What is medical evidence for Disability Support Pension (DSP)? 008-03030010

Customers who provide no medical evidence may have their claims rejected.

Medical evidence is not generally required to be lodged with the claim where the customer:

• is claiming DSP and in receipt of a Department of Veterans' Affairs (DVA) Disability Compensation Payment at Special Rate (Totally and Permanently Incapacitated (TPI)) paid under the Veterans’ Entitlements Act 1986, and can provide a copy of their Special Rate decision letter from DVA or give authority for the agency to obtain the relevant payment and medical information from DVA. This letter provides information regarding the impairment rating and work capacity as determined by DVA
• has been identified as medically eligible for DSP by an Assessor as a result of an ESAt being upgraded to a JCA report which indicates a suitable impairment rating and continuing inability to work
• is a vulnerable customer and a diagnosis of a medical condition can be provided by an Assessment Services Psychologist as part of a Specialist Assessment. For example, a customer with suspected mental health conditions is unable or unwilling to obtain suitable medical evidence outside the assessment process

Assessment Services will assess if there is sufficient medical evidence to assess the claim.

If a Service Officer determines there is a current and valid assessment or current medical evidence for a customer claiming via an online or Assisted Customer Claim (ACC), the required task can be marked as Not required or as Provided via the Request and Manage Customer Tasks (RMCT) guided procedure.

A customer can submit an online claim without medical evidence if they meet any of the following exception criteria at the time of claim submission:

Manifest eligibility

The customer indicates they:

• are permanently blind
• have a terminal illness with a life expectancy of less than 2 years
• require nursing home level care palliative care or equivalent support or supervision from a carer
• have an intellectual disability with an assessment IQ of less than 70
• have category 4 HIV AIDS

Vulnerable (in crisis)

The customer indicates they:

• have been affected by family and domestic violence
• have been in prison or psychiatric confinement for 14 days or more
• are a humanitarian entrant in Australia for the first time
• gone through a natural disaster not covered by the Disaster Recovery Payment

CCM exception criteria or other reasons

The customer:

• has a current (or recently expired) serious illness (ISI) exemption
• is in receipt of a Department of Veterans' Affairs (DVA) Disability Compensation Payment at Special Rate (Totally and Permanently Incapacitated (TPI)), paid under the Veterans' Entitlements Act 1986
• is Illness Separated
• is Indigenous and lives in a remote area
• is in psychiatric confinement
• is claiming JSP Provisional within the DSP online claim and who have all the required documentation for their JSP (but not necessarily for their DSP) claim

If a customer meets 1 of the above criteria, they can submit their DSP online claim without all required documents being provided, including medical evidence. These claims are referred to the Medical Assessment Team (MAT) for an assessment, using a separate work item. The MAT assessor may contact the customer or health professional to discuss medical evidence before making a recommendation.

Once the MAT assessment is completed, the claim is allocated to a Service Officer to action the MAT recommendation.

Medical evidence may consist of the following:

• medical history report/print outs:
• specialist medical reports
• allied health professional reports, such as physiotherapy or audiology reports, and
• psychologist reports
• medical imaging reports
• hospital/discharge summaries and outpatient letters/treatment summaries
• request for Optometrist/Ophthalmologist Report (SA013) for a customer claiming/receiving DSP on the basis of permanent blindness
• report from a special school, for a customer with an intellectual disability, which assesses intellectual function and adaptive behaviour. This information must be supported by a psychologist, and should include information about the customer's IQ score, or ability to undergo IQ testing
• Verification of terminal illness (SA495) form
• medical or case reports from workers compensation processes
• under limited circumstances a diagnosis of a medical condition can be provided by an Assessment Services Psychologist as part of a Specialist Assessment
• conversations between the Assessor or the Health Professional Advisory Unit (HPAU) and the customer's treating health professional documented in the SA463 MAT, JCA or DMA report
• medical certificates (SU415) and Verification of medical conditions form (SU683)
• foreign pension medical report (AUS176); carer medical reports (SA332/SA333); mobility allowance medical reports (MA002)

An Assessor will consider all available medical evidence, if limited or no evidence has been provided the Assessor may make a recommendation that insufficient evidence was provided to assess medical eligibility.

Note: a hearing self-assessment report from a touch screen facility is not sufficient evidence for an Assessor to make an assessment of impairment of hearing function for a DSP claim. The diagnosis must be made by a medical practitioner and a supporting audiogram from an audiologist must be provided.

• information provided by the customer at the medical details section of:
• the DSP online claim which may be available in the Claim Summary and in the electronic Medical/Sensitive Information File Envelope (eMIFE)
• the Claim for Disability Support Pension (SA466). (These are removed and scanned in the MIFE. The 'Office use only' box must also be completed)
• medical reports such as the SA012 may be accepted if provided, but cannot be issued or requested by the agency
• the Disability Support Pension Medical evidence requirements Information for treating health professionals (SA478) form if provided, but it cannot be requested by the agency - only the two-page checklist section at the back of the form needs to be scanned to the eMIFE.
• Employment Assistance - Customer information (SU478) (for assessments made before 1 July 2006)
• social worker reports
• assessment of a customer's IQ:
• a number of assessments may be used by the Assessor and Services Australia as the basis for assessing a customer's FSIQ, diagnosing Intellectual Disability, and assigning an impairment rating for DSP
• if the Assessor has conducted or arranged the IQ test as part of the specialist assessment, the type of test should be identified in the JCA report. This may not be required if an assessment of the customer's FSIQ is included in other medical evidence provided to the agency and the Assessor, for example a psychologist report or letter from a special school

See Job Capacity Assessments (JCA).