B46A/1994 CRITICAL PROCEDURES FOR USING RMA SOPs PRIOR TO THEIR INCLUSION IN CCPS

DATE OF ISSUE:  14 OCTOBER 1994

CRITICAL PROCEDURES FOR USING RMA SOPs PRIOR TO THEIR INCLUSION IN CCPS

It is absolutely essential that all Compensation staff, including Claims Assessors (CAs) and other delegates, fully understand this Procedural Instruction. It explains how to process disability claims using newly gazetted RMA SOPs which are not yet included in the current CCPS version.  If you experience any difficulties or problems with this Instruction please contact Ron Mildenhall or Steve Peacock in the Procedures & Training Unit on 09.3668453 (W-B-PROJ1).

Gazettal of RMA SOPs

Gazettal of the RMA SOPs for the first seven conditions took place on Wednesday 14 September 1994.  From the date of gazettal satisfaction of the contentions in the RMA SOPs is the only way that claims lodged on or after 1 June 1994 for RMA SOP conditions can be accepted. Failure to satisfy a contention means the claims must be rejected.  Details of gazetted SOPs are in Appendix 1.

The RMA has indicated approval for 15 more conditions. Gazettal of the RMA SOPs for eight of these conditions took place on Wednesday 21 September 1994.  The SOP Instruments for the remaining seven conditions are being prepared and are expected to be gazetted on 28 September 1994.  Details are in Appendix 2.

A number of conditions have been submitted to the RMA and are currently under consideration.  While the issue of SOPs for these conditions can be expected, it is not possible to say exactly when. Details of conditions currently being considered by the RMA but not yet covered by a SOP are at Appendix 3.

Distribution of RMA SOPs

Copies of the instruments for the seven conditions for which Statements of Principles have been approved by the RMA have been sent to Branches by the SOP Unit.  The SOP Unit has also issued copies to the national headquarters of the peak Ex- Service Organisations (ESOs).

Branches are responsible for issuing copies of SOPs to all relevant officers in Compensation and other areas of the Branch.  They should also issue copies to any organisation or individual that requests a copy.  It is suggested that VAN, being the main contact area for both clients and ESOs would be best placed to do this.  However, some distribution might be required of the CAs through normal client/advocate contact.

Gazettal of RMA Investigation

In the Gazette of 21 September 1994 was notification of investigations of Carcinoma of the Prostate and Gastro- Oesophageal Reflux Disease (smoking/alcohol contentions) by the RMA under 196B(4) of the Veterans' Entitlements Act.  No claims lodged on or after 1 June 1994 for Carcinoma of the Prostate or death from that condition can be determined until this investigation has been finalised and a SOP gazetted.

Claims for Gastro-Oesophageal Reflux Disease or death from that condition can be determined as accepted, as a SOP for that condition has been gazetted on 21 September 1994.  However, as there is an investigation of the smoking and alcohol contention notified, the only way a claim can be rejected is if one of the gazetted contentions is not satisfied and:

• the veteran did not smoke or drink, or

• the veteran states that smoking or alcohol are not causal factors , or

• the veteran's smoking or alcohol habits are determined not to be related to service.

Otherwise these claims should remain undetermined until the RMA investigation is finalised.

Inclusion of RMA SOPs into CCPS

The broad redesign of CCPS to support the RMA SOPs has taken place recently.  The CCPS system is currently being enhanced to supply this support.  Although new rule bases and commentary are being written, the changes will not be finished by the next new release. In the meantime manual procedures are to be followed.

Procedures

Claims lodged before 1 June 1994

Choosing the Most Beneficial Contention

The Commission has given an undertaking to the ESOs that cases lodged before 1 June 1994 will not be disadvantaged following issue of the RMA SOPs.  This means that when determining these cases CAs and other delegates will always investigate the most beneficial contention from either a Commission SOP or a RMA SOP.  In CCPS this is being incorporated as the Most Beneficial Path (MBP).

This means that where a RMA SOP has been issued the system will be modified to indicate to the CA which is the MBP for each contention (either the Commission SOP contention or the RMA SOP contention) and automatically present this to the CA.  Until the system is updated this will have to be done manually.

To assist this process, a comparison between RMA SOPs and Commission SOPs has been carried out to show the MBP to be used when deciding claims. The details for each RMA SOP condition are included in charts at Appendix 4.

Investigation, Decision and Reasons Using CCPS

Where Commission SOP contentions are more beneficial or essentially the same as RMA SOP contentions,  CAs can use the current rule bases and system-produced investigative material.  Where contentions are similar but the RMA SOP is more beneficial the current rule base and investigative material can be used but the questions and answers should be manipulated to result in a reflection of the RMA SOP.  When a condition is accepted because of a more beneficial contention in a RMA SOP,  the system-produced Reasons for Decisions will require little adjustment.

Reasons for acceptance in these cases will remain simple and straightforward. The heading of the contention and the basis of the acceptance are all that will show.

For example:  The veteran is claiming Peptic Ulcer on the basis of taking NSAIDS for a service related disability within 14 days of onset of PU.  He ceased taking NSAIDS 13 days prior to onset of the condition.  This would not be accepted under the current rule base which has a seven day limit.  However as the RMA SOP allows this contention the CA should answer the rule base question to allow acceptance.

If the RMA SOP contains a new contention this will have to be investigated outside of CCPS using manually produced investigative material.  If this  results in acceptance the Override facility should be used to accept the case and Reasons for Decision inserted manually.

Where a claim is rejected it is unnecessary to explain in detail to every claimant the different paths taken for each condition.  Not only is it labour intensive but it adds a variety of different paragraphs that may be difficult to understand.  When a pre 1 June 1994 condition is rejected after investigating the most beneficial contentions the reasons should simply say:

"I have considered all the evidence available, including Statements of Principles issued by the Repatriation Commission and the Repatriation Medical Authority.  These Statements set out the ways in which a condition can be connected to service.  I find that ... ".

The contention headings with findings should then be listed. Once CCPS has been updated the Reasons will appear differently.

Claims lodged on or after 1 June 1994

Differences between RMA SOPs and Commission SOPs

CAs should be aware of the differences between RMA SOPs and Commission SOPs which are included as rule bases in CCPS.  The differences are indicated and commented on in the charts attached to Appendix 4 for each condition.

ICD Coding Conditions covered by a RMA SOP

It should be noted that RMA SOPs will not always cover the same range of ICD codes as Commission SOPs.  For instance Gout previously only covered ICD Code 274 but the RMA SOP now also includes Code 984.  Whereas Pathological Substance Abuse previously covered ICD Code 305, this is not covered by the RMA SOP on Psychoactive Substance Abuse or Dependence.

Claims Assessors should check carefully that the claimed condition is actually covered by the RMA SOP.  If it is not, it cannot be determined under that SOP.

If the condition comes under a code which was not previously included in the Commission SOP it will have to be processed through CCPS as a non SOP condition.  Condition specific Reasons will have to be inserted manually.  This should be simple for acceptances but may prove more difficult for rejections.  It may be easier to code it as "unspecified" for that condition(eg use code 274.9 for gout).  It can then be processed using the support from CCPS in investigative material and Reasons.

Investigation, Decision and Reasons Using CCPS

Where the RMA issues a SOP for a condition for which there was no Commission SOP (eg Fractures) the claim will have to be processed as a non SOP on CCPS until the system is updated.  Condition specific reasons are to be inserted manually.  For all other conditions individual contentions will have to be compared.

Where RMA SOP contentions are essentially the same as Commission SOP contentions CAs can use the current rule bases and system-produced investigative material.  Where contentions are similar but the RMA SOP is more or less beneficial the current rule base and investigative material can be used.  However, the questions and answers must be manipulated to result in a reflection of the RMA SOP limitations.

If the RMA SOP contains a new contention this will have to be investigated outside of CCPS using manually produced investigative material.  If this results in acceptance the Override facility should be used to accept the case and Reasons inserted manually. The Reasons to be issued for acceptances should remain simple.

The RMA SOPs contain many definitions of the terms contained in the contentions.  Commentary is currently being written to explain the contentions.  If a CA has any difficulty interpreting any contention in the RMA SOPs issued they should consult with their Team Manager.  If it is still unclear then contact Dave Goldrick (C-B-RD-5) in Compensation Operations Section, Central Office or phone 06.2896580.  Mr Goldrick is coordinating development of the Rule bases and Commentary for the RMA SOPs and liases with the Department's SOP Development Unit.

The system is being redesigned with regard to reasons for rejection and CAs should follow the outline provided to keep consistency with future system-produced Reasons.  An example copy of the Reasons for a rejection is at Appendix 5. Paragraphs for use in Reasons are at Appendices 6 and 7.

The main points included in this example are:

• The Law paragraphs have been reduced to merely state the standard of proof that applies.  The definitions of the Standard of Proof, War Caused Injuries, Defence Caused Injuries, War Caused Death and Defence Caused Death have been dropped from the Explanatory Attachment.

• A new heading and paragraph on the Statements of Principles has been added.  This paragraph refers to further detail on what the RMA and Statement of Principles are in the Explanatory Attachment.  A new Section of the Explanatory Attachment on this subject has been added.

• The introductory paragraphs on each rejected condition explaining what it is and how it can be accepted has been dropped.  Instead a generic paragraph has been added under the heading "Reasons for Rejected Conditions".  This indicates the CA has considered all the factors contained in the SOPs.  It also indicates that these are listed in the Explanatory Attachment.

• The Explanatory Attachment contains a short section on each rejected condition that states what it is and what contentions are listed in the SOP.  It does not go into detail on the contentions.  It suggests the claimant obtain a copy of the SOP if they want further detail.

• If aggravation cannot be considered because the condition developed after service a general paragraph is added to this affect.

• Any contention which has been fully investigated has a heading and details of the finding.

• Contentions for which there is no history are grouped together under the heading "Other Factors".  A few sentences indicate the findings for all these contentions.

• Contentions where there is no evidence to suggest they could apply are grouped together and dealt with in one general sentence.

• Any contention put forward by the claimant is dealt with by a paragraph at the end of the contentions.

• The final paragraph includes reference to the SOPs.

Reasons generated will need to be checked carefully. Amendments may need to be added in accordance with this outline to cover all RMA SOP contentions.  New paragraphs as outlined above that are included in the attachment should be inserted into Glossaries for ease of use.

Future SOPs

The Procedures & Training Unit will issue further updates on MBP for RMA SOP conditions as they are gazetted.

A W ASHFORD

NATIONAL PROGRAM DIRECTOR

BENEFITS

EDITED COPY OF DEPARTMENTAL INSTRUCTION

The following appendices consisting of 47 pages are attached to the original of this Departmental Instruction - B46/94.  These are purely procedural instructions for the use of Compensation staff when processing Compensation claims.  In order to reduce printing costs they have not been included in this copy of the instruction.

A full copy of the DI - B46/94 is available on 'The General' or from Compensation Section.

APPENDIX 1RMA Statements of Principles Gazetted on 14/9/1994

APPENDIX 2RMA Statements of Principles Gazetted on 21/9/94

RMA Statements of Principles expected to be Gazetted on 28/9/1994

Conditions Gazetted on 21/9/1994 for Investigation by the RMA Under S196B(4) of VEA.

APPENDIX 3Conditions Currently being considered by the RMA but SOP not yet approved.

APPENDIX 4Comparison of Commission SOPs and RMA SOPs showing most beneficial path

APPENDIX 5Example of Reasons for Decision for RMA SOP condition

APPENDIX 6Replacement paragraphs for Reasons involving RMA SOPs