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2.5.2 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 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.
- 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.
- 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.
- 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.
- 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 HI — A.
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.
- 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:
- 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.
- There is an identified Service need. These include;
- 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)
- ADF reputation risk should the person be retained in the service
- Medical Separations where the ADF is awaiting transfer of a members care to DVA
- Urgency highlighted by Senior Leadership.
- 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.
- 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.
- 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.
- 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.