C07/2013 Prioritisation of Compensation Claims

Replaces DI No.

N/A

Purpose

This Departmental Instruction provides guidance to Rehabilitation and Compensation Staff regarding the prioritisation of compensation claims, and in particular the introduction of the criteria for Defence requested priority cases.

Background

In December 2011, the Repatriation Commission and the sub committee of the Military Rehabilitation and Compensation Commission approved revised guidance on the prioritisation of claims for compensation under the Veterans' Entitlements Act 1986 (VEA), the Safety Rehabilitation and Compensation Act 1988 (SRCA) and the Military Rehabilitation and Compensation Act 2004 (MRCA).  New prioritisation of compensation claims guidance was promulgated via Businessline (TRIM Ref 127413E) in January 2012.  This listing included a priority for claims highlighted by Defence - DVA Priority Guidance No. 5, with advice that the Defence criteria for cases that will require a request of this nature were still to be determined and agreed.

All three services have since agreed to the criteria that will be used to identify Defence requested priority cases and this is included in the below guidance.  In addition to this both Defence and DVA have agreed internal procedures for the processing of these claims.  This was endorsed by the Repatriation Commission and the Military Rehabilitation and Compensation Commission on 7 February 2013.

Timely Approach to Claims Processing

It is the duty of all delegates to determine all claims for compensation in an accurate and timely manner.  The accuracy of determinations is not negotiable.  No compromise can be accepted in the degree of care and diligence in deciding any entitlement under the Act.  Claims assessors should always aim to meet the targets for time taken to process of 75 days for the VEA and 120 days for the SRCA and MRCA.  Where possible, the assessment of claims should commence as soon as possible after receipt and the regular ongoing management of those claims conducted in a reasonable timeframe.  To achieve this it is important that both the claims assessors and their managers closely monitor the claims that are received and on hand to ensure a good awareness of the status of claims and circumstances of the clients.  The principles to be applied to claims processing to assist in achieving this goal are as follows;

• Start the investigation of all claims within 7 days of assignment of the claim
• Complete all follow up actions on the day they become due
• Refuse to get stuck, ask for help on the day that a problem becomes evident.

In some cases however, the urgency associated with the matter means that a claim must be dealt with ahead of older claims and significant attention needs to be given to obtaining the necessary information to make a determination.  This is a judgement call for the delegate and/or the manager based on the degree of personal distress, financial hardship and medical or rehabilitation concerns of the client.

Priorities need to be attributed by the claims assessor and their manager, and based on the circumstances of the claim at the time of receipt and allocation.  These priorities will need to be regularly reviewed during the progress of the claim where changes to the claimant's circumstances may provide a greater urgency.  This regular review can be conducted as part of the case conferencing process between claims assessors and their team leader or Director/Manager.

Guiding Principles

Effort should always be made to ensure the determination of claims within the target period.  To ensure this, the commencement of the assessment of the claim must occur within 7 days of assignment of a claim to a claims assessor.  In some cases claims may take longer to determine due to a number of factors such as non-availability of relevant information or being held within ongoing backlogs.  However, claims that have encountered difficulty during assessment must be highlighted as part of a regular case conferencing process.  It is during this process that claims nearing the target for processing may be raised to a higher priority.

The other principle in determining any priority is the needs of the client.  All clients will have differing needs and expectations, but some clients' circumstances will involve a greater urgency than others.  These may be based on the requirement to meet financial/medical/mental health/rehabilitation needs and to alleviate immediate distress so that the client's circumstances and requirement for benefits are met. Guidance on the circumstances in which a claim may be considered as a higher priority is detailed below.  In some cases the client's circumstances can change over the course of consideration of a claim.  Claims assessors must be aware of the changing circumstances of a client and, if required, reassess the priority for consideration of the claim.

Initially the priority will be assessed through the process of initial assessment of the claim and assignment to a claims assessor.  However, the urgency of a claim can change in the process of determination and so the support of team leaders or the regular case conferencing process should be used to ensure that the correct priorities are regularly reviewed and identified.

The following provides guidance on the circumstances that may result in a claims assessor determining that a claim needs to be considered as a higher priority.

Priority Guidance

1. High Profile cases including deaths or injuries.  These include high profile deaths or injuries, such as those on deployments or in a high profile accident, where there is significant public attention.  This category also includes cases identified by the DVA executive that require urgent attention.

2. Deaths or imminent death.  This covers deaths in cases that do not have the same degree of attention as those in priority 1.  It will also cover the deaths or terminal illnesses such as cancer where the death will leave the dependants with no financial support e.g. war widows.  The exception to these cases will be where the widow and/or dependants are already receiving some form of payment and the veterans' death has a lesser financial impact.

3. Mental Health and Serious Injury/ Illness.  This priority takes into account the needs of those seriously injured and the seriousness of mental health issues.  It includes those members medically evacuated from operational areas, clients who are at risk of self harm or harming others because of their illness.  Mental conditions to be considered under this priority will include Depressive Disorders, Post Traumatic Stress Disorder, Anxiety, Adjustment Disorder and Acute Stress Disorder.  It will also include those with serious conditions who, in the opinion of the Claims Assessor, are more at risk of developing mental health conditions. The potential to put an indicator for these conditions on to systems used by Claims Assessors is being investigated.

Some of the cases handled by the Client Liaison Unit and/or Case Co-ordinators will be considered under this priority, but it should be noted that these are potentially high profile cases as well.

4. Immediate or imminent financial hardship.  This priority recognises the needs of families with rental commitments, reservists who may be incapacitated for their civilian employment or require medical treatment where they have no medical treatment available through the ADF and recently discharged members with minimal accrued ADF entitlements such as recruits and officer cadets.  It also considers those whose employment is about to cease.

It is important to take into consideration whether the member is being medically discharged and /or has chosen to have their separation from the ADF Held-In-Abeyance (HIA) pending determination of liability for the compensation claim. If HIA has been chosen, the financial hardship prospect is not as great as previously with the separation held until DVA have determined liability.  However, if a member elects to be HIA and fails to submit their claim and/or is obstructive in the claims process, then the ADF may elect to separate the member regardless of the claim status. Also for the purpose of appeals ADF members will not be HIA.

Part of the consideration with this priority should take into account the commencement/continuation of medical treatment and an appropriate rehabilitation program particularly vocational rehabilitation.

5. Defence requested priority cases.  The Defence decision for cases that require a request of this nature will be made by the Director General Navy Personnel (DGNP), Director General Personnel – Army (DGPERS-A) or Director General Personnel – Air Force (DGPERS-AF).  The criteria for Defence to seek priority consideration is:
   1. Delay will be detrimental to the wellbeing of the individual. For example, the member is nearing discharge and will not have access to ADF income or the member requires urgent transfer to the DVA medical or rehabilitation providers.
   2. There is an identified Service need. These include;
      1. Operational need (eg the need to ensure that a role that could require deployment is not held by someone waiting claim acceptance prior to discharge)
      2. ADF reputation risk should the person be retained in the service
      3. Medical Separations where the ADF is awaiting transfer of a member's care to DVA
      4. Urgency highlighted by Senior Leadership.

6. Cases returned by VRB or AAT that have entailed a delay in processing of entitlement.  This priority recognises a case that is referred to the Department by the VRB or AAT and there have been other appeal or reconsideration processes or there has been any other similar action that has resulted in a significant delay in the receipt of benefits, some priority should be afforded to the determination of benefits.  Some of these cases, such as those involving significant mental illness or financial hardship will fall within the previous priorities, but when there is no other priority and the claim has been delayed for a considerable period as a result of appeals etc, this priority will be relevant.

7. Medical Treatment Costs.  Processing is given priority in cases where treatment for a compensable condition is denied or delayed until a payment is made or a service is not provided until a 'guarantee' is given.  It will also be given priority where the continuation of medical treatment for the claimed condition must be implemented quickly.

8. Deaths In Payment.  This priority covers war widows and/or dependants who are already receiving some form of payment and therefore the veterans' death has less financial impact.

9. Over 90 Years.  Where the client submitting the claim is over 90 years old, the claim is treated with priority because of the high risk of the client's death before the claim is finalised.

Processes for Defence Requested Priority Cases

The recommendation that the member's compensation claim be highlighted as a priority for consideration by DVA will be passed to an ADF decision maker as part of the review of the person's employment status, or as part of the ongoing management and review of wounded, injured and ill members.  The recommendation will be accompanied by a Defence WebForm which contains the following:

• Identify if the claim is already with DVA or a new claim is to be raised
• Member details
• Criteria for priority
• Justification for priority processing consideration
• Member acknowledgment of:

• Defence request for claims status update;
• Contact with member by DVA; and
• Requirement to expedite DVA access to requested information

• Delegate approval; and
• Detail of the action by DVA to the request for prioritisation.

Submission of Defence Requested Priority – New Claim

Defence Responsibility – new claim

Claims may be mailed to DVA or taken to a DVA office or hand delivered through the On Bases Advisory Service (OBAS).  In all cases it will be clear the claim is a Defence Priority. Attached to the claim will be a covering notification from Defence, signed by the relevant DGPERS, highlighting the priority and the reasons as listed above.  To enable DVA to treat the claim with the required urgency, the claim will be accompanied by the Request For Priority Processing form and the following documentation:

• A completed and signed claim form;
• A completed and signed separate injury or disease details sheet with information provided by the member's medical officer;
• An electronic copy (where possible) of all medical documentation relevant to the claimed condition/s, including entry medical examination record, outpatient clinical record notes, specialist reports, imaging reports, periodical medical board reports etc;
• Proof of Identity documents;
• An electronic copy (where possible) of Service History;
• An electronic copy (where possible) of any relevant OHS incident report;
• Witness statements (if required).

DVA Responsibility – new claim

DVA will manage the claim in line with priority protocols as outlined above. As with all claims coming into DVA, they will be screened for validity (e.g. DVA claim form signed, POI satisfied) and ensure that all necessary supporting documentation is with the claim.  If any documents are missing, a request will be made to obtain them as soon as possible.  DVA may make contact with the member directly or through the OBAS or their Advocate where one has been identified to ensure minimum delays for receipt of all supporting documentation.

A copy of the Defence form (Request for Priority Processing) is to be copied and saved into the clients UIN container in TRIM (where other Defence documents are saved by the DVA SAM team).

Each of the processing systems is to be noted correctly to provide a systems record that this is a Defence requested priority claim by ticking the correct priority identifier as the claim is registered in Defcare, Cadet or CCPS.  In addition to this a note is to be put into VIEW under 'Important Information' advising that Defence have the client's authority to discuss their claim.  This enables all R&C, Client Contact Support (CCS) and VAN staff to be able to identify this information quickly and easily.

Highlighting Defence Requested Priority – Existing Claim

Defence Responsibility – existing claim

Where a claim already exists, the relevant area in Defence (DGNP, DGPERS-A, DGPERS-AF) must obtain written acknowledgement from the member that DVA may be approached to seek the status of the claim using the Request for Priority Processing form.  The relevant area will then approach the DVA via a single point of contact phone number (managed by the R&C Liability and Registrations area) to seek advice on the claim status and to ascertain whether the relevant documents have been received by DVA.  Defence will then highlight the increased priority and client authority using the Request For Priority Processing form which will be scanned and emailed to DVA.

DVA Responsibility – existing claim

Defence will contact DVA via a single point of contact phone number which will be managed by the R&C Liability and Registrations area.  Staff in the R&C Liability and Registrations area will check VIEW to identify if the client has been assigned to CLU or Case Coordination and if so will transfer the call to them.  Staff in the R&C Liability and Registrations area will also check VIEW for a comment to advise that client authority has been given for Defence to contact DVA on their behalf. If no authority has been given, the R&C Liability and Registrations area will not provide any information to the caller, but will identify the delegate responsible for the claim and transfer the call.  The R&C delegate will need to explain to the caller the processes for establishing authority via the Request For Priority Processing form.

If authority has been given, staff in the R&C Liability and Registrations area will identify the status of the claim in VIEW before transferring the call to the responsible delegate.  The R&C delegate will then provide a status update to the Defence caller, acknowledge the new Defence requested priority, and assure Defence the claim will be processed in accordance with the priority guidelines as listed above.  Once the Request For Priority Processing form is received from Defence it is to be saved into the client's e-file in TRIM (via UIN) in line with other documents received electronically from Defence via the SAM process.  The appropriate processing system/s (Defcare/CCPS/Cadet) should also be updated to indicate a 'Defence Priority Request'.

Action Required

Staff are asked to familiarise themselves with the Priority Guidance for processing compensation claims outlined in this Departmental Instruction.