3.6.3.03 Guidelines to the rules for applying the Impairment Tables - information that must be taken into account in applying the Tables

Summary

This topic provides guidance on Part 2 of the Social Security (Tables for the Assessment of Work-related Impairment for Disability Support Pension) Determination 2023 (the Determination), which sets out rules that are to be complied with in applying the Impairment Tables. This topic has headings emphasising significant principles, concepts and information that MUST be taken into account when applying the Impairment Tables to assess a person’s functional impairment, which underpin provisions contained in that part of the Determination. It also provides guidance on the concepts and practical application of the DSP eligibility criteria contained in the SSAct.

This topic does not restate the definitions contained in Part 1 of the Determination. These definitions are to be accessed directly from the Determination.

Diagnosis by an appropriately qualified medical practitioner

The diagnosis of the condition causing the impairment must be made by an appropriately qualified medical practitioner.

Note: The instrument defines ‘appropriately qualified medical practitioner’ as a medical practitioner whose qualifications and practice are relevant to diagnosing a particular condition. This may include a GP or other specialist.

Corroborating evidence

A condition must be diagnosed by an appropriately qualified medical practitioner AND supported by corroborating medical evidence. Where there is no corroborating medical evidence, or where medical evidence is contradictory to the diagnosis, a condition cannot be considered diagnosed for the purpose of DSP. In some cases, a diagnosis must be supported by evidence from another health professional, as specified in the relevant Table.

Corroborating evidence includes medical and non-medical evidence. Medical evidence (1.1.M.100) is the primary source of corroborating evidence used in determining whether a person’s condition is diagnosed, reasonably treated and stabilised (1.1.D.140) and is likely to persist for more than 2 years, for DSP purposes and, if so, what impairment rating, if any is to be assigned under the Impairment Tables.

However, other forms of corroborating evidence may support a person’s DSP claim including, but not limited to:

• information, such as reports or letters provided by medical, health or allied health professionals (for example, chiropractors, exercise physiologists, physiotherapists, psychologists, occupational therapist, osteopath, pharmacist, podiatrist, rehabilitation counsellor, registered nurses, or optometrists)
• reports from other sources, such as social workers, mental health workers or counsellors, and training or work attendance records
• results of diagnostic tests (for example, medical imaging reports)
• any additional work capacity information that may be available, reports from previous examinations or assessments, or
• any information that is required to be taken into account under individual Tables, including as specified in the introduction to each Table.

A person claiming DSP is responsible for obtaining corroborating evidence, usually medical documentation from their treating doctor and other health professionals. (Refer to 3.6.2.10 'Medical evidence & diagnosis for vulnerable people'). Where a person indicates they have a condition not included in their medical evidence, they must be requested to provide medical evidence detailing the diagnosis, treatment, prognosis and functional impact of the condition. This may involve requesting the person obtain further information from their treating doctor or other relevant appropriately qualified medical, health, and or allied health practitioners.

If medical evidence has insufficient detail, consideration should be given to contacting the person’s treating health professionals for further information and or referring the claim to the HPAU. Medical evidence must include sufficient information including:

• the diagnosis of a person's condition, including date of onset and whether the diagnosis is confirmed
• clinical features including history and symptoms
• past, present and future/planned treatment, including periods of hospitalisation
• adherence with recommended treatment
• impact of the condition on a person's ability to function, including prognosis of the condition, in particular, the expected effect of the condition on a person's ability to function in the next 2 years
• any impact on life expectancy as a result of the condition, and
• supporting information such as, medical imaging reports specialist reports, allied health reports, hospital records, or pathology test results.

All relevant medical evidence must be taken into consideration. Generally this will be recent medical evidence, however, all evidence that is representative of a person’s current level of impairment should be considered.

More detailed information on corroborating evidence, including examples of medical evidence that could be taken into account in assessing impairment is contained in 3.6.2.10.

While older evidence may be useful for the purposes of confirming diagnosis of a condition, consideration must be given as to whether or not it reflects the current level of impact of such conditions on a person's ability to function or more recently available treatments likely to significantly improve function.

Where the nature or severity of a condition is unclear, further information must be sought to clarify the condition's current impact on a person’s functioning. This could include a person providing further information, or their treating health/allied health professional being contacted for clarification.

At an assessment, a person may be asked to demonstrate abilities specified in the relevant Tables. This can only be done where:

• the assessor is qualified and competent to assess abilities of this nature (for example, a physiotherapist assessing movement)
• the requested task/function/ability is unlikely to cause a person pain, discomfort or undue emotional distress
• there are no medical or psychological contraindications (for example, acute pain), and
• the ability can be demonstrated in the assessment setting.

When assessing a person’s functional capacity, an assessment of their impairment must be made on the basis of what a person can, or could do, not on the basis of what the person chooses to do or what others do for the person. It is not appropriate to rely on the person’s own assessment of their ability to perform tasks or activities. Nor is it appropriate to rely on domestic arrangements, which may reflect cultural traditions regarding the performance of activities and not the person’s abilities and/or capabilities.

When assessing whether a person can perform an activity described in a descriptor, the descriptor applies where the person can complete or sustain that activity when they would be expected to do so and not only once or rarely. Consideration should be given to where a person performs a certain activity because they have to (such as, if they need assistance but do not have anyone to assist them), and the impact of any subsequent symptoms experienced as a result of performing that activity. It would not be reasonable to determine that a person who pushes themselves to perform the activity, despite the adverse consequences of doing so, is capable of completing or sustaining an activity.

People living in remote areas

Assessments for DSP purposes must be based on the best available medical evidence. In the case of people from remote areas who may have limited access to medical services and doctors, and may find it difficult to obtain medical evidence in relation to their condition/s, a community nurse can assist in collating their medical evidence. This will generally be based on clinical notes from an appropriately qualified medical, health or allied health practitioner and must meet the diagnostic requirements of the relevant Table.

In these cases, it may be possible for the job capacity assessor or GCD to form an opinion regarding a person's medical qualification on the basis of the best available medical evidence. This will only apply if the condition has been diagnosed, reasonably treated and stabilised to the extent that an impairment rating can be assigned. In all cases, any diagnosis must have been made by an appropriately qualified medical practitioner supported by evidence from another health professional, if specified in the relevant Table.

Culturally appropriate considerations

Particular care should be given to an individual’s cultural background where it is relevant to the diagnosis and/or treatment of their condition. An individual’s cultural affiliations can affect where and how they seek care, how they describe symptoms, how they select treatment options, and whether and how they follow care recommendations.

Linguistic diversity can also exacerbate barriers to seeking diagnosis and undertaking treatment as well as access to services and navigating mainstream supports.

The prevalence and prognosis of conditions may also vary across different cultures, with some cultures experiencing markedly higher rates of, and impacts from, particular conditions. For example, research shows Aboriginal and Torres Strait Islander people continue to experience a higher burden of disease in areas, such as mental health, substance use disorders, chronic kidney disease, cardiovascular disease, cancer and other chronic health conditions. These factors may be reflected in a person’s medical evidence and should be considered when assessing whether a condition has been diagnosed, reasonably treated and stabilised.

When assessing a condition, care, sensitivity and understanding should be given in understanding that disability is understood, communicated and navigated differently between cultures.

The Impairment Tables allow for the use of culturally appropriate standardised assessment tools (for example, in the assessment of intellectual and adaptive function under Table 9 – Intellectual Function). Specific advice relating to the use of such tools can be found at 3.6.3.90.

Cultural considerations should also be considered when determining whether or not a person has undertaken reasonable treatment for their condition. The Impairment Tables allow conditions to be considered ‘reasonably treated’ in cases where an individual’s religious or recognised cultural beliefs prohibit particular treatments (such as, blood transfusions), or where strict cultural guidelines may guide a person’s actions (such as, guidelines around appropriate interactions between genders).

Note: All available information on treatment options, risks etc. (the objective test) must also be considered in such situations.

See also 3.6.3.02 for further information on compelling reasons for not undertaking reasonable treatment.

In other cases, it is not appropriate to assess a person’s condition with reference to their religious or cultural identity, as not all religious or cultural factors are relevant to the assessment and/or treatment of a person’s condition or their level of functional impairment. In addition, the cultural belief should be a widely held, rather than a personal idiosyncratic, belief, and consideration must always be balanced alongside information on treatment options, risks etc. (for example, where a person may have cultural beliefs that are at odds with scientific medical practice, including believing only natural treatments are of benefit).

For example, in some cultures, the tasks a person is expected to complete in their household are based on gender. While this may be reflective of the cultural norm in that household, it is not reflective of the person’s capability to undertake a task, nor does it have any bearing on the level of functional impairment the person may have. See 3.6.3.04 for information that must not be taken into account in applying the Impairment Tables, as well as further examples.

Note: A determination that a person cannot perform certain activities must always be based on an objective assessment of a person's capability to do those things.

Assessing co-morbid conditions

Comorbidity refers to the occurrence of 2 or more conditions in a person at one time. While the existence of these multiple health conditions may be unrelated, in many instances, and particularly in relation to chronic diseases, there is some association between them. It is also possible for a person to have many comorbidities at the same time.

Comorbidity may also be referred to as concurrent conditions, coexisting conditions or multi-morbidity.

Having comorbidities can complicate treatment for a condition. Treating comorbid conditions usually involves a person seeing separate specialists to develop a treatment plan for each condition. Different conditions may require separate medications, which can cause additional problems. Some medications might not be safe to take together, or one might lower the effectiveness of another. The presence of some comorbidities can complicate surgery as well.

When reviewing a person's medical evidence, it is important to consider the effect of any comorbid conditions the person may have when determining whether the person’s condition/s are diagnosed, reasonably treated and stabilised. See also 3.6.3.02 ‘Assessing functional impact of chronic pain’.

It is important to keep in mind, 2 individuals with the same conditions may not necessarily have the same impairment rating assigned, even though they share the same diagnosis. This is because it is their functional impact rather than their condition that is assessed under the Impairment Tables.