11.3.2 Choosing a doctor to advise the Delegate

DVA engages Contracted Medical Advisors (CMA) to assist in the timely consideration of claims. 

CMA advice can and should be used where appropriate. Depending on the circumstances, it may be sufficient to disallow a claim if the weight of all available evidence led the delegate to conclude that there was no liability.

It is important that contemporary (ie current) medical evidence is considered as medical records already in a claimant’s file (or obtained from Defence) can be a number of years old and it is necessary to confirm whether a diagnosis is still current, and whether the diagnosis available adequately addresses the claim. Each case should be considered on its merits. If there is sufficient information on the file already, in particular for injuries which have resolved (and there is no suggestion of a sequela condition), or a chronic disease that has stabilised, it may not be necessary to seek further contemporary medical evidence. Advice from a CMA may be helpful to confirm this. However, if further evidence is required, contemporary medical evidence is not necessarily limited to specialist reports, it may also include x-rays, test results and other reports. This does not apply to psychiatric conditions, where specialist medical evidence is required.

In some cases where a condition has stabilised (ie. it is unlikely there will be be any further change in the condition), and the medical evidence reflects this, it may be appropriate for a claim to be accepted or disallowed based on consideration of the existing medical evidence on a claimant’s file and after consultation with a CMA, without a need to seek further specialist medical advice. In addition, where it is clear that the condition cannot possibly be related to service, eg. the condition is hereditary or the causes unknown, it may be appropriate to reject the claim based on CMA opinion.

For further information on when to obtain a medical opinion refer to Chp 11.2.

In circumstances where:

• the claimed condition is one which ordinarily would not change over the intervening period; and

• the relevant service and medical documents have been considered; and

a CMA has been consulted;

It would be open to a delegate to reject the liability claim, if they are satisfied on the balance of probabilities that a claimed condition is not related to Defence service, or to accept the claim if they are satisfied the condition is related to service.

Before a claim is rejected, the delegate should contact the claimant to discuss the matter and allow the claimant the opportunity to provide further medical evidence to support the claim before it is rejected. Refer to Chapter 3.2 of CLIK for further information.

If a DVA CMA’s opinion was that there was a probable connection between a claimed disease and the employee's service in the ADF, the delegate may in such circumstances consider it reasonable and appropriate to find liability under the DRCA.

Specialist Reports  

Note that, for the purposes of establishing the diagnosis and causation of a disease, the opinion of a medical specialist – i.e. a specialist in the medical field relating to the disease – is to be sought in preference to a General Practitioner. Reports from General Practitioners provided by the client and forwarded with the claim form in disease cases, should be noted but are not usually accepted as definitive.

Furthermore, in most cases, the medical opinion of the client's treating medical specialist is (at least initially) to be sought in preference to other (i.e. consultant) specialist medical opinion.

This is because the various appeal forums (AAT, Federal Court) generally give greater credence to the opinion of a specialist who has seen the client over a period of time and for the purposes of treatment, rather than a consultant who has seen the person only once and only for the purposes of writing a report.

In the case of a client who is still serving, and as a rare exception to this general rule, it may be sufficient to address the standard 'liability questionnaire' to GPs within the ADF Health Service unit responsible for that client's case management. (Note: This applies to cases when there has been as yet no specialist involvement.)

This is particularly valuable in cases where there is little delay between injury or onset of a disease and the claim for compensation. In that case, the current treating ADF doctor is likely to be the person to whom the symptoms were first reported, and may have further information relating to the circumstances surrounding causation.

Nevertheless, where the ADF Health Service has already referred a serving member to a consultant medical specialist, the liability questions should be referred to that specialist for response, i.e. rather than to the GP-staffed Health Service. Note that since the MRCA came into effect on 1 July 2004 all injuries sustained as a result of service since that time will come under that Act resulting in most claims under the DRCA in respect of an injury being already some years' old.

Where the member has discharged, the Delegate should usually address the liability questions to the current (i.e. civilian) treating specialist.

However, this does not mean that the Delegate may not also refer to a specialist consulted by the ADF whilst the member was still serving. Indeed, in some circumstances clarification of the medical reports current at the time of injury or onset of the disease, may be vital to the outcome of the case.

However, it frequently happens that a client does not have a treating specialist. Also, but more rarely, there may be a treating specialist but the Delegate may be unsatisfied with that doctor's response. In either case, the Delegate may need further medical advice to make an informed decision on liability.