3.6.2.10 Medical & other evidence for DSP

Summary

Medical evidence (1.1.M.100) is required to determine whether a person meets the DSP impairment and CITW (1.1.C.330) qualification requirements. It is the person's responsibility to provide medical evidence in support of their DSP claim and payment continuations.

For DSP claims lodged on or after 3 September 2011 and certain DSP recipients aged under 35 years subject to review (6.2.5.03), other evidence is also required to determine whether a person who does not have a severe impairment (1.1.S.127) or is a reviewed 2008-2011 DSP starter (1.1.R.285) has actively participated in a POS (1.1.A.30).

Medical and other evidence is used for the purposes of:

• conducting a JCA (1.1.J.10) and preparing reports to inform DSP decision making
• completing a DMA (1.1.D.180)
• making determinations about granting, rejecting, cancelling or continuing DSP, and
• reviewing decisions about DSP eligibility made under social security law (reviews and appeals).

Changes to medical evidence for DSP claims

From 1 July 2015, people claiming DSP are not required to submit a medical report from their treating doctor. Instead, they need to provide their medical records.

Prior to 1 January 2015, the primary source of medical evidence for DSP was a medical report from a person's treating doctor (1.1.T.160). From 1 January 2015, changes were made to the way medical evidence is sourced and provided in support of a claim for DSP.

Some people claiming DSP were no longer required to submit a medical report from their treating doctor, and instead needed to provide their medical records. Initially these changes applied to people aged under 35 and living in a capital city.

From 1 July 2015, medical reports from treating doctors are no longer required for any DSP claims. From that date, the primary source of medical evidence is a person's medical records provided by the person.

Medical report - DSP reviews

DSP recipients whose medical qualification is being reviewed, are still required to provide a medical report from their treating doctor. The person may also provide additional information about their condition (1.1.M.90) and how these impact on their ability to work.

Primary medical evidence

DSP determinations are based on a range of considerations that relate to the qualification criteria for the payment. These considerations include whether a person's condition is diagnosed, reasonably treated and stabilised, and more likely than not, in light of available medical evidence, to persist for more than 2 years. Diagnosis of medical conditions for DSP purposes can only be provided by an appropriately qualified medical practitioner (exceptions are outlined below). Medical evidence should therefore contain sufficient information to enable DSP determinations to be made, including details of:

• the diagnosis of the person's medical condition/s, including
  • date of onset
  • whether the diagnosis is confirmed, and
  • the details of the medical professional who made the diagnosis
• clinical features including history, current symptoms and prognosis
• past, present and future/planned treatment
• impact of condition/s on ability to function, including the expected period of impact and whether the effect of the condition on the person's ability to function is expected to remain unchanged, improve, or deteriorate
• any impact on life expectancy as a result of the medical condition/s, and
• any supporting information used by the doctor, such as X-Rays, hospital records or pathology results.

Types of evidence acceptable in certain circumstances

The above primary medical evidence requirements may not apply in certain circumstances where sufficient information to make a DSP determination is available from other sources, including for:

• People with an intellectual disability who have attended a school which provided tailored education for children with disability, or classes within a mainstream school which were tailored to meet their needs, and are able to provide a report from their school which indicates their IQ.
• People who are blind and are able to provide a report from an ophthalmologist, or a report from an optometrist, which is supported by a report from the treating or formerly treating ophthalmologist.
• A child assessed before 1 July 2009 as being a profoundly disabled child (1.1.C.146) whose carer was being paid CP up to the time the child turns 16.
• A person in receipt of a DVA disability pension at special rate (totally and permanently incapacitated (TPI)). The person must provide their special rate decision letter from DVA or give authority for Services Australia to obtain the relevant payment information from DVA.

In limited circumstances a claimant's eligibility for DSP may be based on the provisional diagnosis of a mental health condition provided solely by a Services Australia registered psychologist (see below).

Unclear evidence

If a person indicates that they have a medical condition that is not included in their medical evidence, they should be asked to provide additional medical evidence detailing the diagnosis and treatment of this medical condition. This may involve the person asking the provider of the medical evidence for further information (if this doctor has treated them for the unlisted condition), or obtaining evidence from another doctor or specialist. It is generally the person's responsibility to provide all relevant medical evidence in support of their claim or payment continuation.

If a report, document or other material contains unclear terminology or lacks clarity, it should also be discussed with its author. If there is still a need for an expert medical opinion, the HPAU (1.1.H.60) can provide advice, clarification and interpretation of medical information to a job capacity assessor (1.1.J.20) and Services Australia staff for DSP claim, review and appeal purposes.

Any discussions to clarify unclear evidence must be recorded and form part of the evidence used to support the decision about qualification for DSP.

People living in remote areas

JCAs, DMAs and payment decisions informed by these assessments must be based on the best available medical evidence. In the case of people from remote areas who may have limited access to doctors, a community nurse can assist in collating their medical evidence, which should generally be based on clinical notes from a GP (the diagnosis must be made by a qualified medical practitioner). In these cases it may be possible for the job capacity assessor or the GCD to form an opinion regarding the person's medical qualification on the basis of available evidence. This will only apply if the medical condition has been diagnosed, reasonably treated and stabilised, and is likely to persist for more than 2 years (1.1.D.140) to the extent that it is possible to assign an impairment rating.

Medical evidence & diagnosis for vulnerable people

There are a small number of vulnerable people with suspected mental health conditions who are likely to be qualified for DSP or eligible for a significant reduction in their participation requirements but are unable to be effectively assessed through normal DSP assessment procedures. This may be because they are disengaged from the health system, or do not acknowledge the impacts of their condition on their capacity to work or comply with requirements. This may include people who:

• are living in remote communities with little or no access to health services, and/or
• have been identified by Services Australia staff based on the information (which may originate from within Services Australia or externally, for example, from relevant state authorities or employment service providers) that is contained in the person's Services Australia records, as continually unable to comply with the relevant requirements, and demonstrating behaviours consistent with a mental health condition.

In these circumstances the provisional diagnosis of a mental health condition can be made by a Services Australia psychologist and this assessment may be considered sufficient medical evidence for DSP purposes.

In all these cases the evidence/case history should be discussed with the HPAU so that consideration can be given to other medical factors which may be impacting on the person.

In limited and specifically defined circumstances, a person's medical condition/s may be verified as diagnosed, reasonably treated and stabilised without written medical evidence. Diagnosis and other details relevant to assessment of DSP may be based solely on documented conversations with the person's treating doctor in the following limited circumstances:

• where the person is unlikely to provide written medical evidence because of a mental health or other serious condition, and/or
• where the person lives in a remote area and has limited access to medical services.

Medical information provided in these circumstances must contain the same level of details as that normally contained in the primary medical evidence outlined above.

Other medical evidence

The person may choose to provide other relevant medical evidence. This type of evidence may also be available from other sources such as Services Australia records. However, this type of evidence can only be used as supporting or complementary evidence and cannot be used in isolation from, or instead of, the primary evidence containing the required details (including diagnosis, treatment and prognosis) outlined above. This type of evidence may include but is not limited to:

• medical certificates from the person's treating doctor or specialist
• hospital/outpatient reports
• X-Ray and other medical investigation reports
• psychometric test results
• prescriptions/sample medication
• medical information used by Services Australia to assess entitlement to other payments
  
  • Example: If a person has recently attracted payment of CP or CA, the delegate can refer to previous medical reports held on the CP/CA file for the person.
• reports from para-professionals, or
• reports from non-medical practitioners or community service workers.
  
  • Example: Psychologists, mental health workers, social workers, drug and alcohol counsellors, community medical health workers, physiotherapists and occupational therapists.

Non-medical evidence

The person may also choose to provide non-medical evidence in support of their DSP claim or continuation. This evidence may include but is not limited to:

• reports from alternative health practitioners (for example, naturopaths, massage therapists)
• letters or references from various sources (for example, carers, friends, community members)
• reports from teachers (other than reports from teachers on behalf of special schools that contain IQ test results), or
• work attendance records.

Evidence of active participation in a POS

Any material which is related to a person's participation in a POS can be used to determine whether that person has actively participated. This may include information from one or more designated providers (1.1.D.115). The information in relation to the POS must provide the following:

• details of the designated provider
• periods of participation in the program
• periods of non-participation in the program and associated reasons
• reasons for ceasing the program (if any)
• the terms of the program that were specifically tailored to address the person's level of impairment, individual needs, barriers to employment, and capacity to work
• the terms with which the person had to comply in order to satisfy the program requirements and the level of compliance with those terms
• details of vocational, rehabilitation or employment activities undertaken during the program, and
• the frequency of contact the person had with the designated provider.

Documents or other material that may assist in determining whether a person has actively participated in a POS include but is not limited to:

• EPPs (1.1.J.25), or
• DES, Workforce Australia, CDP (former RJCP) or Australian Disability Enterprise program progress, exit or closure reports.

A person cannot meet the requirements for active participation in a POS unless they have commenced a POS. A person is generally required to have participated in a POS for at least 18 months during the relevant period applying to the person (generally 36 months). However, a person who has commenced their POS will not be required to have participated for the full 18 months, where:

• the POS was terminated before the end of the relevant period applying to the person because the person was unable, solely due to their impairment, to improve their work capacity, or
• at the end of the relevant period (for example, at the date of claim), the person is participating in a POS but is prevented, solely because their impairment, from improving their work capacity through continued participation in the program.

Currency of evidence

The 'best available' medical evidence must be used in the assessment. If the medical evidence is not recent, it may still be useful depending on:

• the person's condition, and
• whether the information is representative of the person's current degree of impairment.

The currency of evidence, used to determine whether a person has actively participated in a POS, will differ depending on people's circumstances.