C04/1998 CLAIMS ASSESSORS TO ADDRESS CLAIMANT CONTENTION AND ALL SOP FACTORS WHEN DETERMINING CLAIMS

Part

Function

1

Gives the reasons for the instruction including its purpose and background.

2

Contains the procedures for addressing the claimants contention in reasons for decision.

3

Contains the procedures for addressing all factors contained in a Statements of Principles.

Purpose

This instruction restates the requirement for Claims Assessors to address the claimant's contention and all factors contained in a Statement of Principles (SoP) when determining a claim for Disability Pension or a claim for War Widow's pension.

Lack of file evidence that all factors are addressed

Ex-Service Organisation (ESO) representatives contend that in some cases they find through a Freedom of Information request, Section 137 report or discussion with a Section 31 Review Officer that there is no file evidence that the claimant's contention or all the SoP factors were investigated or even considered.

Deficient reasons for decision

ESO representatives also produce examples showing that reasons for decisions often contain no clear indication or finding to show that the claimant's contention has been addressed, nor do the reasons always adequately address the range of factors contained in the SoP.

ESO complaint confirmed by QA sampling

The impression gained by the veteran community that the evidence or reasons do not always indicate that all contentions or SoP factors are addressed is supported by the findings of the Death Claims QA Sampling exercise carried out last year.  That exercise showed deficiencies in addressing all possible causes of death and deficiencies in the recording of the results of investigations on file.

Contention must be addressed in reasons

In giving reasons for decisions that refuse claims for Disability or War Widow's pensions, Claims Assessors must always address the contentions made by the claimant or claimant's representative.

The reasons should indicate to the reader that the Claims Assessor has considered and/or investigated the contention, even if the contention is not covered by a factor contained in the relevant SoP, or no SoP has been issued for the condition.

Example

In a case where a claimant makes a contention that smoking led to prostate cancer, the inclusion of a bare comment in the reasons that  “...smoking is not a factor contained in the SoP for prostate cancer...” may not always be sufficient acknowledgment for the claimant to understand that his or her contention or submission has been properly considered.

A more considered response might be “....I have noted your statement in support of your claim that you commenced your cigarette smoking during service as a result the conditions of service.  I have not investigated this matter further because the Repatriation Medical Authority (RMA), after consideration of the medical-scientific evidence available to it, has not included cigarette smoking as a possible factor that can cause prostate cancer in the Statement of Principles for Prostate Cancer.”

How CCPS handles factors

Factors for many SoPs included within the CCPS tool have been divided into what are termed “above line” and “below line” factors.

‘Above line' factors are those that cover the most common contentions or factors. The “preliminary investigation” invoked by CCPS forces the Claims Assessor to individually answer questions in relation to above line factors, each in turn.

‘Below line' factors are those that occur less often or rarely. A “reject no evidence” button can be activated to reject all the below line factors at once as a group.  This facility was introduced following requests from Claims Assessors to include a way of quickly handling factors contained in the SoPs that don't often apply.

Need to consider all factors

All factors contained in a SoP must be considered before a claim involving that SoP is refused.

Although CCPS contains a facility to handle some factors in a SoP more quickly than others, this facility does not remove a Claims Assessor's responsibility to consider and make a judgement on every factor in deciding a claim.  The “reject no evidence” button of CCPS must not be invoked to dismiss a number of factors without this consideration.

This does not mean to say that each below line factor needs to be fully investigated.  For example, in exercising judgement on a particular factor it is often reasonable to expect that if the factor was present it would be mentioned in a general medical report or in the person's medical history.  In these circumstances it might be fair to decide that there is no need to investigate the SOP factor further.

If it is not reasonable to expect the medical history to cover the factor, ie the reports are specific to an unrelated disability or are not of a general nature, then further investigation may be needed.

In these instances a simple telephone call to the claimant, representative or Local Medical Officer will often be sufficient investigation to determine the possible existence, or not, of a particular factor.

Need to record consideration of factors

It should always be evident on the file that the Claims Assessor has considered all factors with a reason given for deciding not to pursue any particular factor.

In many instances a simple recording that particular factors have not been investigated because there is no evidence of their existence in the available medical history is all that is required.

Include all SOP factors in reasons

SOP included in CCPS

There should be reasons for rejection of all SoP factors included in the reasons for decision.  Automatically produced reasons for rejected claims contain a comment on factors contained in a SoP for a disability, whether or not those factors are above or below line.

In these cases the Claims Assessor should have to do no more than proof read the reasons, add a reference to the evidence on which the findings are based and, desirably, personalise the reasons to the individual claimant.

SOP not yet included in CCPS

In cases where a SoP exists, but has not yet been included in CCPS, the Claims Assessor must include a reference in the reasons to all the SoP factors if the claim is to be refused.

All factors must be addressed, even if the factors are not referred to in the claimant's contention because, in the event of an appeal, the claimant's advocate will be seeking this information.

Using ‘Auto Text' feature of ‘Word'

Claims Assessors need to ensure that reasons for decision are appropriate to and adjusted for each particular case.  The extra effort to include an informative response in the reasons for decision should be minimal as good examples of reasons for a particular circumstance can be easily stored and retrieved using the Auto Text feature in “Word for Windows”.

Care also needs to be taken that any automatically produced portion of the reasons are adjusted so that the whole of the reasons are seamless and read sensibly.

Inclusion in QA and training strategies

Because of the level of concern expressed by Ex-Service representatives about the quality of reasons, the quality of the reasons will be a focus of revised National Quality Assurance and Training strategies currently under development.

System changes

System changes are under development to ensure that Claims Assessors are prompted to address claimant contentions in their reasons for decision.