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50.12 Exceptions for the Chronically Incapacitated
The concept of “chronically Incapacitated” applies to both SRCA and MRCA clients. There are different criteria for each category. It would be impractical to apply the normal Ongoing Review criteria for some clients who are considered 'Chronically Incapacitated'. Some differentiation of the review requirements is required for these clients. The client's case is still reviewed against the review checklist at the same points as identified earlier in this document but will have a different focus, especially on the employment nexus and work capacity issues.
MRCA and SRCA Category 'A' identified clients:
Category A clients could be:
•MRCA SRDP eligible persons
•Those assessed as eligible for the Special Rate of pension (TPI) under the VEA
•Severe Injury Adjustment recipients under the Defence Act
•Serious Mental Illness (requiring constant supervision)
•'Frozen' former employees (i.e. over age 65)
•Maintained in a hospital as per s22 of the SRCA or s127 of the MRCA.
When dealing with Category A clients, regard should be had to the following:
•management of the claim and reviews would not have an ongoing medical liability or work capacity focus;
•ongoing SMR's would generally not be required;
•no restriction of length of medical 'certification' i.e. we have accepted that we will have lifelong liability to pay Incapacity and that the degree of Incapacity will not change;
•concentrate on general file management, quality of life and treatment issues, up to date rates being applied, use of the Review of Compensation Payments form etc;
•a Rehabilitation Provider should be engaged every 5 years to ensure that all treatment and (vocational, medical or psychosocial) rehabilitation needs are met. The Rehabilitation Provider must consult with the person's treating General Practitioner during their assessment and address the client's ongoing incapacity to undertake remunerative work in their report. This is optional in the case of ‘Frozen’ former employees as their age may make vocational or psychosocial rehabilitation unnecessary.
•no other medical “certification” is required;
MRCA and SRCA Category 'B' identified clients:
Category B clients could be:
•A person who has returned to paid employment (whether full or part time) and remains in employment and is in receipt of top-up incapacity payments for a minimum of 1 year.
•Longstanding Incapacity Recipients (minimum 5 years in continuous payment post discharge) and an examination of the following characterisations indicate no foreseeable change in circumstances:
•Age (ie 60+),
•multiple rehabilitative attempts,
•psychiatric sequelae associated with chronic pain,
•medical history of claimed condition,
•multiple unsuccessful treatment regimes,
•place of residence
When dealing with Category B clients, regard should be had to the following:
•after the first review, have a less stringent liability/medical focus e.g. an SMR to review ongoing liability and capacity issues would be as advised by previous credible specialist or GP advice (up to a maximum of five years)
•we should obtain a report from the person's treating GP, or Specialist if there is a treating Specialist. If the person is not working, or the delegate considers that the person may not be working to the maximum of their capacity, a referral to a rehabilitation provider could take the place of obtaining a report from the person's treating doctor. However the rehabilitation provider must discuss the person's incapacity for employment with their treating doctor.
•concentrate on general file management, quality of life, aids, treatment issues, up to date rates being applied, use of the Review of Compensation Payments form.
The 'Chronically Incapacitated' category should be reassessed if changes to the client’s circumstances warrant it.
All clients who have not been assessed as chronically Incapacitated (either Category A or B) should be an active participant on a rehabilitation program. Alternatively we should obtain a report from the person's treating specialist (or from an independent specialist if there is no treating specialist) annually.