits by VAC, the Veteran was finally approved but only compensated for one of the two years. After several attempts to resolve the issue, the Veteran contacted my Office. We were able to tell the Veteran which documents were missing from his file, and we were able to contact Ancillary Benefits and resolve the issue. The Veteran was retroactively compensated.
A Reimbursement for Long-Term Care
When a Veteran was admitted to a long term care facility, the Veteran’s family had no idea that VAC covered these costs. They applied for a retroactive reimbursement, back to the date the Veteran was admitted, but the request was denied. After attempting a second level appeal, they contacted my Office for help. What we discovered is that to be eligible for Long-Term Care reimbursements, Veterans are expected to contact VAC the moment their needs change and before being admitted to a long term care facility, unless it’s an emergency. After speaking with a manager from the Department, we were able to show how the circumstances were out of the Veteran’s control and, therefore, considered urgent. The Veteran received a complete reimbursement for the long-term care expenses.
Getting a Veteran Placement in a Long Term Care Facility
A Veteran was rushed to the hospital after falling at home. While there, worsening dementia combined with limited mobility made it impossible for the Veteran to return home. A few years earlier, the Veteran requested a bed in one of three facilities with beds reserved for Veterans, but somehow, there was still a six-month wait. Frustrated, the Veteran’s daughter contacted my Office for help. My Office contacted VAC, and we were able to get the Veteran’s request approved, and shortly after, the Veteran was given a bed.
Getting an Early Hearing Aid Replacement for an Elderly Veteran
An elderly Veteran requested an early hearing aid replacement, and it was denied despite providing to VAC a new audiogram and a letter from an audiologist explaining why new hearing aids were needed. Due to the Veteran’s age, requesting an appeal was challenging. The Veteran contacted my Office for help saying, “I cannot hear properly, and it’s affecting my quality of life, my social interactions and my safety.”
Veterans are eligible for hearing aid replacements every four years. This elderly Veteran was only one year shy of eligibility. My Office researched the policy and discovered that early hearing aid replacements are done, at the discretion of a VAC authority, when:
- there is a significant change in hearing ability;
- repair of the existing aid isn’t feasible; and
- a treatment response is needed for tinnitus.
We contacted a Senior Analyst from VAC’s Treatment Benefits team who authorized the exception. As a result of our intervention, we were able to deliver good news to the Veteran.
An Overpayment Situation: Helping a Veteran’s Survivor
A Veteran with a VIP Grant contribution passed away, so the spouse moved in with their daughter. The spouse immediately informed VAC of the new living arrangement, and later sent several other letters to VAC informing them that the grounds of the new home no longer required assisted maintenance. VAC, however, continued to issue payments for several years.
Eventually, VAC demanded a repayment of several thousand dollars. The Veteran’s survivor was very upset. As far as the Veteran’s survivor knew, VAC was informed and had approved all the necessary benefits. The Veteran’s survivor had done everything correctly, and none of VAC’s communications throughout the years had led the Veteran’s survivor to believe that she would have to repay VAC.
When the survivor contacted our Office for help, we spoke to the daughter who told us, “We did everything VAC asked. We were very upset by these overpayment demands, and it’s unfair to expect us to repay that now.”
After reviewing the file, my Office requested that VAC write-off the overpayment. This request was initially met with resistance, but after contacting Kirkland Lake Finance with a chronological account of what happened and quoting relevant policy, we succeeded.
We were glad we could help!
Helping a Veteran Get a Decision
A Veteran with a service-related health condition needed life-saving treatments that were not available in Canada, so his specialist recommended treatment in the USA. The Veteran followed all of the required procedures for pre-approved Health Related Travel but he was still being shuffled between various VAC offices. With only one business day before his departure date and several costly trips ahead, the Veteran still did not have a decision, so he contacted my office for help.
After reviewing the Veteran’s file, we began navigating the pre-approval procedures for Health Related Travel. When my office took a closer look, they discovered that it was unclear who was responsible for making decisions on pre-approved travel out of country. This, inevitably, caused unfair delays for the Veteran.
We contacted the Exceptional Benefits Unit and asked if they could make a decision right away. They obtained all the information about his travel dates and expenses, and they were able to approve his request before his departure date. The Veteran was relieved to learn that his travel expenses were reimbursable.
I’m glad we were able to help. Procedures need to be streamlined and easy to follow, so Veterans can easily access assistance when and where they need it.
Veteran receives payments for expenses previously denied
An issue of invoices, receipts, and up-front payment
A Veteran, a single parent of four who is working towards a university degree, contacted the Office of the Veterans Ombudsman (OVO) after being denied reimbursement under the Canadian Veterans Vocational Rehabilitation Services (CVVRS).
The Veteran was under financial pressure and struggled to make ends meet each month. This pressure was exacerbated by childcare and tutoring expenses of more than $700 a month. The Veteran was told to submit paid receipts monthly to be reimbursed by CVVRS. One month; however, CVVRS denied the claim because the invoice submitted had not been stamped “paid.” The Veteran contacted my Office to intervene.
My team’s investigation revealed that both tutoring and childcare expenses fall under the same regulations and that nothing in the policy or regulations requires up-front payment. The Veteran’s invoice was, therefore, admissible for payment.
As a result of our intervention, CVVRS was notified, and the Veteran was immediately paid for the expenses previously denied. We also recommended that CVVRS handle the Veteran’s future payments as a priority.
How we helped a homeless Veteran
A Veteran living part-time between a men's shelter and an apartment that also housed drug dealers had an urgent requirement for housing. The location had animal feces throughout the building, police were often called, and his belongings were not secure.
In addition, the Veteran’s service-related medical condition was causing a barrier to employment. He contacted Veteran Affairs Canada (VAC), met with a Case Manager and was given applications for the Rehabilitation Program (Rehab) and the Earnings Loss Benefit (ELB). The Case Manager referred the Veteran to community services to find housing.
The Veteran found the application process for Rehab/ELB confusing and thought a decision was forthcoming. He thought VAC would help him through the process. After a six-month wait, he contacted the Office of the Veterans Ombudsman (OVO) for assistance.
My team reviewed the Veteran’s file and found that, although a VAC Case Manager had interacted with him for a few days, the Department did not walk him through the process and provide him with the personalized approach required by VAC’s case management guidelines.
We intervened by contacting VETS Canada (a non-profit organization helping at-risk and homeless Veterans) to secure adequate housing and then contacting the local VAC office to inform them that the Veteran was still at risk of homelessness. The OVO also recommended that VAC take a more hands-on approach.
As a result of our intervention, VAC immediately assigned a Case Manager who discovered that the Veteran’s Rehab/ELB application had never been submitted. With the Case Manager’s assistance, the Veteran completed the application and was approved for the Rehab Program/ELB and vocational training for a new career, and ultimately, a more promising future.
Continued Treatment during Incarceration
VAC was advised that a Veteran, who is pensioned for PTSD, was incarcerated. He was on the Rehabilitation Program at the time. VAC immediately cancelled his rehabilitation plan thinking he would be unable to participate given that he needed to undergo mental health treatment.
The Veteran repeatedly requested assistance from VAC while incarcerated but was denied. After we intervened, he was put back into the program – while incarcerated – as he was able to find a psychologist willing to provide treatment in a prison.
We also requested a review of the initial cancellation decision made by VAC, based upon the fact that no effort had been made to determine if the Veteran would be able to fully participate in his rehabilitation plan. VAC recognized there was no legislative authority to cancel his rehabilitation plan, and rescinded the cancellation decision.
Veterans who hold either a pension or disability award are entitled to receive treatment for the condition(s) for which the pension or award is granted. A new formal agreement between Correctional Service Canada and VAC is being put into place to ensure incarcerated Veterans continue to get the treatment they need.
Disability pension for student with special needs reinstated to Veteran
Different definitions of “full-time student” were at the heart of a recent Veterans Affairs Canada (VAC) decision to deny a Veteran an additional disability pension for his child who is attending university. The student has special needs, and in September 2015 reduced his course load to two courses totalling six hours a week.
The university considers this a full-time course load for a student with special needs. In contrast, VAC requires that a student take a minimum of three courses totalling nine hours per week to be considered full time. VAC turned down the application because the child no longer qualified under the “Children Following a Course of Instruction” policy even though that policy states, “Full time shall be as defined by the institution.”
The Office of the Veterans Ombudsman (OVO) intervened and was able to clarify the case and ensure the necessary documentation was completed and submitted to VAC. VAC responded the same day and reinstated benefits effective January 1, 2016. The Veteran was “very pleased with the service” the OVO provided.
Further delays in providing Veteran with ER-prescribed drug prevented
In August, a Veteran experienced a four-day delay in receiving a drug prescribed by an Emergency Room (ER) physician for an acute condition. The ER doctor prescribed a drug that the Veteran learned, after two pharmacy visits, required special authorization from Medavie Blue Cross (MBC). Unable to afford the up-front medication cost, the Veteran contacted the Office of the Veterans Ombudsman for help.
The OVO intervened immediately, but four days later received an initial VAC decision to deny approval for the ER-prescribed medication. VAC told the Veteran to visit another medical practitioner to obtain a different prescription for a pre-approved drug. Once again, OVO intervened and VAC issued an “exceptional” approval so the Veteran was able to fill the original prescription. VAC also agreed to consider the prescribed drug for inclusion on their approved list of medications.
Finally, when following up with the Veteran, it was the OVO front-line rep who communicated news of the approval so that the Veteran was able to obtain the required medication. VAC had not immediately communicated the decision to the Veteran.
The OVO identified five issues and contacted VAC to determine what steps they could take in the future to prevent this from recurring. VAC has responded (see below), and the OVO hopes that these positive steps will result in better service for Veterans.
- Medavie Blue Cross (MBC) needs a 24-hour phone line for pharmacists to call. VAC responded that their National Pharmaceutical Advisor is reviewing the special authorization criteria associated with the prescription drug in this case. Any recommendation changes will be brought forward to the Formulary Review Committee for review and implementation. In addition, VAC states that this particular drug will also be considered for addition to the interim supply list. VAC’s Prescription Drug Team will also ensure the 24-hour pharmacy is contacted to investigate why they did not receive the message with the answering service number.
- Drugs prescribed by an Emergency Room physician require immediate approval to ensure Veterans do not experience delays in accessing necessary treatment or suffer from unnecessary financial hardship.
- Veterans should not be made to seek additional medical care while suffering from an acute medical condition. With respect to points (2) and (3), VAC noted that in this situation, a gap was identified in the process – specifically, when a prescription for a special authorization drug is received after hours, and the particular drug is not included on the interim supply list. VAC states that its Prescription Drug Team will bring this gap forward to be discussed at the next Formulary Review Committee meeting. The Committee will be asked to consider putting any special authorization drug requiring a medical consultation on the VAC interim supply list so that the Veteran can receive immediate treatment. VAC will then advise Medavie Blue Cross (MBC) of the resulting recommendation and have it implemented so that the gap is filled going forward. In addition, the Prescription Drug Team will provide information on the updated process to the OVO once the recommendation is implemented.
- Urgent situations require capacity for same-day VAC decision.
- VAC needs to take charge of client contact and follow-up. With respect to points (4) and (5), VAC stated that its Prescription Drug Team will continue to expedite decisions for urgent inquiries and will make contact with the Veteran directly as required. VAC’s Prescription Drug Team will evaluate future scenarios similar to this situation and make further adjustments to the prescription drug process as required.
Considering the human factors for fair treatment
The son of a 101-year-old frail Veteran called the Office of the Veterans Ombudsman (OVO) seeking assistance in appealing VAC’s denial of a prescribed therapeutic nutrient for the Veteran. This Veteran was suffering from a decreased appetite and weakness for two weeks, and after hospitalization, was prescribed Glucerna meal replacement to supplement the Veteran’s daily food consumption. The Veteran was also suffering from a broken wrist, diabetes and other serious health conditions. Unfortunately, the Veteran’s request for Glucerna coverage was denied as it did not meet VAC’s criteria for therapeutic nutrients. The OVO found that the Veteran was not treated fairly, as VAC’s criteria for therapeutic nutrients do not take into account important factors such as the client’s age, frailty and special health needs. The OVO contacted the National Manager, Treatment Programs, for a revision to these criteria, and launched the appeal on a “Red Zone” (priority) basis. With OVO intervention, VAC approved the client for Glucerna on an exceptional basis.
Significant Increase in Disability Assessment
A Veteran contacted the Office of the Veterans Ombudsman because he was unsatisfied with the initial (interim) assessment of 28 percent that he had received for several major injuries sustained as a result of an IED explosion. The Office contacted Veterans Affairs Canada’s Head Office Senior Medical Advisor and through discussion was able to have the injuries evaluated holistically (as opposed to each in isolation). This resulted in an increase in the assessment from 28 percent to 72 percent.
Veteran’s Vocational Rehabilitation Plan Gets a Second Look
A Veteran contacted the Office of the Veterans Ombudsman because he was feeling unsure about the career path Veterans Affairs Canada had selected for him and was worried that the Department was on the verge of closing out his Vocational Rehabilitation Plan. This Veteran had served as an air traffic controller and a trucker in the Canadian Forces. The Department’s vocational service provider had sent the Veteran to a custom broker training program, but the Veteran did not feel that this was a suitable gainful employment career path for him. The Veteran claimed that all that was required to become a custom broker was some studying and successful completion of a written exam at a cost of $500. Our Office contacted the Department to address the Veteran’s concerns and, through discussion, the Department agreed to keep the Veteran’s Vocational Rehabilitation Plan open so that other, more suitable occupational goals could be explored.
Home Gym Equipment Approved
A Veteran pensioned at 100 percent had been waiting for a year for approval of home gym equipment to help alleviate the pain to his condition caused by excessive car travel. This Veteran is required to do a six hour return trip three times a week to the nearest town to get physiotherapy treatment. The Veteran had submitted to Veterans Affairs Canada a prescription from his doctor and a written recommendation from his physiotherapist for the home gym equipment, but it had not been approved by his Case Manager. By intervention of the Office of the Veterans Ombudsman, the home gym equipment was approved and the Area Director of the Region was to investigate the situation.
Permanent Impairment Allowance Approved
A Veteran applied to the Rehabilitation Program and at the same time submitted an application for the Permanent Impairment Allowance (PIA). The PIA application was declined because the Rehabilitation Program request had not yet been approved – a requirement of PIA application. When the Rehabilitation Program was approved, the PIA was not considered. The Veteran contacted the Office of the Veterans Ombudsman seeking help to get his PIA application approved. By intervention of the Office, this Veteran will receive all the PIA benefits for which he is eligible.
An Outstanding Ambulance Bill is Paid
A Veteran contacted the Office of the Veterans Ombudsman because he had an outstanding ambulance bill that had been sent to a collection agency. The Veteran had submitted the bill to Veterans Affairs Canada for payment, but the Department denied payment due to insufficient information. Our Office intervened with the collection agency and asked them to put it on hold while we investigated the issue. After proving to the Department that the ambulance service was incurred as a direct result of the Veteran’s pensioned condition, it agreed to pay the ambulance bill. We then updated the collection agency and confirmed that payment would be issued.
Red tape in the way of a Veteran getting needed chiropractic treatments
A Veteran contacted the Office of the Veterans Ombudsman about his difficulties in obtaining approval for additional chiropractic treatments, beyond and above the number of treatments allowed by the Department. Every year, for the past eleven years, the Veteran requested approval for additional treatments, which were needed to maintain his present mobility, and prevent his condition from deteriorating. One year he would get approval from the Department, and the next year, his request would be declined. After discussion with the Department, we were successful in resolving the issue in favor of the Veteran.
Medication reimbursed but not the medical procedure
A Veteran asked for our assistance in obtaining reimbursement for a medical procedure. On two previous occasions, the Department had reimbursed the Veteran for the cost of the medication as well as the cost of the injection that was done by his doctor. The last time the Veteran requested reimbursement, the Department agreed to reimburse the Veteran for the cost of the medication but did not authorize the reimbursement of the medical procedure. The Office of the Veterans Ombudsman intervened on behalf of the Veteran, and, as a result, the Department has since agreed to cover the cost of the injections.
VIP going astray
VIP reimbursements of a surviving spouse had gone missing in recent months without explanation. The client’s September reimbursement had already been issued to her twice, and had to be combined with her missing November reimbursement and reissued again in late January. Instead of risking the reimbursement going astray for a third time, we communicated with VAC and they agreed to courier the cheque to the recipient, thus relieving the financial stress that was beginning to mount because of the delays.
It’s worth the Insulin
An 87 year old Veteran contacted the OVO indicating that he requires a specific type of insulin that is not covered through the VAC drug plan. The client submitted a Doctor’s note indicating why he needed this specific type of insulin and was still denied reimbursement. We contacted VAC on his behalf, and asked why a fixed income Veteran with B coverage would choose to pay out of pocket for a non-formulary type of insulin unless he did indeed suffer serious side-effects from the listed types? VAC has since agreed to cover the insulin for the client on an exceptional basis, and reimburse him back to July of 2007 when he was first denied.
Vindication through Perseverance
A Veteran had a TTY (teletypewriter) device installed during the early 1990s, which was required due to his pensioned condition for hearing loss. In 1996, he began writing and phoning VAC requesting they pay the monthly TTY bill. VAC denied his requests. We did a review of his file and encouraged him to appeal the initial decision. He appealed and partially won, with reimbursement back to April 2008. We encouraged him to go to a second level of appeal. In the meantime, we indicated to VAC that a total review of his file would be required to obtain a full understanding of this case. VAC, much to their credit, did review his file in its entirety which resulted in the Veteran being awarded reimbursement of monthly TTY charges back to December 1996.
Health Related Travel
This story is somewhat related to one of the hot issues that we listed last month. An 82 year old Veteran has taken the same route to his medical appointments for years because he feels that it is the safest route for him. VAC used to reimburse him based on his odometer reading. However, VAC has recently been reimbursing him based on the mileage calculated via Google Maps, which uses his home address and the address where his appointments take place to calculate the distance. Although he had written to VAC to advise that he took his route due to safety, but nothing had changed. We checked his exact route on Google Maps and could see that the shortest route would involve this Veteran merging into and out of a three lane highway. We contacted VAC, on his behalf, and advised that although the Health Related Travel (HRT) guidelines state that an online calculator can be used to determine mileage, the policy is not so strict that it specifically states that a calculator has to be used. Travel is to be by the most convenient and economical means. As such, we requested VAC review the Veteran’s letter, pointed out the safety issue for him and the related policy. VAC agreed to overturn its decision and will backdate his previous HRT claims to reflect the full mileage.
Light Therapy for Depression
A Veteran was recommended light therapy by two physicians as treatment for a pensioned condition. VAC denied the coverage as the device was not on their benefits grid. Following discussion with the Department, it was found that a fair amount of evidence was available supporting this type of therapy. This in turn resulted in VAC amending their benefits grid to include this treatment. The treatment will now be covered for this Veteran.
Restrictions on Grounds keeping under VIP
We were recently successful in a case involving the grounds maintenance portion of VIP services. The Veteran had been denied hedge and shrub trimming based on policy, which we felt was being misinterpreted to the Veteran's disadvantage. According to regulations, the maintenance that is the responsibility of the client, and would normally be performed by him aside from his health condition, should be covered. After mediation and discussion with VAC the decision was reviewed and overturned, granting this client the services he needed.
Long-Term Care Expenses
In one instance, a Veteran's daughter contacted our Office because she was frustrated with delays in receiving reimbursement by VAC for her father’s long-term care expenses. We asked VAC if it was possible to set up direct billing with the facility to ensure a smoother process for all involved. VAC agreed and arranged for the facility to directly bill VAC. In addition, they will change all existing and new residents (Veterans) of this facility to direct billing.
Veterans Independence Program
In another instance, VAC denied a request from a Veteran for social transportation costs under the Veterans Independence Program. The reason for the decline was that although he was a pensioned veteran, he did not meet the income qualification. Upon review of his VAC file, we noticed his eligibility for the War Veterans Allowance for the purposes of treatment benefits. That eligibility, for all intents and purposes, identifies him as an income qualified veteran. Upon contacting the District Office for clarification on the reason for declining the service, they reviewed their decision and granted him eligibility to the service.
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