5.3.5 Psychiatric Conditions - Table 5

'Confined environment' for ratings of WPI greater than 50

The WPI ratings of 50, 60 and 90 under Table 5.1 require consideration of whether a client has 'need for supervision and direction in a confined environment'.

In Dwight and Comcare (2006) AATA 730 the Tribunal stated that 'confined environment' 'refers to an enclosed situation in which a person is not free to come and go as he or she pleases; for example, where the person is confined in a hospital or psychiatric institution'. Mr Dwight did not meet the definition as when he was 'on optimum medication and when his condition is reasonably stable, he does not require that kind of care'. The confinement would therefore need to be a constant and permanent arrangement.

The 'need for supervision and direction' for ratings of WPI greater than 10

The WPI ratings of 15 or more under Table 5.1 require consideration of whether a client has the 'need for supervision and direction’ in activities of daily living.

Where the DRCA PI Guide does not provide any definition of the terms ‘supervision’ and ‘direction’ the policy position supports using the Comcare Guide for guidance. Therefore for the purposes of an assessment under Table 5.1, the delegate or assessing doctor may consider the following definitions for guidance:

Supervision means the immediate presence of a suitable person, responsible in whole or in part for the care of the person.

Direction means the provision of direction to the person by a suitably qualified person, responsible in whole or in part for the care of the person.

The term ‘need’ can potentially be interpreted differently, however the ‘need’ for supervision criteria can still be met in cases where the client is not actually receiving the supervision and direction with their activities of daily living. For example, if there is medical evidence that the impairment from the person’s condition indicates the need for the supervision and direction, but the person is unwilling, or unable to receive it, they could still meet the criteria for a rating.

Fellowes and Table 5.1 - multiple ratings for psychiatric conditions

Since Fellowes and Robson, it is possible to compensate a person for two ratings under Table 5.1. In these cases, delegates would need to be satisfied that:

• both accepted conditions met the DRCA definitions of injury, permanent and impairment; and
• the effects of the conditions can be isolated from one another i.e. the person is not being compensated twice for the effects of one impairment.

In order to determine this second point, delegates will need to look in detail at the medical evidence provided. In order to assess each injury in isolation, the doctor must assess the impairment suffered by the person due to their injury against the functional capacities of a hypothetical normal healthy person, rather than the actual capacity of the person just prior to the injury in question.

If the information cannot be properly assessed from the reports alone, then further information should be sought from the specialist(s) involved in the assessment(s) to clarify how they came to more than one rating under Table 5.1. For example, it should be asked which impairments are attributed to which condition, whether they can be isolated and how this was determined.

The concept of a “bodily system” when considering the definition of an impairment and how psychiatric conditions are to be assessed is clearer since Robson. The fundamental DRCA principle, that injuries must be assessed separately, extends even to psychiatric conditions and impairments that relate to the same bodily system (the brain) and produce markedly similar functional impairment. This will mean where a person has already been paid for one psychiatric injury, it cannot be deducted from the amount determined for the second injury; and will generally result in the person receiving two separate amounts of %WPI for both injuries.

When to determine multiple PI

Robson makes it clear that separate injuries and their associated PIs must be assessed separately and in isolation, even if they relate to the same body part, system or function. For example, a person can have liability accepted for PTSD due to a traumatic incident which occurred whilst they were on DRCA service, and subsequently lodge a PI claim and be assessed with a PI rating of 40% WPI under Table 5.1 for that injury. Sometime later, the person suffers another injury that is diagnosed as Paranoid Personality Disorder (PPD) and this injury is accepted as related to DRCA service.

The medical evidence specifies that the person's PPD is a separate injury to their PTSD, rather than an alternate diagnosis of/or impairment from the PTSD. The PI assessment reveals that the PPD would produce approximately 50% WPI on its own under Table 5.1. This WPI rating represents the effect the PPD would have had on a hypothetical normal healthy person, with no pre-existing psychiatric condition/s.

In this case, the delegate must assess each condition in isolation, which would result in a total WPI percentage of 90% (40% + 50%). This is because each injury is considered a separate claim for PI. 

In addition, the PI already paid in respect of the client's PTSD (40%) cannot be deducted from the amount determined for their second injury (50%). However, when assessing entitlement to NEL for each psychiatric condition, the delegate must ensure based on the medical evidence, that the person is not being compensated twice for the same effects on their lifestyle (part B of the NEL formula).

When not to determine multiple PI

It would not be appropriate to assess and compensate a person for a second distinct injury that causes impairment, if that impairment cannot be isolated from the impairment resulting from the first injury. For example, a person has liability accepted for PTSD due to a traumatic incident relating to their DRCA service and is assessed with a PI rating of 25% WPI under Table 5.1. Over time the person develops another stand-alone injury of Chronic Pain Disorder, suffering nociceptive pain in the lower limbs and back. The medical evidence specifies that the impairment suffered by the person arises from both the PTSD and Chronic Pain Disorder, and the conditions cannot be isolated to the exclusion of the other. The specialist evidence states that the Chronic Pain Disorder causes an impairment of 15% WPI under Table 5.1, however reports a bi-directional influence of the two psychiatric conditions, and does not show how each condition in isolation causes impairment.

In this case, there is not sufficient evidence to compensate the client separately for the two accepted conditions.  This is because the assessing doctor has reported that the two conditions are not causing impairment in isolation, rather they contribute collectively to cause the same impairment.

The delegate should determine that no further WPI assessment can be made in relation to the Chronic Pain Disorder, as the impairment cannot be assessed in isolation from the PTSD. This will mean that no PI is payable for the condition as the impairment has already been compensated for.

Specialist questions to assist in multiple psychiatric impairment cases

It is not possible to provide definitive advice on assessment of psychiatric conditions.  As with any PI claim, assessments depend on the individual circumstances of each case, particularly with reference to the medical evidence.  Delegates should be mindful to provide clear instructions to medical assessors and to seek clarification from the report writer if required.

The following questions have been formulated (not as an exhaustive list) to guide a Delegate in seeking medical evidence relating to these types of claims for permanent impairment.

1. Are each of the psychiatric conditions appropriately identified as separate and distinct diagnoses for the applicant? If so, why?

2. Of the currently accepted diagnosed psychiatric conditions, is there symptomatology/impairment which can solely be attributed to one of those conditions to the exclusion of the other conditions

3. What overlap, if any, is there in the symptomatology/impairment referable to each of the diagnosed conditions?

4. Having regards to Table 5.1 of the Guide:

(a) Can the impairment arising from each of the diagnosed conditions be isolated and identified to the exclusion of the other conditions? 

If yes, please explain how one condition would satisfy the rating under Table 5.1 of the Guide independently of any other condition’s impairment.

Can you describe how one condition satisfies the impairment rating alone, as if no other condition exists? For example, if the person had no previous history of mental illness, would the condition give rise to the impairment alone and be assigned the rating under Table 5.1?

(b) What impairment arises from each of those conditions having regard to the criteria in Table 5.1?

For example, if one of the diagnosed conditions is Depression and it is considered the condition that causes reactions to the stressors of daily living and the second condition of Anxiety Disorder that also causes reactions to the stressors of daily living, are those reactions identifiably different between conditions? Please describe.

(c) What is the assessment rating under Table 5.1 in respect of each of the accepted conditions?

Use of psychologists

Under s28(6) of the DRCA, delegates are required to have regard to medical opinion concerning the nature and effect of the injury.

This reference to ‘medical opinion’ does not necessarily preclude the use of psychologists for assessments under the Permanent Impairment Guide.  Such evidence can be used as supporting or complementary and should not be considered in isolation of, or instead of any primary evidence such as from a GP or psychiatrist.

Where a treating psychologist provides evidence that is not contradicted by evidence on file from a psychiatrist or GP with a medical doctorate, delegates can consider this evidence for the purposes of PI assessment. This would be the case unless the delegate has a concern over the validity of such evidence (or the evidence contradicts the evidence previously provided by a medical doctor).  Where the delegate is not reasonably satisfied that the evidence available supports the rating under table 5.1, they are open to seek clarification or further evidence to this effect.

The Department takes a broad view as to the acceptability of psychologist evidence where such evidence is favourable to the client.