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4.3.2 Criteria for making an interim assessment
Section 25 establishes a number of criteria which must be met before an interim payment of compensation may be made:
- the member must be suffering from an impairment as a result of a compensable injury that is not expected to resolve completely (i.e. is permanent)
- the degree of impairment must be equal to or more than 10% at the completion of any current or expected treatment, or the natural healing process (i.e. is not yet stable)
- the member makes a written request for an interim assessment, and
- a final assessment under section 24 has not yet been made.
The delegate should also be satisfied that there is no reasonable possibility that the degree of permanent impairment may subsequently decrease below 10% (e.g. as a result of medical treatment or surgery). Where medical treatment will result in an improvement in the client's condition, the degree of impairment assessed for the interim payment should be based on the impairment level expected after the treatment or surgery. Where a client’s condition may not have stabilised, the medical evidence should be reviewed in totality and where there is sufficient evidence to support an interim decision, the client should receive interim compensation. When the ultimate outcome of the medical intervention is known, a final assessment under section 24 should be made.
Delegates should be careful in considering a person’s circumstances if they are considering rejecting a claim based on a lack of stability or upcoming surgery. For example if a person is due to have imminent surgery for the accepted condition, the claim should not be rejected based on stability without any investigation. There should be a review of the medical evidence (this may include discussion with the treating or assessing medical practitioner and/or client) to confirm if the condition will be permanent after surgery, and if there is a minimum level of impairment that will remain following surgery and recovery. If there is evidence to support an interim decision, one should be made.
An interim payment should not be made purely on the assertion that other impairment(s) exist and will be claimed at a later date. If all claimed impairments have been assessed a final determination can be made in accordance with S24. If such an assertion is made then the claimant should be given 28 days in which to lodge evidence of further impairments. Interim payments should not be used as a vehicle for circumventing the 10% threshold for payment of a further PI payment.
In cases where the client is not eligible for interim compensation, it is important to contact the client to discuss the outcome of their claim prior to sending the letter that clearly explains why the claim has been rejected (i.e. for lack of stability, or a CMA downgrade). For example if the treating doctor cannot confirm the degree of impairment following surgery will be above 10%, it would be reasonable to reject the claim. It should also be explained to the client that after treatment is undertaken and the condition has stabilised, they are entitled to be assessed again for compensation.
Note: Where a delegate is making a negative decisions, they should be following the Departmental guidelines when contacting clients (TRIM 17929385E).
Under no circumstances should an interim payment be made on the basis of an expected future deterioration in the degree of impairment.
An interim payment should not be made purely on the assertion that other impairment(s) exist and will be claimed at a later date. If all claimed impairments have been assessed a final determination can be made in accordance with s 24. If such an assertion is made then the claimant should be given 28 days in which to lodge evidence of further impairments. Interim payments should not be used as a vehicle for circumventing the 10% threshold for payment of a further PI payment.
Where a final assessment under section 24 is made following an interim assessment, the final amount to be paid is the amount at time of the final determination. Even where WPI for the injury has not increased, final payment will still include any increase as a result of indexation, and the inclusion of section 27 payments.