B25/1995 DETERMINING COMPENSATION CLAIMS FOR CONDITIONS WHERE REPATRIATION MEDICAL AUTHORITY (RMA) HAS NOT YET ISSUED A STATEMENT OF PRINCIPLE (SOP)

DATE OF ISSUE: 4 APRIL 1995

DETERMINING COMPENSATION CLAIMS FOR CONDITIONS WHERE REPATRIATION MEDICAL AUTHORITY (RMA) HAS NOT YET ISSUED A STATEMENT OF PRINCIPLE (SOP)

1. The Repatriation Commission has decided that it will now allow its delegates to determine compensation claims lodged on or after 1 June 1994 for conditions and causes of death for which no RMA SOP has yet been issued. This instruction outlines the procedure to be followed in processing claims for these conditions. It also supplies the wording for Reasons and other correspondence which SSOs can load into local Word glossaries for processing staff support.

Background

2. The Budget changes effective from June 1994 introduced new sections to the VEA which established the RMA. Sections 120B(3) and 120B(4) of the Act provide that once SOPs for a condition have been issued by the RMA claims for that condition must be determined in accordance with them. However Sections 120A(4) and 120B(4) provide that claims may be determined by Commission if a SOP is not in existence.

3. As you are aware, although it has been legally possible to determine (accept or reject) claims for conditions where no RMA SOP has yet been issued, Commission's previous policy has been that its delegates should only determine these claims if it resulted in the acceptance of the condition. Any determination that would result in rejection of a claim has been put on hold awaiting issue of a RMA SOP.

4. This policy was decided upon in the early days of the RMA's existence. It was based on an assumption that RMA SOPs would be issued more rapidly than has been the case. Since then it has become clear that the RMA requires significant research to be undertaken into each condition before it considers issuing a SOP. Therefore a substantial number of claims have accumulated where a decision cannot be made and many claimants have been waiting months for a decision.

5. Before amending its policy in this regard the Secretary and Deputy Commissioners in all states undertook extensive consultation with ex-service groups. The Commission did not wish to proceed with the change unless it had satisfied any outstanding concerns in the ex-service community. Positive support was received and Commission has therefore decided to change its policy.

6. Claims Assessors can now make decisions to accept or reject conditions for which the RMA has yet to issue a SOP. However, Commission has also decided that claims should not be rejected for conditions where a SOP is expected to be issued within a month. At Attachment A is a list of conditions where the issue of a SOP is considered likely within a month. National Office will regularly update this list.

Changes to Reasons for Decision

7. Changes have been made to CCPS (Code Version update 2.1a) to allow Claims Assessors to confirm rejection of a condition where there is no RMA SOP issued.

Changes to automatically generated Reasons will take some time to amend and implement for these cases. In the meantime the system will generate two types of rejection Reasons for these cases.

where there is currently a Commission SOP in existence
where there is no SOP at all in existence

8. For both types of Reasons the system will generate "Statement of Principles" and "Reasons for Rejected Conditions" paragraphs. It will also generate a Statement of Principle section in the Explanatory Attachment. These should be replaced with the paragraphs at Attachment B.

9. For conditions where a Commission SOP has been in existence the system will also generate contention specific paragraphs and a conclusion paragraph. As the Commission SOP still reflects Commission policy until it is replaced by an RMA SOP it is to be followed and therefore the contention specific paragraphs are still valid. However the conclusion paragraph needs to be replaced with the paragraph at Attachment B. An additional paragraph advising of the Section 31 review is to be inserted for both types.

Section 31 Action

10. To ensure that claimants are not disadvantaged by a rejection decision being made on their claim before the issue of an RMA Statement of Principles, Commission has decided that the following procedures should apply.

11. When a condition for which there is no RMA SOP is being rejected the Reasons should contain the extra paragraphs at Attachment B. An action to commence a review under Section 31 of the Act will then be started on the basis that evidence may become available as a result of the RMA's investigations. A form to be signed by a review delegate and placed on file indicating that a review has been commenced is at Attachment C. This is necessary to legally commence a Section 31 review and allow maximum backdating of any decision that may subsequently be made.

12. It is not currently possible to process Section 31 cases on CCPS. State offices may therefore wish to register these cases on CMS as Section 31 reviews. Activities can be used to indicate the conditions under review. Attributes may also be used to indicate what type of Section 31 review it is (as opposed to a normal Section 31 review). National Office is currently examining the possibility of running a Mainframe program which would print out Section 31 reviews with the ICD code of any disabilities recently rejected. This may be possible but would have limitations for death cases. State Offices will be advised shortly on what can be made available.

13. Alternatively local monitoring systems may be more efficient (with such software as Excel) allowing reviews of the same conditions to be quickly identified when a SOP is issued. After examination of the SOP and the evidence of the case only those to be reviewed and accepted would require registration and processing on CMS.

14. The National Office may require management information on the number and type of claims registered and state offices should ensure that monitoring systems are established which will allow easy supply of this information.

15. State offices will continue to receive copies of SOPs as they are issued from the RMA. If the RMA has decided not to issue a SOP for a condition Nation Office will advise state offices and the Section 31 review is discontinued. If registered on CMS the case is withdrawn and claimants are sent an advice at Attachment D. The claimant has no right of review against the Section 31 action being discontinued as no decision to revoke or vary a previous decision has been made (Section 135 (2) refers).

16. If the RMA issues a SOP then the evidence should be examined and if necessary further evidence obtained by the review delegate. If the claim still cannot be accepted then the review is discontinued. If registered on CMS the case is withdrawn. Claimants are to be sent an advice at Attachment E. Again the claimant has no right of review against the Section 31 action being discontinued.

17. If the RMA issues a SOP and the claim can now be allowed a Section 31 decision to vary the original decision should be made. The effective date will be the date that would have applied to the original decision. The case should be processed through CMS and the claimant sent a decision advice along the lines suggested at Attachment F. The claimant has the normal right of review to the VRB against the Section 31 decision. (eg. review of date of effect or assessment of pension)

Applications For Review By The VRB

18. Even though a Section 31 review had been commenced, the claimant will retain the right to request a review of the original decision by the VRB within the prescribed period in the Act.

Claimants Who Lodge VRB Applications

19. If the claimant lodges an application for review by the VRB within the prescribed period normal preparation of Section 137 reports should take place. Claimants may inquire about proceeding with the application for review by the VRB. They should be advised that this must be their own decision but once they give the VRB a Certificate of Readiness then the VRB will probably proceed with the hearing as soon as it can be heard.

20. The claimant may decide not provide the VRB with a Certificate of Readiness because they wish to wait for the RMA to issue a SOP before going ahead with the VRB review. This is a matter they should discuss with the VRB. In these cases the Section 31 review action will continue until a SOP is gazetted. However, it should be remembered the dismissal provisions apply to the VRB once the application to the VRB is two years old.

21. If after giving the VRB a Certificate of Readiness the claimant wishes the hearing delayed until the RMA issues a SOP, they must ask the VRB for a deferral of hearing. This is up to the VRB to decide based on the merits of the application for deferral and may not necessarily be granted.

22. If the claimant provides the VRB with a Certificate of Readiness, the hearing is commenced and the review determined the Section 31 review action lapses. The Section 31 form on file is noted and the claimant sent the advice at Attachment G.

23. If a decision under Section 31 is made to grant the claim (para 17) then, as is normal, the claimant will be advised that the application to the VRB will be treated as an application for review of the Section 31 decision if the applicant wishes to continue with it (eg. review of date of effect or assessment of pension).

24. If the Section 31 review is discontinued without a decision being made (paras 15 & 16) then the original application for review by the VRB is still valid and is continued with. The VRB will of course be bound by any RMA SOP that is in existence.

Further Evidence Lodged During The Review Period

25. During the Section 31 review period a claimant may lodge further evidence in relation to the causal relationship to service of the condition. In this case the evidence should be examined as it normally would. If it allows the claim to be accepted then a Section 31 review decision should be made as it normally would. There is no need to wait until the issue of an RMA SOP in these circumstances.

Assisting Claimants

26. It may be difficult for many claimants to decide whether to wait for the issue of an RMA SOP or to lodge or go ahead with a VRB review. Claims Assessors should ensure that they are fully aware of the possible implications of all the options. These options are to be fully explained to any claimants that wish to discuss them or have any concerns. Ex-service organisations may also be able to assist claimants in these matters.

W MAXWELL

A/G NATIONAL PROGRAM DIRECTOR

(BENEFITS)

Attachment A

CONDITIONS FOR WHICH A SOP IS EXPECTED TO BE ISSUED BY THE RMA IN THE NEXT MONTH

Conditions which will be considered by the RMA at its next meeting

DENTAL CARIES

DENTAL ABSCESS

CONJUNCTIVITIS

CAISSON DISEASE

SMALLPOX

ASCARIASIS

ANCYLOSTOMIASIS

CERVIX, MALIGNANT NEOPLASM

ANXIETY DISORDER (MEDICAL)

PERSONALITY DISORDER

MENIERES DISEASE

DIABETES MELLITUS

ENDOMETRIUM, MALIGNANT NEOPLASM

OVARY, MALIGNANT NEOPLASM

PARKINSONS DISEASE

DENGUE FEVER

Conditions which will possibly be considered by the RMA at its next meeting

CHRONIC FATIGUE SYNDROME

MULTIPLE SCLEROSIS

MOTOR NEURONE DISEASE

SOLAR SKIN DAMAGE

NON-MELANOTIC SKIN CANCER

TOXIC PLANTS

STINGS & BITES

HYPOTHERMIA

ELECTROCUTION

FROSTBITE

PILONIDAL SINUS

BENIGN PROSTATIC HYPERTROPHY

Attachment B

CHANGES TO REASONS FOR A CLAIM WITHOUT AN RMA SOP BEING REJECTED

(Claim for Disability Pension)

(Operational service)

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable. These factors specify how a condition can be related to service. Information about the RMA is contained in the Explanatory Attachment to this letter.

In this case the RMA has not yet issued a Statement of Principles for {condition}. Therefore I am deciding the case on the basis of all the evidence before me at this time.

Reasons for Rejected Conditions

I have considered the evidence that is relevant to this claim. This includes the details of service, the history of the claimed conditions and the factors that can cause or aggravate these conditions.

I find that:

**** Claims Assessor to insert reasons for decision****

The evidence does not raise a reasonable hypothesis connecting {condition} and service. I am therefore unable to accept it as war caused.

(Eligible service)

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a connection to service to be probable. These factors specify how a condition can be related to service. Information about the RMA is contained in the Explanatory Attachment to this letter.

In this case the RMA has not yet issued a Statement of Principles for {condition}. Therefore I am deciding the case on the basis of all the evidence before me at this time.

Reasons for Rejected Conditions

I find that:

**** Claims Assessor to insert reasons for decision****

The evidence does not show an reasonable connection between {condition} and service. I am reasonably satisfied that the condition was not caused by eligible service.

Section to be added after RIGHT OF APPEAL

Issue of a Statement of Principles by RMA

As previously mentioned, a Statement of Principles on the condition of {condition} has not yet been issued by the RMA. To ensure that you are not disadvantaged by having your claim for {condition}decided before the RMA has issued a Statement of Principle, a review under Section 31 of the Veterans' Entitlement Act 1986 is being commenced. This allows a senior delegate of Commission to review and vary this original decision should the issue of an RMA Statement of Principles contain enable your claim to be accepted as service related.

After a Statement of Principles for {condition}has been issued you will be advised whether:

new causal factors included in the Statement of Principles has enabled a senior delegate to review and accept your claim for this condition, or
no new evidence about the condition or its causes is contained in the Statement of Principles and therefore the review under Section 31 will be discontinued.

The commencement of a review under Section 31 of the VEA does not affect your right to lodge an application for a review of my decision by the VRB (explained in the section above headed RIGHT OF APPEAL). Your application for a review to the VRB can be withdrawn if a favourable decision is made by a senior delegate after issue of a Statement of Principles by the RMA.

(Claim for Death)

(Operational service)

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as causing death related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a hypothesis to be considered reasonable. These factors specify how a condition causing death can be related to service. Information about the RMA is contained in the Explanatory Attachment to this letter.

In this case the RMA has not yet issued a Statement of Principles for the cause of death {condition}. Therefore I am deciding the case on the basis of all the evidence before me at this time.

Reasons for Rejecting Death

I have considered the evidence that is relevant to this claim. This includes the details of service, the history of the cause of death and the factors that can cause or aggravate this condition.

I find that:

**** Claims Assessor to insert reasons for decision****

The evidence does not raise a reasonable hypothesis connecting the death of {veteran} and service. I am therefore unable to accept the death as war caused.

(Eligible service)

Statement of Principles

The Repatriation Medical Authority (RMA) issues Statements of Principles on conditions claimed as causing death related to service. These Statements are based on sound medical - scientific evidence and state what factors must exist for a connection to service to be probable. These factors specify how a condition causing death can be related to service. Information about the RMA is contained in the Explanatory Attachment to this letter.

In this case the RMA has not yet issued a Statement of Principles for the cause of death {condition}. Therefore I am deciding the case on the basis of all the evidence before me at this time.

Reasons for Rejecting Death

I have considered the evidence that is relevant to this claim. This includes the details of service, the history of the cause of death and the factors that can cause or aggravate this condition.

I find that:

**** Claims Assessor to insert reasons for decision****

The evidence does not show an reasonable connection between the death of {veteran} and service. I am reasonably satisfied that the death was not caused by eligible service.

Section to be added after RIGHT OF APPEAL

Issue of a Statement of Principles by RMA

As previously mentioned, a Statement of Principles on the cause of death of {condition} has not yet been issued by the RMA. To ensure that you are not disadvantaged by having your claim decided before the RMA has issued a Statement of Principle, a review under Section 31 of the Veterans' Entitlement Act 1986 is being commenced. This allows a senior delegate of Commission to review and vary this original decision should the issue of an RMA Statement of Principles enable death to be accepted as service related.

After a Statement of Principles for {condition}has been issued you will be advised whether:

new causal factors included in the Statement of Principles has enabled a senior delegate to review and accept your claim, or
no new evidence about the condition or its causes is contained in the Statement of Principles and therefore the review under Section 31 will be discontinued.

Explanatory Attachment to be amended as follows.

Delete the forth paragraph from the section headed "STATEMENTS OF PRINCIPLES"

Commonwealth Department of

Veterans' Affairs

COMPENSATION

SECTION 31 REVIEW ACTION

RMA SOP not yet issued

Claimant Details

Surname	Given Names	DVA File Number

A review under Section 31 of the Veterans' Entitlements Act has been commenced on this case for the following condition(s). ______________________________________________________________________________________________________________________

____________________________________ _________________

Delegate of the Repatriation Commission Date

ACTIVITY		DATE	ACTION OFFICER INITIALS
Claim lodged		/ /
Claim rejected		/ /
Claimant advised of Sec 31		/ /
SOP issued	Y/N	/ /
Sec 31 review decision	Y/N	/ /
Sec 31 review discontinued	Y/N	/ /
Veteran applied to VRB	Y/N	/ /
VRB review determined		/ /
Sec 31 review lapsed	Y/N	/ /

Comments______________________________________________________________________________________________________________
Attachment D

LETTER TO BE SENT TO CLAIMANT WHEN RMA HAS DECIDED NOT TO ISSUE A SOP FOR A CONDITION

(Claim for Disability Pension)

Dear ........................

REVIEW OF THE DECISION TO REJECT {CONDITION} AS NOT DUE TO SERVICE

On / / you were notified that a delegate of the Repatriation Commission had decided to reject your claim for {condition} on the basis that it was not related to your service. You were also notified that the Repatriation Medical Authority had not issued a Statement of Principles for {condition}. As a result a review by a senior delegate of the Repatriation Commission under Section 31 of the Veterans' Entitlements Act was being considered on the decision.

This review was being considered on the grounds that any Statement of Principles issued by the Repatriation Medical Authority may include new medical evidence about the factors which may cause {condition}.

The Repatriation Medical Authority has now considered this condition and decided not to issue a Statement of Principles. Therefore there is no new evidence to be considered in your case and the review by a senior delegate of the Repatriation Commission has been discontinued. The original decision dated / / rejecting this condition as not due to service still stands.

(Option if VRB application already lodged)

This has no effect on your application for review by a Veterans' Review Board lodged on / / . This application is still being processed.

(Claim for Death)

Dear ........................

REVIEW OF THE DECISION TO REJECT THE DEATH OF {VETERAN} AS NOT DUE TO SERVICE

On / / you were notified that a delegate of the Repatriation Commission had decided to reject your claim for the death of {veteran} on the basis that it was not related to service. You were also notified that the Repatriation Medical Authority had not issued a Statement of Principles for {condition} a cause of death. As a result a review by a senior delegate of the Repatriation Commission under Section 31 of the Veterans' Entitlements Act was being considered on the decision.

(Option if VRB application already lodged)

This has no effect on your application for review by a Veterans' Review Board lodged on / / . This application is still being processed.

Attachment E

LETTER TO BE SENT TO CLAIMANT WHEN RMA HAS ISSUED SOP BUT CLAIM STILL CANNOT BE ALLOWED

(Claim for Disability Pension)

Dear ........................

ISSUE OF STATEMENT OF PRINCIPLES FOR {CONDITION} BY REPATRIATION MEDICAL AUTHORITY

The Repatriation Medical Authority has now issued a Statement of Principles for this condition. This Statement of Principles lists the factors which must exist for {condition} to be related to service.

Unfortunately in your case this statement still does not raise any new evidence to allow review of the original decision and the review by a senior delegate of the Repatriation Commission has been discontinued. The original decision dated / / rejecting this condition as not due to service still stands.

(Option if VRB application already lodged)

This has no effect on your application for review by a Veterans' Review Board lodged on / / . This application is still being processed.

(Claim for Death)

Dear ........................

ISSUE OF STATEMENT OF PRINCIPLES FOR {CONDITION} BY REPATRIATION MEDICAL AUTHORITY

(Option if VRB application already lodged)

This has no effect on your application for review by a Veterans' Review Board lodged on / / . This application is still being processed.

Attachment F

DECISION ADVICE TO BE SENT TO CLAIMANT WHEN RMA HAS ISSUED SOP AND CLAIM IS REVIEWED UNDER SECTION 31 AND ALLOWED

Dear Mr Miller,

THIS LETTER IS ABOUT review OF THE PREVIOUS DECISION ON YOUR DISABILITY PENSION CLAIM

Decision

I have reviewed the decision dated / / rejecting the claim for {condition}. Under Section 31 of the Veterans' Entitlements Act I have decided to vary this decision and accept the claim for {condition}. This decision takes effect from {effective date}.

I have decided that pension is to be granted/increased to {rate of DP}with effect from / / .

Reasons for Decision

Original decision on your claim

On 10 March 1995 a claim for "{condition} was received at the Department of Veterans' Affairs.

This was subsequently investigated and on / / a decision was made by a delegate of the Repatriation Commission rejecting the claim for {condition}. The delegate was unable to relate the condition to service based on the evidence available.

Review under Section 31 of the Veterans' Entitlements Act

At the time of the original decision the Repatriation Medical Authority had not issued a Statement of Principles for {condition}. As a result a review under Section 31 of the Veterans' Entitlements Act was commenced. This section of the Act allows me to review and vary a previous decision on a claim by a delegate of the Repatriation Commission where appropriate.

The Repatriation Medical Authority has now issued a Statement of Principles for {condition}. This statement now includes {contention} as a causal factor for {condition}.

I have reviewed the evidence in this claim including the Statement of Principles. I find that a causal connection between Mr {claimants} service and his {condition} has been establish on the basis of service related {contention}. {condition} is therefore accepted as service related.

Date of Effect

The law allows me to backdate acceptance of a disability for a maximum of 3 months prior to the lodgement of the claim if the disability existed at that time. In this case acceptance has been backdated to / / .

Assessment of Pension

The rate of pension payable for accepted disabilities is assessed under the "Guide to the Assessment of Rates of Veterans' Pensions" (commonly called GARP).

A summary of this assessment is as follows:

the GARP Impairment rating is X points;
the GARP Lifestyle rating is X point;
the combined GARP Impairment and Lifestyle ratings give rise to a General Rate pension entitlement of X%.

Pension is payable at X% of the General Rate.

Your Pension

Advice about regular pension payments and any backpayments due will be forwarded shortly.

RIGHT OF APPEAL

If you are not satisfied with any part of my decision you can ask the Veterans' Review Board (VRB) to review the case. You would have to do this in writing. There are time limits on lodging an application to the VRB.

(Alternative para if VRB application has previously been lodged)

RIGHT OF APPEAL

I note you have previously lodged an application for review by the Veterans' Review Board (VRB) of the original decision on this condition. If you are not satisfied with any part of my decision (such as date of effect or assessment of pension) you can continue with this review to the VRB which will review my decision. If you do not wish to continue with this review you should notify the VRB in writing.

HELP AVAILABLE

Help can be obtained in dealing with any part of this decision, the reasons for it and appeal rights by contacting:

Murray Harrison, as per contact details at the beginning of this letter.
an ex-service organisation - their addresses and telephone numbers are listed in the telephone book.

Yours sincerely,

Murray Harrison

Senior Delegate of the Repatriation Commission

.
Dear Mrs Miller,

THIS LETTER IS ABOUT review OF THE PREVIOUS DECISION ON YOUR CLAIM TO HAVE THE DEATH OF WILLIAM MILLER ACCEPTED AS SERVICE RELATED

Decision on your claim

I have reviewed the decision dated / / rejecting the claim for the death of {veteran}. Under Section 31 of the Veterans' Entitlements Act I have decided to vary this decision and accept the that the death of {veteran} is causally related to service. This decision takes effect from {effective date}.

I have decided that pension is to be granted with effect from / / .

Reasons for Decision

Your claim

On 10 March 1995 a claim for acceptance of the death of {veteran} was received at the Department of Veterans' Affairs.

This was subsequently investigated and on / / a decision was made by a delegate of the Repatriation Commission rejecting the claim. The delegate was unable to accept the death as service related as, based on the evidence available, the delegate was unable to relate the cause of death {condition}to service.

Review under Section 31 of the Veterans' Entitlements Act

The Repatriation Medical Authority has now issued a Statement of Principles for {condition}. This statement now includes {contention} as a causal factor for {condition}.

I have reviewed the evidence in this claim including the Statement of Principles. I find that a causal connection between {veteran} service and {condition} has been establish on the basis of service related {contention}. The death of {veteran} is therefore accepted as service related.

Date of Effect

The law allows me to accept a claim for death of a veteran from the day after death or 3 months prior to the lodgement of the claim if the claim is lodged more than three months after the veteran's death. I have therefore accepted the death of {veteran} from / / .

Your Pension

Advice about regular pension payments and any backpayments due will be forwarded shortly.

RIGHT OF APPEAL

(Alternative para if VRB application has previously been lodged)

RIGHT OF APPEAL

I note you have previously lodged an application for review by the Veterans' Review Board (VRB) of the original decision on this condition. If you are not satisfied with any part of my decision (such as date of effect) you can continue with this review to the VRB which will review my decision. If you do not wish to continue with this review you should notify the VRB in writing.

HELP AVAILABLE

Help can be obtained in dealing with any part of this decision, the reasons for it and appeal rights by contacting:

Murray Harrison, as per contact details at the beginning of this letter.
an ex-service organisation - their addresses and telephone numbers are listed in the telephone book.

Yours sincerely,

Murray Harrison

Delegate of the Repatriation Commission

Attachment G

LETTER TO BE SENT TO CLAIMANT WHEN SECTION 31 HAS LAPSED BEFORE RMA SOP ISSUED

(Claim for Disability Pension)

Dear

REVIEW OF THE DECISION TO REJECT {CONDITION} AS NOT DUE TO SERVICE

The Repatriation Medical Authority has not yet issued a Statement of Principles for this condition. However, I note that on / / the Veterans Review Board determined an application for review of the original decision. Consequently the review of the original decision by a senior delegate of the Repatriation Commission has lapsed and no further action will be taken.

(Claim for Death)

Dear

REVIEW OF THE DECISION TO REJECT THE DEATH OF {VETERAN} AS NOT DUE TO SERVICE

Source URL: https://clik.dva.gov.au/compensation-and-support-reference-library/departmental-instructions/1995/b251995-determining-compensation-claims-conditions-where-repatriation-medical-authority-rma-has-not-yet-issued-statement-principle-sop