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5.4 When is an Impairment Stable?
Stable - simply means it is unlikely to improve to any major degree. This should not be judged on the basis of possible improvement in impairment ratings
Permanent - means that the condition is not likely to resolve.
Essentially, it is a matter of medical evidence when an impairment becomes stable for the purposes of PI compensation. A delegate should rely, in particular, on medical opinion to establish a date when the impairment stabilised. However, the last date of any active (as opposed to palliative) treatment of the impairment may also be indicative of stabilisation, if that treatment is no longer required.
Where a condition is stable, but more information is required to determine the exact date, the question that should be asked of the treating doctor is: “Based on the available evidence and the plausible natural history of the condition(s), when was the current, stabilised level of impairment reached?”
In cases where the stability of an impairment is unclear, the treating doctor should be the first point of call. If this is unsuccessful, the delegate may consult a CMA for medical input, but rather than ask the CMA to decide a stability date, the delegate should seek an opinion on whether the evidence supports the date they are considering for their determination.
It is important to note that there is a difference between the date an impairment becomes stable and the date an impairment becomes permanent. An impairment may well be permanent (i.e. likely to continue indefinitely, or not likely to resolve) but not yet stable (i.e. further treatment is likely to provide an improvement in the impairment, such as a back injury where active treatment is being undertaken or surgery is scheduled).
In some cases impairment may be intermittent, that is, remain at a low or negligible level of impairment between discrete episodes of increased impairment. A sufferer of epilepsy who remains well between “fits” is a useful example. This does not necessarily mean that the impairment should not be considered stable. Many conditions will have periods where symptoms may be more or less severe, including fluctuations of symptoms or 'spikes' as part of their normal manifestation.
It will always be medical opinion provided by the assessing medical practitioner or the CMA that will guide a decision around the permanence and stability of a condition.
In cases where the stability of a condition, the timeframe for follow-up, or an estimate of points post stabilisation is unclear, it may be appropriate to seek the assistance of a CMA in providing a medical opinion based on the available evidence, or to liaise with the clients treating medical practitioner for clarification via a supplementary report.
Client has an accepted condition of Major Depressive Disorder and has been receiving treatment for the past 6 months. The assessing medical practitioner states that the condition is permanent, and whilst treatment to date has been beneficial, further improvement is expected with ongoing treatment over the next 6 months. On the basis of this information the conditions is considered permanent but not yet stable, therefore interim compensation is appropriate with a review recommended for 6 months’ time. On review 6 months later the assessing medical practitioner states that despite a requirement for ongoing regular treatment and fluctuations in the condition as a result of ongoing life events such as stress at work and moving house, the condition is now considered to be stable as it is not expected to improve to any further major degree.
The client has an accepted lumbar spondylosis condition and has been receiving physiotherapy for 12 months. They have a long-term treating medical practitioner who completes the requested medical impairment assessment forms and states the condition is permanent and stable at the current level of impairment.
The delegate notices the medical practitioner fails to provide the specific date at which they believe the impairment became stable at the current level.
In this instance the delegate should write back to the treating doctor, asking for their opinion on the specific date they consider the impairment became stable at the current level. The treating doctor should be able to provide a specific date as they have treated the client for many years. It is not appropriate to assume the impairment became stable at the date of the assessment or date of the report, however if upon questioning, the medical practitioner provides the opinion that the impairment became stable on the date of the assessment (based on their own medical expertise and knowledge of the condition) that date can be used.
The client has accepted osteoarthritis of the knees, shoulders and spine and has advised that the treating medical practitioner is not prepared to complete a permanent impairment assessment report.
The client subsequently agrees to consult with an independent orthopaedic surgeon and arrangements are made to obtain a medico-legal report. The orthopaedic surgeon completes the medical impairment assessment forms however states in the report that they are not able to provide a date of stability due to a lack of historical clinical information.
The delegate obtains copies of clinical notes from the client’s treating practitioner, which are subsequently provided to the independent surgeon and supplementary report requested.
Unfortunately, despite the provision of clinical notes, the independent surgeon is unwilling to provide a date of stability.
In this scenario it is the delegate’s responsibility to consider all evidence on file and ultimately decide the date the impairment became stable at the current level. As part of this process the delegate may consult a CMA for medical input, but rather than ask the CMA to decide a stability date, the delegate should seek an opinion on whether the evidence supports the date they are considering for their determination. In other words, the CMA opinion should complement and support the delegate’s determination, rather than be in place of the delegate’s determination. The CMA is not the decision maker. Where the date of assessment is the only reliable clinical date, it may be appropriate to use this date as the date of stability.