2.6 Medical certificates

Part of investigating a person’s eligibility for payment will involve seeking medical evidence to support the contention that the person is incapacitated due to their accepted condition/s.

Neither the DRCA nor MRCA defines what type of medical evidence is required to establish eligibility for incapacity payments.  While minimum certification requirements have been developed (as below), the delegate must still determine what evidence is required in each case (i.e. GP, treating specialist or independent specialist). The following factors should be considered and may indicate that specialist evidence is required:

• Whether the person has psychiatric conditions, multiple injuries, sequelae conditions or whether there is contribution to the incapacity by non-compensable injuries.

• The time between the claim and the date of injury, date of discharge or the last period of incapacity.

• The quality of the medical certification. Delegates are able to seek further justification for a medical certificate from its author or seek another opinion provided they have a reasonable basis for doing so.

• Any other relevant information i.e. evidence to suggest the person has left suitable employment for reasons other than their accepted injury but the person has a GP certificate.

In most cases the medical opinion of the person’s treating medical specialist is preferred (provided that the specialty is in the relevant field), though it may be appropriate to obtain advice from an Occupational Physician rather than a person’s specialist.

Certification for those participating in the Wellbeing and Support Program (WASP)

When a person is participating in the WASP, this should be considered similar to a non-return to work rehabilitation plan and medical certification indicating the person is incapacitated for work is required to support ongoing payments.  

* A Medical Capacity for Work questionnaire is available on Sharepoint. However a comprehensive medical report or certificate of any format that satisfies the delegate of the person's capacity for employment and ability to participate in rehabilitation is acceptable.  The doctor completing the report or certificate should be made aware of the scope of DVA's rehabilitation support available to veterans.

In exceptiional circumstances, if the delegate is satisfied that new medical evidence is not required at the 6 pay review to support payment of incapacity compensation beyond 12 weeks, the reasons for this should be documented.

See section 4.10 of the Incapacity procedures manual for more  guidance.

2.6.1 Qualifications of those persons certifying incapacity

The DRCA contains reference to treatment, and claims supported by a certificate, from a 'legally qualified medical practitioner'. Subsection 5(2) of the MRCA defines medical practitioner as a person registered or licensed as a medical practitioner under a law of a State or Territory that provides for the registration or licensing of medical practitioners.  The approach adopted under both the DRCA and MRCA is that medical certificates can only be accepted from a registered or licensed medical practitioner.

2.6.2 Retrospective periods of incapacity

A medical certificate must be signed and dated by the certifying doctor on the day of the examination. Medical certificates covering retrospective periods of incapacity i.e. a period prior to the date of the examination, may be acceptable in limited circumstances:

• the certifying doctor was responsible for the care of the client during the whole period, or
• evidence of hospital admission or a continual period of care encompassing the retrospective period, or
• clinical notes available to the doctor which establish that the incapacity existed, or
• the doctor has other evidence which is sufficient for them to establish that a retrospective period of incapacity is consistent with the clinical presentation on the day of examination.

The certifying doctor should include the basis on which the retrospective period was certified. For example "based on clinical notes available to me." Otherwise advice may be sought from a Contracted Medical Advisor (CMA) in order to provide a further opinion i.e. that based on the current presentaiotn of the condition it would be consistent that the client was also incapacitated for a previous period. The level of investigation required would be guided by how far back the retrospective period goes.

A retrospective period of incapacity should not be denied based on the reason it is retrospective alone. A retrospective period on a medical certificate will be the basis to seek further clarification (if required).

2.6.3 Waiving the requirement for current medical certification

In certain circumstances, such as those clients who are ‘Category A’ the requirement for ongoing medical certification may be waived (see section 4.10.4 of the procedures manual).

Where a Category 'B" client is working full-time, and the contemporary medical evidence shows no variation of that capacity over a sustained period, i.e. we are satisfied based on medical advice that the condition is unlikely to change, then no further medical certification should be sought.

Should the client report a change in capacity, contemporary medical evidence will be required.

2.6.4 Minimum requirements of a valid medical certificate of incapacity

To substantiate a person’s incapacity as a result of an accepted condition, a medical certificate should:

• state the medical cause of the incapacity, and/or list all conditions contributing to the incapacity

• state the degree of incapacity, for instance wholly incapacitated for all work, or partly incapacitated for work or capable to work with some restrictions. If only partly incapacitated, the certificate should indicate the residual capacity i.e. in terms of daily hours and days per week. If capable of some work but with restrictions those restrictions should be clearly specified, for example... ‘no bending or stooping’ or ‘no lifting more than 10k’ etc.

• specify the period of the incapacity i.e. contain both the start and end date of the period certified. Open-ended certificates and those claiming the person is incapacitated indefinitely’ or ‘Totally and Permanently Incapacitated’ are generally not acceptable (see section 4.11.4 of the procedures manual). The end-date of the certificate should be that date at which the doctor anticipates the incapacity will have ceased or at least changed in degree.

• identify the person providing the certificate in addition to a signature (i.e. an indecipherable signature is not sufficient identification), and the provider number, address, phone or contact details of that doctor

• must contain the date of examination/consultation.