As outlined at 9.1.1 [2], Delegates may only accept liability for a defined medical condition.
The condition claimed by the employee on the claim form is, at the start of the Delegate's investigation, an alleged condition only. The matter of defining what – if anything – the employee suffers from must be resolved before inquiring as to whether that condition can be attributed to ADF employment.
It is important for the Delegate to be as accurate and specific as possible in detailing the actual diagnosis of the condition claimed by the client, including whether the injury is left, right or bilateral. If the diagnosis supplied by the client's doctor (i.e. accompanying the claim form) is inadequate, it is important to follow up with the doctor concerned.
An example of an insufficiently specific description would be 'ligament/tendon damage left knee' if the injury were in fact 'rupture to the anterior cruciate ligament left knee'. The latter, more specific description would enable future claims managers to differentiate between the accepted condition and a later, non-compensable injury to the fibular collateral ligament of the same knee.
General descriptions such as 'shoulder injury', 'knee injury' or 'low back pain' should not be used at all. All reasonable efforts should be made to find a specific diagnosis and it is this specific medical diagnosis for which we accept liability.
In fact Delegates should not usually accept 'pain' however described, as a compensable matter. Pain is usually a symptom, rather than a medical condition in its own right.
Nevertheless, there are exceptions, i.e. psychological ailments where pain occurs without physical cause. These pain syndromes, if present, should be noted as such. Similarly, 'stress' is not an acceptable description of a psychological disease. A more specific diagnosis of the actual claimed condition is required.
The ICD (International Classification of Diseases) is an international standard for classification of morbidity and mortality information and for the indexing of hospital records published by the World Health Organisation. ICD-9 and ICD-10 are now widely utilised in Australia, including by the Commonwealth Department of Health and Family Services for national health statistics and by the Commonwealth Department of Veterans' Affairs for disability and MRCA claims processing.
At this stage, there is no requirement that a doctor should identify the appropriate ICD code(s) for use in processing a claim under the SRCA. Please note, however, that ICD codes should be obtained wherever this is convenient because:
Where the employee is or was a full time member of the ADF, reference to that employee's service Medical File will often provide an accurate diagnosis of the claimed condition. These medical notes and reports are contemporary with the injury and are therefore the preferred source of information in most cases.
The issue of access to these medical documents and the employees statutory obligations to provide medical certification of injury with the claim form has already been dealt with in this Handbook at 6.5 [7]. However, for the sake of completeness of this present instruction, the following extracts from 6.5 are repeated here:
Delegates should be aware that full-time ADF members are not permitted to access medical attention other than through the ADF Health Service so that any injury whilst serving could not be recorded anywhere else other than the employee's medical file. Because RCG is in fact the employer's (i.e. the ADF's) insurer, these records are deemed to be already in RCG's possession.
However for practical purposes the initial onus is on the employee to obtain and supply the relevant supporting medical evidence. This merely means that Delegates can ask the client to produce copies of the relevant folios from the ADF Medical File. This is a matter of administrative convenience and particularly appropriate where the member is still serving and therefore has greater access to the medical file than does DVA.
Delegates should however take over this task where the employee is having trouble meeting this requirement.
Clients declining to participate in the recovery of Defence documents should not, in view of the Commonwealth's status as the owner of the medical records, be penalised in any way for this refusal. The Delegate should instead undertake a prompt document search by means of a DOCTRACKER request to the SAM team. In the case of a discharged member, the request should also be made through SAM.
In fact, Delegates should not hesitate to apply directly to SAM for copies of all relevant medical documents from file, in cases where matters of diagnosis and date of onset of a condition are unclear, based on documentation provided by the employee. Cases have been known where employees have edited those medical documents which come into their possession, i.e. prior to passing these to the Delegate. Delegates may therefore choose to request ADF Health Records directly through a DOCTRACKER request to SAM, in all contentious cases involving diseases.
It may also occur that a Delegate becomes aware that a claimant has a medical report or other relevant document in their possession and has chosen not to provide it for consideration. However, S58 gives the Delegate power to demand documents relevant to the claim and which are in the employees possession. Section 58 also refers to documents which the claimant '...may obtain...without unreasonable expense or inconvenience..' In that situation the Delegate may refuse to deal with the claim unless the employee complies within 28 days. It is however rare to invoke S58 in respect to a full-time member of the ADF because the document is usually available from other sources (i.e. ADF Health or DVA's VEA files).
Nevertheless the 'obtain ...without unreasonable expense...' provision of S58 may sometime relevant and of use in Reserve employees cases: See 9.2.10 [10] – 9.2.12 [11].
RCG Delegates may also seek those ADF medical documents contemporary with injury and also pre-existing post discharge medical assessments from DVA's files relating to the employee's claims under the VEA.
Nevertheless, having obtained access to a VEA file dealing with the same injury, Delegates should use some caution in determining liability under a worker's compensation Act using medical data gathered for the purposes of separate legislation. The Acts have different acceptance criteria and the focus of attention on medical issues is quite different in some cases.
The situation for reserves members injured on training nights or annual camps is quite different to that of a full time serving ADF member. Reservists do not receive general, full-time medical care from the ADF. They access their own on-going medical care on the same footing as the rest of the general population. This means that most of the medical and treatment notes are not owned by the Department of Defence but are scattered among whatever medical providers the reservist chooses to consult.
Reservists will however receive health care (through Defence Health Services) for injuries or illness resulting from their Defence service until such times as the transfer of the member into the RCG scheme is complete. That is until a decision is made by RCG including the reconsideration process. Details of these processes are contained in DI(G) 16-1, amendment 4 dated 8 May 2002.
Reserves claimants should instead be briefed on their responsibilities, and the need for them to provide medical evidence from a doctor – preferably the treating specialist rather than a GP – with a clear diagnosis of the injury, and any other medical information relevant to the claim. They should be told verbally and in writing that while RCG may receive and acknowledge the claim we are unable to start processing or to finalise that claim until we have a diagnosis from a treating doctor.
Delegates may make the reserves claimant aware that S58 of the SRCA gives the Delegate power to demand documents which the claimant can 'obtain...without unreasonable expense or inconvenience' or, after 28 days, decline to deal with the claim. However, Delegates should also hesitate to formally invoke S58 while there are still other, more consensual methods of obtaining the required information.
The Delegate may exercise discretion to approach the claimant's nominated treating doctors directly for a diagnosis and other related opinions, where direct interrogation appears more efficient. This may be preferable where the 'injury' is in fact a disease and the Delegate therefore needs very specific information. The Authority signed by the claimant at part 8 of the Claim Form D2020 is sufficient to permit a Delegate to make this approach without further approval by the claimant. Note however that the written request to the doctor will need to include a copy of this Authority. While GP advice may be acceptable, a report from a treating specialist (if there is one!) would be preferable.
Rarely, the Delegate may become aware that the reservist holds medical documents relevant to the case but refuses to make these available. This may occur where a lawyer acting for the claimant has commissioned a medical report but has subsequently suppressed it because the report does not find what the advocate was expecting. Delegates have the power under S58 to demand such a report and to refuse to deal further with the claim unless it is delivered within 28 days. In practice, S58 is very seldom used, not least because of the difficulty of discovering that the claimant has a relevant document in his/her possession.
Delegates may find that the ADF medical notes, even those contemporary with the alleged injury, report symptoms but do not contain a valid diagnosis. Similarly, reports or letters from a reservist's GP or even the treating specialist may not contain a satisfactory diagnosis either.
In that case Delegates are empowered by S57 of the SRCA to require the claimant to attend a medical examination by a doctor of the Delegate's choosing. This requirement is enforceable. Failure to attend the examination without reasonable excuse leads to automatic suspension of the case.
In the context of this present discussion, the purpose of such a medical examination may be only to clarify the diagnosis (i.e. what, if anything, the claimant suffers from). However, the usual practice is to ask the examining doctor to report on a whole suite of issues, including the nexus between any diagnosed injury and employment, current capacity for employment etc.
Issues related to medical examinations and reviews have therefore been consolidated at part 12 of this Handbook and Delegate's seeking guidance on clarifying a diagnosis by means of an independent medical opinion should refer to that section.
Links
[1] https://clik.dva.gov.au/user/login?destination=node/20453%23comment-form
[2] https://clik.dva.gov.au/military-compensation-srca-manuals-and-resources-library/liability-handbook/ch-9-defining-injury/91-what-consequences-employment-are-compensable/911-diagnosable-medical-conditions
[3] https://clik.dva.gov.au/user/login?destination=node/20207%23comment-form
[4] https://clik.dva.gov.au/user/login?destination=node/20492%23comment-form
[5] https://clik.dva.gov.au/user/login?destination=node/20396%23comment-form
[6] https://clik.dva.gov.au/user/login?destination=node/20109%23comment-form
[7] https://clik.dva.gov.au/military-compensation-srca-manuals-and-resources-library/liability-handbook/ch-6-claims-compensation/65-claim-be-accompanied-medical-certificate
[8] https://clik.dva.gov.au/user/login?destination=node/20504%23comment-form
[9] https://clik.dva.gov.au/user/login?destination=node/20221%23comment-form
[10] https://clik.dva.gov.au/military-compensation-srca-manuals-and-resources-library/liability-handbook/ch-9-defining-injury/92-need-clear-and-accurate-diagnosis/9210-delegates-discretionauthority-approach-reservists-doctor
[11] https://clik.dva.gov.au/military-compensation-srca-manuals-and-resources-library/liability-handbook/ch-9-defining-injury/92-need-clear-and-accurate-diagnosis/9212-medical-examination-commissioned-delegate
[12] https://clik.dva.gov.au/user/login?destination=node/20199%23comment-form
[13] https://clik.dva.gov.au/user/login?destination=node/20439%23comment-form
[14] https://clik.dva.gov.au/user/login?destination=node/20226%23comment-form
[15] https://clik.dva.gov.au/user/login?destination=node/20106%23comment-form
[16] https://clik.dva.gov.au/user/login?destination=node/20303%23comment-form
[17] https://clik.dva.gov.au/user/login?destination=node/20146%23comment-form