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2.6 Medical certificates

Document
Last amended 
8 August 2017

Part of investigating a person’s eligibility for payment will involve seeking medical evidence to support the contention that the person is incapacitated due to their accepted condition/s.

Neither the SRCA nor MRCA defines what type of medical evidence is required to establish eligibility for incapacity payments.  While minimum certification requirements have been developed (as below), the delegate must still determine what evidence is required in each case (i.e. GP, treating specialist or independent specialist). The following factors should be considered and may indicate that specialist evidence is required:

  • Whether the person has psychiatric conditions, multiple injuries, sequelae conditions or whether there is contribution to the incapacity by non-compensable injuries.

  • The time between the claim and the date of injury, date of discharge or the last period of incapacity.

  • The quality of the medical certification. Delegates are able to seek further justification for a medical certificate from its author or seek another opinion provided they have a reasonable basis for doing so.

  • Any other relevant information i.e. evidence to suggest the person has left suitable employment for reasons other than their accepted injury but the person has a GP certificate

In most cases the medical opinion of the person’s treating medical specialist is preferred (provided that the specialty is in the relevant field), though it may be appropriate to obtain advice from an Occupational Physician rather than a person’s specialist.

 

Minimum certification requirement

Intermittent or short periods of incapacity

 

GP certificate. However if incapacity is likely to be ongoing, e.g. where a person is not in employment, a specialist report should also be obtained.

Loss of allowances or rank and pay while still serving

ADF service records and medical documents.

 

Medical discharge (from f/t service)

 

Certification for the 1st 4 weeks post discharge provided that the DM042 and/or MECRB decision indicates an accepted condition as the cause of discharge.

4 – 12 weeks post medical discharge

 

GP certificate, RTW medical guidelines and/or a capacity for work medical certificate.

After 6 Pays

 

Specialist report; and referral to a Rehabilitation Coordinator for a rehabilitation assessment by an approved rehabilitation service provider

26 pay reviews

 

Treating Specialist report or an independent specialist if there is no treating specialist. This is in addition to the specialist report that was obtained at 6 pays.

26 pay review and on RTW rehab

 

RTW medical guidelines suffice while rehabilitation is progressing.

RTW Rehabilitation

 

RTW medical guidelines with a specialist report during the 1st 6 pay periods. Incapacity delegates should not cease payments for a person who is an active participant in a vocational rehabilitation program.

Category A (including those assessed as SRDP eligible or TPI under the VEA)

 

A rehabilitation assessment by a rehabilitation service provider every 5 years. Once a person is assessed as Category A no further medical evidence is necessary unless a delegate decides that a specialist report is necessary.

Category B (including top-up payees, p/t reservists incapacitated for reserve service only etc.)

Treating GP's report every 5 years, and a rehabilitation assessment if necessary.(Note that there should also be a specialist report from the initial period of incapacity)

See section 4.10 and 4.11 of the Incapacity procedures manual for more detailed guidance.

2.6.1 Qualifications of those persons certifying incapacity

The SRCA contains reference to treatment, and claims supported by a certificate, from a 'legally qualified medical practitioner'. Subsection 5(2) of the MRCA defines medical practitioner as a person registered or licensed as a medical practitioner under a law of a State or Territory that provides for the registration or licensing of medical practitioners.  The approach adopted under both the SRCA and MRCA is that medical certificates can only be accepted from a registered or licensed medical practitioner.

2.6.2 Retrospective periods of incapacity

A medical certificate that outlines retrospective periods of incapacity i.e. a period prior to the date of the examination is not acceptable unless the certifying doctor was also the treating doctor for all of that retrospective period. That is, the period of certification must reflect only the period over which the certifying doctor had a direct, personal (i.e. first hand) knowledge of the case.

2.6.3 Waiving the requirement for current medical certification

In exceptional circumstances, i.e. generally with respect only to those who are ‘Category A’ the requirement for ongoing medical certification may be waived (see section 4.11.4 of the procedures manual).

2.6.4 Minimum requirements of a valid medical certificate of incapacity

To substantiate a person’s incapacity as a result of an accepted condition, a medical certificate should:

  • state the medical cause of the incapacity, and/or list all conditions contributing to the incapacity

  • state the degree of incapacity, for instance wholly incapacitated for all work, or partly incapacitated for work or capable to work with some restrictions. If only partly incapacitated, the certificate should indicate the residual capacity i.e. in terms of daily hours and days per week. If capable of some work but with restrictions those restrictions should be clearly specified, for example... ‘no bending or stooping’ or ‘no lifting more than 10k’ etc.

  • specify the period of the incapacity i.e. contain both the start and end date of the period certified. Open-ended certificates and those claiming the person is incapacitated indefinitely’ or ‘Totally and Permanently Incapacitated’ are generally not acceptable (see section 4.11.4 of the procedures manual). The end-date of the certificate should be that date at which the doctor anticipates the incapacity will have ceased or at least changed in degree.

  • identify the doctor in addition to a signature (i.e. an indecipherable signature is not sufficient identification), and the provider number, address, phone or contact details of that doctor

  • must contain the date that the doctor examined the person.

2.6.4.1 Example

A reservist falls and breaks his collar bone during a reserves camp, is given emergency treatment and strapping etc. in the emergency room of a hospital and is released to the care of his GP. He is incapacitated for his civilian work as a factory process worker but it is anticipated that the break will heal without complication. Capacity for civilian employment purposes will return in three to five weeks. In this case, only the GP certificate of incapacity is required to initiate the weekly payments. No specialist orthopaedic intervention would be necessary and the delegate should not insist on a specialist opinion on incapacity.

However, if incapacity were to continue beyond this expected period – i.e. the GP continued to write incapacity certificates two to three months after the accident – the delegate should seek a specialist review of the case. Alternatively, if there was some early suggestion that damage may be more widespread or there were complications (i.e. of the shoulder joint, for this example) which may prolong incapacity, a delegate should also seek specialist advice.