3.6.2.20 Manifest grants & rejections for DSP

Summary

Where sufficient information is contained in the evidence provided by the claimant, a DSP claim can be determined without the need for further assessment in the following situations:

• manifest medical/work capacity grant
• manifest medical/work capacity rejection, and
• non-medical/non-work capacity rejection.

DSP claimants are considered to be manifestly (1.1.M.30) qualified, when they clearly and obviously meet all the qualification criteria in SSAct section 94. Only in very clear cut cases outlined below, can claims be granted without further assessment.

This provision also applies in reverse, in that a claim from a person who is clearly and obviously NOT qualified can be rejected without further assessment.

As with all other claims for DSP, documented medical evidence of the extent and severity of the condition/s is necessary to assess the impact on the claimant's CITW (1.1.C.330). All decisions must be fully documented.

To help decision makers identify and expedite manifest grants of DSP, 2 lists of catastrophic, profound and/or terminal conditions can be found below. See 'List of conditions for determining manifest eligibility'.

Manifest grants

DSP may only be granted without the need for further assessment in LIMITED CIRCUMSTANCES.

Manifest grants may only be made where a person:

• has a terminal illness (life expectancy of less than 2 years with significantly reduced work capacity during this period)
• has permanent blindness (meets the test for permanent blindness for social security purposes)
• has an intellectual disability where medical evidence clearly indicates an IQ of less than 70
• has an assessment indicating that they require nursing home level care (see note below)
• has category 4 HIV/AIDS, or
• is in receipt of a DVA disability pension at special rate (totally and permanently incapacitated (TPI)).

Note: Care recipients may be accepted as requiring nursing home level care if they were assessed as a profoundly disabled child (1.1.C.146), and the person's carer must have:

• claimed CP in respect of the care receiver before 1 July 2009, and
  been receiving CP up to the time the care receiver turned 16, OR
• claimed CP in respect of the care receiver on or after 1 July 2009, and
  the child care receiver has a THP score of >= 4 and an ACL score of >= 300.

Terminal illness

Manifest qualification for DSP is accepted if medical evidence indicates the claimant's current medical condition (1.1.M.90) is chronic and debilitating with a prognosis (1.1.P.440) that the condition is terminal, and the average life expectancy of a patient with this condition is 24 months or less, and there is a significant reduction in work capacity within this period.

Permanent blindness

A claimant whose medical evidence clearly indicates that they have no vision is accepted as being manifestly qualified for DSP.

A claimant whose supporting report (SA013) completed by their treating ophthalmologist confirms that they meet the criteria for permanent blindness is accepted as being manifestly qualified for DSP.

Note: It is not acceptable to make a manifest grant if an optometrist completes the SA013, even if the details of a treating or formerly treating ophthalmologist are provided.

Intellectual disabilities

A claimant whose medical evidence clearly indicates that they have an IQ of less than 70 is accepted as manifestly qualified for DSP.

Nursing home level care

A claimant who has evidence indicating they are a long term patient of a hospital or nursing home, or require nursing home level care because of illness or infirmity and are unlikely to be discharged in the foreseeable future, is accepted as manifestly qualified for DSP. The medical evidence needs to provide details of:

• the nature of the impairment and reason for long term hospitalisation
• the likelihood of discharge, and
• ability to perform activities of daily living.

Note: A person does not have to be in a nursing home to be manifestly granted DSP, it is sufficient that they require the same level of care (usually provided by carer/s).

Category 4 HIV/AIDS

A claimant who has category 4 HIV/AIDS is accepted as being manifestly qualified for DSP, subject to medical evidence (1.1.M.100) supporting the claim.

DVA disability pension at special rate (totally & permanently incapacitated (TPI))

Where the claimant is in receipt of a DVA disability pension at special rate (TPI) they are considered manifest for the purposes of DSP qualification. The claimant must provide their special rate decision letter from DVA or give authority for Services Australia to obtain the relevant payment information from DVA.

List of conditions for determining manifest eligibility

From 1 July 2010, 2 lists of conditions are available to help decision makers determine manifest eligibility for DSP on the grounds of terminal illness, nursing home level care requirements, and/or intellectual disability.

The lists supplement, rather than replace existing manifest guidelines, therefore manifest grants can still be made for claimants with conditions not yet listed. Additionally, the lists are not designed to cover manifest grants on the grounds of permanent blindness nor category 4 HIV/AIDS.

About list 1

List 1 catalogues conditions which are accepted as manifest (clearly and obviously meet all the DSP qualification criteria) on diagnosis alone.

Decision makers will check whether the condition listed in the DSP claimant's medical evidence is on list 1, and if it is then they will establish eligibility without the need for a JCA.

List 1

Note: A manifest grant of DSP is able to be made when a claimant is diagnosed with one or more of the following conditions (on list 1).

About list 2

The second list of conditions includes those which may, upon some further investigation, be manifest on the grounds of terminal illness, nursing home level care requirements, or intellectual disability which would attract 20 or more points under the Impairment Tables and a CITW.

If the DSP claimant's medical evidence lists a condition from list 2, the Services Australia decision maker will obtain on the spot advice about the condition, treatment regime and likely prognosis by contacting the treating doctor and/or the HPAU.

The treating doctor, or the HPAU may be able to confirm the expected prognosis, including whether terminal, or would necessitate nursing home level care, or indicates a manifest intellectual disability, and thereby expedite the claim as manifest without a JCA.

For a number of conditions on list 2, it will be important to establish the date of onset and/or the level of care the claimant requires for decisions of manifest eligibility.

For other conditions, the associated grade/stage/phase will be crucial for decision making about manifest eligibility. Examples include 'Grade III or IV', 'with distant metastases or inoperable or unresectable or recurrent', and 'stage 3 or 4' or 'Blast Phase'.

Where the medical evidence not only names the listed condition, but its associated grade/stage/phase are also indicated, then a manifest decision is able to be made from that evidence.

However, where the medical evidence lists the condition in name only, further investigation is required to determine the expected prognosis by calling the treating doctor or HPAU.

For some list 2 conditions, marked variation in prognosis appears more likely and it will be important for decision makers to clarify the expected prognosis by calling the treating doctor or the HPAU.

There are a number of list 2 conditions which cause intellectual impairment and have marked variation in their prognosis. Further investigation with the HPAU or the treating doctor is required to determine prognosis and whether there is an existing IQ score to support a manifest determination.

List 2 includes conditions of the lungs where further investigation is required to confirm the claimant is receiving domiciliary oxygen therapy in order to make a manifest grant of DSP.

List 2 includes a general listing for dementia rather than naming numerous conditions associated with it. The HPAU, or treating doctor, will therefore be required to confirm the prognosis before a manifest decision can be made.

List 2

Note: A manifest grant of DSP is able to be made when a claimant:

• is diagnosed with one or more of the following conditions on list 2, AND
• undertakes the additional action in the table, AND
• provides evidence that the claimant is clearly qualified for DSP.

In contrast, where that evidence does not support a manifest grant, the claimant must be referred for a JCA.

The table below is the additional action key.

The follow up action is to ascertain information on the prognosis or severity/progression of the condition so that a decision can be made whether a manifest grant is appropriate. For potentially terminal cancer type conditions, if the medical evidence indicates the condition has reached the grade or stage indicated in action 2, 3 or 5 in the table below, manifest grant for terminal illness may be made even if the evidence will not state that the condition is likely to be terminal within 2 years. For other conditions, information must be obtained indicating that nursing home level care is required or an intellectual disability attracting at least 20 points exists. If not a JCA should be booked.

Young people

All the guidelines about impairment ratings and inability to work apply equally to adults and young people applying for DSP.

Non-medical or work capacity rejections

A claim for DSP can be rejected without any further assessments where the claimant does not meet the basic qualifications for DSP (other than medical or work capacity), the person cannot make a proper claim for DSP or DSP is not payable.

Manifest rejections (medical or work capacity)

A claim for DSP can be rejected without an assessment if there is substantial evidence to indicate that:

• where the condition is not diagnosed, reasonably treated and stabilised, that is a temporary condition, and/or
• where the conditions resulting impairment would clearly not persist for more than 2 years, and/or
• the person's impairment would clearly score an impairment rating of less than 20 points on the Impairment Tables, and/or
• the person has a clear ability to work 15 hours or more per week at relevant minimum wages (1.1.R.133).

It is expected that the decision to reject a claim for DSP without a JCA would only be exercised where the presented information is unambiguous.

Where a claimant seeks a review of the decision to reject DSP on the grounds of being manifestly ineligible, the delegate must then refer the case for an appropriate assessment.