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2.6 Medical certificates
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 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).
Where a client is working full-time, see section 2.6.3.
See section 4.10 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 must be signed and dated by the certifying doctor on the day of the examination. Medical certificates covering retrospective periods of incapacity i.e. a period prior to the date of the examination, may be acceptable in limited circumstances:
- the certifying doctor was responsible for the care of the client during the whole period, or
- evidence of hospital admission or a continual period of care encompassing the retrospective period, or
- clinical notes available to the doctor which establish that the incapacity existed, or
- the doctor has other evidence which is sufficient for them to establish that a retrospective period of incapacity is consistent with the clinical presentation on the day of examination.
The certifying doctor should include the basis on which the retrospective period was certified. For example "based on clinical notes available to me." Otherwise advice may be sought from a Contracted Medical Advisor (CMA) in order to provide a further opinion i.e. that based on the current presentaiotn of the condition it would be consistent that the client was also incapacitated for a previous period. The level of investigation required would be guided by how far back the retrospective period goes.
A retospective period of incapacity should not be denied based on the reason it is retrospective alone. A retrospective period on a medical certificate will be the basis to seek further clarification (if required).
A client voluntarily discharged 5 years ago with a compensable knee injury which has subsequently deteriorated. The client has been self-managing the condition, but left employment 5 months ago.
The client seeks treatment from a GP who has not previously seen the client. The doctor provides medical certification covering the period since last employment and ongoing, pending specialist referral. The medical certificate does not provide any clarification for the retrospective period.
Incapacity payments can be commenced for the prospective period, while further investigation of the retrosptective period is undertaken. This may include seeking further information from the certifying doctor in order to understand the basis of the certification, and/or advice from a CMA.
2.6.3 Waiving the requirement for current medical certification
In certain circumstances, such as those clients who are ‘Category A’ the requirement for ongoing medical certification may be waived (see section 4.10.4 of the procedures manual).
Where a Category 'B" client is working full-time, and the contemporary medical evidence shows no variation of that capacity over a sustained period, i.e. we are satisfied based on medical advice that the condition is unlikely to change, then no further medical certification should be sought.
Should the client report a change in capacity, contemporary medical evidence will be required.
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.
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.