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.

For DSP claims lodged on or after 3 September 2011, other evidence is also required to determine whether a person who does not have a severe impairment (1.1.S.127) has actively participated in a program of support (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,
• making determinations about granting, rejecting, cancelling or continuing DSP, and
• reviewing decisions about DSP eligibility made under social security law (reviews and appeals).

Act reference: SSAct section 94(1) Qualification for DSP, section 94(3C) A person has actively participated in a program of support if...

Policy reference: SS Guide 3.6.2 Assessment for DSP

Sources of medical evidence

The primary source of medical evidence for DSP is a medical report from a person's treating doctor (1.1.T.160).

Generally people claiming DSP and those DSP recipients whose medical qualification is being reviewed must provide a medical report from their treating doctor (exceptions are outlined below). This report provides information about the person's medical condition(s), and how these impact on their ability to function. The person may also provide additional information about their medical conditions (1.1.M.90) and how these impact on their ability to work.

Medical report - DSP

The medical report for DSP must be completed by the person's treating doctor (exceptions are outlined below).

The medical report should include details of:

• the diagnosis of the person's medical condition(s), including date of onset and whether the diagnosis is confirmed,
• clinical features including history, current symptoms and prognosis,
• past, present and future/planned treatment,
• compliance with treatment,
• impact of condition(s) on ability to function, including whether this impact is long term or temporary and whether the effect of the condition on the person's ability to function is expected to remain unchanged, improve, or deteriorate,
• any supporting information used by the doctor, such as x-rays or pathology results, and
• periods of hospitalisation.

People living in remote areas

JCAs and related decisions must be based on the best available medical evidence. In the case of people from remote areas who may have limited access to doctors, the medical report may need to be completed by a community nurse, generally 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 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, treated and stabilised to the extent that an impairment rating can be assigned.

Explanation: People living in remote areas may have limited access to medical services and may find it difficult to obtain current medical evidence in relation to their condition(s).

Medical report not required in certain circumstances

A medical report is not required where sufficient information is available from other sources. People who are not required to provide a medical report include:

• 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 DHS to obtain the relevant payment information from DVA.
• In limited circumstances a claimant's eligibility for DSP may be based on the diagnosis of a mental health condition provided solely by a DHS registered psychologist (see below).

Diagnosis by a DHS psychologist

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 DHS staff or employment service providers as continually unable to comply with requirements, and demonstrating behaviours consistent with a chronic mental health condition.

In these circumstances the diagnosis of a mental health condition provided by a DHS psychologist, may be considered sufficient medical evidence for DSP purposes.

In all these cases the evidence/case history should be discussed with the Health Professional Advisory Unit (1.1.H.60) so that consideration can be given to other medical factors which may be impacting on the person.

Recent CP or CA recipients

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.

Conditions not listed on the medical report

Diagnosis of medical conditions for DSP purposes can only be provided by an appropriately qualified medical practitioner (exceptions are outlined above). If a person indicates that they have a medical condition that is not listed on their medical report, they should be asked to provide medical evidence detailing the diagnosis and treatment of this medical condition. This may involve the person asking the provider of the medical report 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.

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 DHS records. Other appropriate medical evidence supporting the person's condition and inability to work may include but is not limited to:

• additional reports from the person's treating doctor(s) or specialist(s),
• 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 DHS to assess entitlement to other payments,
  • Example: SA, NSA (incap), CP, or CA.

• reports from para-professionals, or
• reports from non-medical practitioners or community services.
  • Example: Psychologists, mental health workers, social workers, drug and alcohol counsellors, community medical health workers, physiotherapists and occupational therapists.

Explanation: This type of information may supplement the material from qualified medical practitioners.

Limited circumstances where medical information may be provided verbally

In limited and specifically defined circumstances, a person's medical condition(s) may be verified as fully diagnosed, treated and stabilised (1.1.F.240) 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 contained in the medical report.

Evidence of active participation in a POS

Any material which is related to a person's participation in a POS, undertaken in the 36 months prior to their claim for DSP, can be used to determine whether that person has actively participated. This may include information from a previous or current employer or one or more designated providers (1.1.D.115). The material must provide the following information:

• 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 demonstrate a person has actively participated in a POS include but is not limited to:

• EPPs (1.1.E.103),
• DES program summary and/or program review reports,
• transition to work plans,
• injury management or return to work plans,
• rehabilitation plans, and/or
• other program progress, exit or closure reports.

Other non-medical evidence

The person may also choose to provide other non-medical evidence that demonstrates they meet the DSP impairment and CITW criteria. This evidence may include but is not limited to:

• reports from alternative health practitioners (e.g. naturopaths, massage therapists), or
• letters or references from various sources (e.g. carers, friends, community members),
• reports from teachers (other than reports from teachers on behalf of special schools that contain IQ test results),
  • Explanation: Reports from special schools/teachers on behalf of special schools that contain IQ test results and information about capacity for independent living and any behavioural problems are treated as medical evidence.

Non-medical evidence alone cannot be used for determining DSP eligibility.

Unclear evidence

If a report, document or other material contains unclear terminology or lacks clarity, it should be discussed with its author.

In the case of a medical report, clarification should be sought from the treating doctor in the first instance. 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 job capacity assessors and DHS 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.

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.

Example: A report which is several years old may still be of value in forming an opinion if the condition remains unchanged since the time the report was completed.

The evidence used to determine whether a person has actively participated in a POS must relate to a program undertaken in the 36 months prior to the date of claim for DSP.

Policy reference: SS Guide 3.6.1 DSP - Qualification & Payability

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Last reviewed: 9 February 2012