IMPAIRMENT ASSESSMENTS FOR LUMP SUM COMPENSATION AND INDEPENDENCE ALLOWANCE OPERATIONAL GUIDELINES

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1 V1.0 IMPAIRMENT ASSESSMENTS FOR LUMP SUM COMPENSATION AND INDEPENDENCE ALLOWANCE OPERATIONAL GUIDELINES This is a living document content; we ll review it regularly and amend it when it needs updating.

2 While we ve done everything we can to ensure that it s correct, the legal information in this document is only a summary. Your Impairment Assessment Service Schedule has more detailed legal information. Contents 1. Introduction... 3 Key contact details Service specifications... 5 Overview... 5 Roles and responsibilities Service Requirements... 7 ACC s referral... 7 The assessment... 7 Useful information to include in your reports... 7 Writing the apportionment sections... 8 The apportionment methods... 8 Examples of apportionment... 9 Assessing by analogy...11 Rapidly deteriorating conditions The respiratory system...12 Overview...12 Notes on some commonly incountered conditions The visual system...13 Overview...13 Example Mental injury...17 Background and context...17 Apportioning for conditions...17 Examples...17 Not otherwise specified cases...20 Example Pain...22 Overview...22 Assessment method The spine...25 Overview...25 Example...25 Rating multi-level spinal impairments Travel...28 When can you claim for travel? Invoicing...29 Additional information...29 Functional sub-units...29 Cases of did not attend...29 Accident Compensation Corporation Page 2 of 29

3 1. Introduction These guidelines aim to help ACC-approved assessors to assess ACC clients who have a whole-person impairment as a result of their injuries. The assessments help us to decide whether these clients are entitled to compensation in the form of an independence allowance or lump sum compensation. You should read these guidelines in conjunction with: The Impairment Assessment Service Schedule (your contract ) The ACC User Handbook to the AMA Guides to the Evaluation of Permanent Impairment, 4th Edition (the ACC User Handbook to AMA4) The American Medical Association Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA4 Guides). Your impairment assessments must comply with all three of these documents. We ll update these guidelines as and when required. We ll each new version to you once it s available on the ACC website at Key contact details Your role in undertaking impairment assessments on ACC s behalf is likely to involve contact with a number of our teams. Here are their contact details. ACC Provider Helpline Ph: ACC Client/Patient Helpline Ph: Provider registration Ph: Fax: Post: ACC, PO Box , Lower Hutt 5040 ACC ebusiness Ph: , option 1 Impairment Assessment and Lump Sum Units Ph: For regions north of New Plymouth and Gisborne: ACC Hamilton Service Centre, PO Box 952, Waikato Mail Centre, Hamilton 3240 Fax: Accident Compensation Corporation Page 3 of 29

4 For New Plymouth, Gisborne and all areas south: ACC Dunedin Service Centre, PO Box 408, Dunedin 9054 Fax: Health Procurement If you have a question about your contract or need to update your details, please contact the ACC Health Procurement team: Ph: Supplier managers ACC website Supplier managers can help you to provide the services outlined in your contract. Contact the Provider Helpline for details of the supplier manager in your region. For more information about ACC, please visit: Accident Compensation Corporation Page 4 of 29

5 2. Service specifications Overview Impairment Assessment Lump Sum/Independence Allowance Operational Guidelines Who qualifies for the independence allowance and lump sum compensation? ACC clients who have a whole-person impairment as a result of their injuries may be entitled to compensation in the form of an independence allowance or lump sum compensation. The independence allowance is available to those injured on or before 31 March 2002, and lump sum compensation to those injured on or after 1 April Some special rules apply if a client has a treatment injury or a work-related gradual process disease or infection, or has made a sensitive claim (for mental injury arising from sexual abuse or assault). In these cases the injury date is usually considered to be the date they first sought treatment or, for a work-related gradual process disease or infection, the date they first couldn t work. If this date was after 1 April 2002, they may still qualify for an Independence Allowance if they have a: treatment injury and the date of the treatment that caused the injury was before 1 April sensitive claim and the date on which the abuse or assault last happened was before 1 April 2002 work-related gradual process disease or infection and (in most cases) they last performed the task that caused the injury or worked in the relevant work environment before 1 April The assessment referral process Before we assess a client s application for an independence allowance or lump sum compensation, we gather all the relevant information about their impairment including whether they ve made any previous claims for an independence allowance or lump sum compensation. If the client s claim meets the criteria that allows an assessment to be undertaken, we refer them to an ACC-approved assessor for a formal assessment. The assessment involves rating the client s impairment using the ACC User Handbook to AMA4. These are sometimes referred to as the assessment tool, and set out the assessment procedures, report formatting and other requirements. Accident Compensation Corporation Page 5 of 29

6 Roles and responsibilities To be effective, impairment assessments depend on everyone involved working in partnership, with a mutual understanding of each other s roles and responsibilities. Here s a list of the key people involved in the impairment assessment process: the assessor undertakes impairment assessments and re-assessments on ACC s behalf. the independence allowance and lump sum compensation teams (in our Hamilton and Dunedin service centres) process claims for Independence Allowances and lump sum compensation. Each team is led by an ACC team manager. ACC claims officers/claims managers work with the injured clients and their health treatment providers to manage the clients claims. the ACC Branch Medical Advisor provides clinical opinions and advice on cases when required. Accident Compensation Corporation Page 6 of 29

7 3. Service Requirements ACC s referral Impairment Assessment Lump Sum/Independence Allowance Operational Guidelines When we refer a client to you we ll indicate the condition(s) that needs to be assessed and, if relevant, provide special instructions for anything else that needs to be considered. If you find any inconsistencies between the injuries we have asked you to assess please mention them in your assessment report and if you have any questions about covered injuries just contact us. See pages 3 & 4 for our phone numbers. The assessment The key aim of your assessment is to determine the client s whole-person impairment rating, using the ACC User Handbook to AMA4 and the AMA4 Guides. Your resulting report should meet the specifications of the assessment tool. The report format is outlined on page 11 of the ACC User Handbook to AMA4. Note you should only rate impairments that result from conditions we cover. Assessing a condition that our referral doesn t mention can cause delays, not to mention false expectations of compensation for the client. If a non-covered medical condition affects the body site for which you re rating the impairment, you ll need to consider apportionment (see below for more on this). Useful information to include in your reports We appreciate the time you take to draft and write your reports, which can often be lengthy and complex. The information you provide is vital to ACC, particularly when we re answering client queries. Information that s particularly useful includes: 1. The assessment date, time and duration: clients often need reassurance that you ve considered all of their injuries and taken time to listen to them 2. The injuries you ve assessed: the injuries you list in your report should be consistent with those specified in our referral documents and any additional injuries that we ve asked you to assess since our referral. This avoids any doubts about what the client was assessed for 3. Listing the documents you used in your assessment: this provides valuable assurance to the client that you ve considered all the medical information we sent you. Please also include any notes from the client; this can be important if they ask for a review of our decision on the basis that the information wasn t considered 4. Apportionment of non-covered conditions: this is a difficult area as the client will see your final impairment rating, then see it reduced. The clearer you are about your clinical reasoning for apportionment, the easier it will be for us to explain to the client why we couldn t include a specific non-covered condition in our final impairment and entitlement decision 5. Providing your clinical opinion on changes since the previous assessment: if the client s impairment has been previously rated (we ll give you a copy of the report), Accident Compensation Corporation Page 7 of 29

8 it s important that you provide your clinical opinion on any deterioration or improvement since then. This helps the client and us to understand any changes to their impairment rating 6. Accredited Employer reports: as yours is the only report that the Accredited Employer sees, it needs to be comprehensive enough for them to understand how you reached your conclusion. When writing the report, make sure you only include details about the client that are related to the injury the employer has covered. It s also important to avoid making small errors. Any error, even in the spelling of a client s name, can lead a client to doubt your report, raise concerns about possible rating errors and request a review of our decision. Writing the apportionment sections All your assessment reports should include a comment on apportionment, even if it s simply that it wasn t required. When is apportionment appropriate? You should consider apportionment when: a medical condition not covered by ACC has contributed to the impairment percentage. You ll need to apportion your rating into covered and non-covered impairments a body part (eg a lower limb) has been injured in more than one accident the impairment spans different entitlement periods (eg lump sum compensation, combined independence allowance and separate independence allowance). For example, a client may have two knee injuries, one suffered in a lump sum period and the other in a combined independence allowance period. You need to rate the current impairment and apportion the impairment to attribute the relevant percentages to the two separate injuries. This enables us to consider possible entitlements according to the claim type. Whatever method you use, remember to ensure that the final rating relates only to impairment for the condition(s) covered by ACC. The apportionment methods The question that apportionment needs to answer is: Once it stabilised, what contribution did the particular injury make to the impairment of a body part? The ACC User Handbook to AMA4 (page 10) outlines two apportionment methods: use medical records to estimate the impairment before the covered injury happened. However, this method has its challenges. For example, you might not have enough information to do this (especially if the injury happened many years ago), and a non-covered condition or issue that also contributes to the overall impairment might have developed after the covered condition. use the available records and your assessment findings and exercise your clinical judgement (as detailed in the ACC User Handbook to AMA4, page 10). Resources could include your objective findings, old medical reports, previous Accident Compensation Corporation Page 8 of 29

9 impairment assessment reports, relatives or close friends comments, and specialist opinions. Unfortunately patient histories are not necessarily reliable; in some cases the patient is convinced that all of a particular impairment is due to an accident despite other evidence not supporting this. Once you ve decided on the percentage impairment of the body part for each time period, the impairment due to each injury is simply a case of subtraction. Explaining apportionment in your report It s important that you explain your reasons for apportionment clearly and simply in your report, so that anyone reading it can understand them. Clients often want to discuss them when we advise them of our decisions, and it helps to reduce the risk of clients requesting reviews of our decisions. For example, in apportioning mental and behavioural impairment, it can be useful to comment on how the covered and non-covered conditions affect functions such as activities of daily living, social functioning, concentration, persistence and pace and adaptation and decompensation. See Section 6 on page 17 for more detail. Examples of apportionment The ACC User Handbook to AMA4 includes examples of using pre-existing impairments based on medical records. However, a non-covered impairment might have changed or be from a condition that arose after the injury. In these situations, please use your clinical judgement. Example 1 In 1982 Mr X was involved in a motorbike accident. He suffered a right-lower-tibia fracture that required internal fixation, which resulted in his right leg shortening by three centimetres (a 10% lower-extremity impairment). In October 2007 Mr X s right total hip joint was replaced owing to medical osteoarthritis. He said it healed very well and he was pain free. The available medical records confirmed this good result (a 37% lower-extremity impairment). In December 2007 Mr X fell, suffering a periprosthetic fracture of his right femur. ACC covered the injury and his right total hip joint was properly replaced in late A history and examination at the impairment assessment appointment showed a poor result, but no additional lower limb shortening (a 75% lower-extremity impairment). Mr X s available medical records showed that he suffered osteoarthritis of both knees and his left hip. He said he suffered constant back pain because of his right leg shortening, and believed the osteoarthritis affecting his right side and his back pain were a result of his 1982 injury and right leg shortening. This opinion was not supported by specialist records. Mr X had had previous diagnoses of depression, anxiety disorder and bipolar disorder. He suffered migraine headaches, had a longstanding history of chronic pain, and had a past history of head injuries and drug abuse. Accident Compensation Corporation Page 9 of 29

10 The apportionment Mr X s two covered injuries and his medical osteoarthritis can be apportioned as follows: before 1982: 0% right-lower-extremity impairment injury: 10% right-lower-extremity impairment due to the tibia fracture (10% minus 0%). October 2007 medical event: 37% right-lower-extremity impairment due to the hip replacement, combined with the pre-existing 10% right-lower-extremity impairment = 43%. The medical event thus increased the right-lower-extremity impairment by 33% (43% - 10% = 33%). December 2007 accident: 75% right-lower-extremity impairment due to the now poor hip replacement result, combined with the pre-existing 10% right-lowerextremity impairment = 78%. The December 2007 covered injury increased Mr X s right-lower-extremity impairment by 78% - 43% = 35% lower-extremity impairment. This means that Mr X has a 10% lower-extremity impairment, a 4% whole-person impairment due to his 1982 accident (which was before 1 July 1999 so stands alone), a 35% lower-extremity impairment and a 14% whole-person impairment due to his December 2007 accident (which was after 1 April 2002 so also stands alone). In this example, the medical condition is rated and apportioned as it contributes to the lower-extremity impairment. The unrelated medical conditions aren t included in the rating or the apportionment, as they re not considered to influence the injuryrelated impairment assessment. Example 2 Mr Y has a stroke causing left hemiparesis and reduced motor function in his left leg. This makes it difficult for him to walk distances and he s limited to walking on flat surfaces. Mr Y then falls and fractures his neck of femur. A subsequent hip replacement has a poor outcome when graded using AMA4 Guides (Table 65, page 87 and Table 64, page 85). It s clear that Mr Y suffered a lower-limb impairment from his medical condition before the injury. The figure to apportion can be justified using the AMA4 Guides brain and cranial nerve section or the Handbook s lower-extremity section. You could use Table 13 or Tables 38 and 39 in the AMA4 Guides (pages 148 and 77 respectively) to determine the percentage to apportion for the pre-existing impairment for the reduced lower-limb function. The assessment tool does not allow weakness to be combined with a diagnosisrelated estimate, so the highest current rating would be 30% whole-person impairment. Accident Compensation Corporation Page 10 of 29

11 The apportionment The rating would be 30% for the poor hip replacement minus 15% for the preexisting weakness. This means a 15% whole-person impairment, reflecting the effect of the hip replacement. Example 3 Mr Z fractures his ankle; it heals with 10 degrees of angulation. He later has an amputation below the knee with a 7.6-centimetre stump, following an arterial occlusion (not a covered injury). The healed extra-articular fracture with angulation was a 15% Lower Extremity Impairment, a 6% whole-person impairment (AMA4 Guides. Table 64. page 86). The current state is the amputation; a 28% whole-person impairment (AMA4 Guides, Table 63, page 83). The fracture is no longer present, but did cause impairment, so the increase in impairment from the amputation is therefore 28% - 6%, a 22% whole-person impairment attributed to the arterial occlusion and subsequent amputation. Assessing by analogy In rare situations the AMA4 Guides won t provide an impairment rating. If this happens you should determine the rating by comparing the impairment with a similar impairment of a similar body site. If you use this approach, your report must include your reasons. Rapidly deteriorating conditions When we receive a claim from a client whose health condition is rapidly deteriorating (whether it s injury or non-injury related), our staff may ask you to conduct an assessment via a file review. This will need to be done as quickly as possible so that clients can qualify for lump sum compensation. If there s likely to be a delay, please let us know as soon as possible. Accident Compensation Corporation Page 11 of 29

12 4. The respiratory system Overview Impairment Assessment Lump Sum/Independence Allowance Operational Guidelines The rating method for impairments of the respiratory system is detailed in the ACC User Handbook to AMA4 Guides (page 450). However, it has been modified in relation to mesothelioma. Notes on some commonly incountered conditions Mesothelioma When we receive a claim from a client who has mesothelioma, our staff work closely with them and their case manager to establish whether the client is well enough to attend a face-to-face assessment or their medical condition means the assessment needs to be done via a file review. Either way, it s important that an assessor undertakes the assessment, to ensure an official and independent interpretation of and report on the clinical information. In 2005, ACC determined that clients with confirmed diagnoses of mesothelioma would automatically be given a whole-person impairment rating of 80% irrespective of their clinical condition. Currently this is the only cancer rated in this manner. When you receive a referral for a client with mesothelioma, please arrange your assessment quickly. If for any reason there s a delay in seeing them, let us know as quickly as possible. Lung cancer Please use the method in the ACC User Handbook to AMA4 (page 45) to assess clients with lung cancer other than mesothelioma. Clients with cancers at other body sites should be rated using the relevent chapters in the AMA4 Guides. Asbestosis/pleural plaques When we receive a claim from a client who has asbestosis or pleural plaques, we ll provide you with lung function tests from the previous 12 months. If these aren t available we ll arrange a test before we send you the referral. As asbestosis typically causes a restrictive defect on spirometry, this is the component that s usually rated. It can be difficult to apportion for co-existing lung disease, such as when there is a mixed picture with an element of obstruction on spirometry, for example smoking. If needed, we can arrange for a respiratory physician to comment on the proportions of the client s obstructive and restrictive breathing impairments. This will help you support your rationale for apportioning breathing impairment from exposure to asbestos as opposed to non-acc-covered conditions. Accident Compensation Corporation Page 12 of 29

13 5. The visual system Overview The rating method for clients visual systems is detailed in the ACC User Handbook to AMA4 (pages 54-55). If a client has a visual field defect, the referral documents you receive should include a recent optometrist s assessment indicating its full extent. If the client needs visual field testing beyond 30 degrees, please contact one of our service centres; they have the details of providers who undertake these tests. Example Mr A was cutting a tensioned wire when it sprang back, knocking off his safety glasses and penetrating his right eye. An urgent repair was attempted, but after the operation it was noted that the retina had detached. An assessment also revealed a cataract in Mr A s left eye, which was considered unrelated to the trauma. A visual acuity examination revealed: Right eye- light perception only Left eye 6/12, n8 Despite further surgery to his right eye, Mr A s vision in the right eye was completely lost. Calculating the impairment In calculating the impairment due to Mr A s injury, the assessor needs to consider the impairment before the injury, as Mr A s visual system was already impaired owing to the cataract in his left eye. Assuming the right eye had normal vision before the injury, the impairment calculation using the worksheet from the ACC User Handbook to AMA4 (page 71) would be as follows: Accident Compensation Corporation Page 13 of 29

14 Topic Comment Right Left Monocular aphakia is No No present Visual acuity (VA) distance (Snellen) See AMA4 Guides, Table 2, page 211 6/6 20/20 6/12 20/40 A VA near See AMA4 Guides, Table 2, page 211 Also see Visual Acuity near on page 54 of the ACC User Handbook to AMA4 NS 14/18 NB 14/24 B Percent loss of VA Combine A and B for each eye (see AMA4 Guides, Table 3, page 24, including footnote) Note: Aphakia = loss of lens Pseudophakia = artificial lens Loss of visual field (VF) See Visual Fields page 55 of the ACC User Handbook to AMA C 0 0 D Loss of VA combined with loss of VF Loss of ocular motility (OM) (diplopia) Combine C and D for each eye See AMA4 Guides, page 322 Enter under worse eye See AMA4 Guides, section 803, Figure 3, page E 0 0 F Loss of VA, VF and OM For worse eye, combine E and F. For the other eye, transfer E to G. See AMA4 Guides, page G Other ocular functions and disturbances Loss of VA, VF and OM and ocular dysfunction Convert both eyes to the visual system May combine 5%-10% impairment for an ocular abnormality or dysfunction if you believe it isn t adequately reflected in the VA, VF or diplopia testing (see AMA4 Guides, page 209, paragraph 3) Enter any rating you assess under the involved eye Justify in your report If an eye has additional impairment, combine G and H If not, transfer G to I See AMA4 Guides, page 322 See AMA4 Guides, Table 7, page H 0 11 I 3 J Convert the visual systems to whole person Convert J to whole person See AMA4 Guides, Table 6, page K Cosmetic deformities Can allow for permanent cosmetic deformities causing up to 10% whole-person impairment See AMA4 Guides, page 222, section 8.5 Grand total Combine K and L See AMA4 Guides, page 322 This is a 3% whole-person impairment. 0 L 3 M Accident Compensation Corporation Page 14 of 29

15 Following the injury and failed salvage surgery. The rating is: Topic Comment Right Left Monocular aphakia is present No No VA distance (Snellen) See AMA4 Guides, Table 2, page 211 6/12 A 20/40 VA near See AMA4 Guides, Table 2, page 211 Also see Visual Acuity near on page 54 of the ACC User Handbook to AMA4 NB 14/24 B Percent loss of VA Combine A and B for each eye (see AMA4 Guides, Table 3, page 24, including footnote) Note: Aphakia = loss of lens Pseudophakia = artificial lens Loss of VF See Visual Fields page 55 of the ACC User Handbook to AMA C D Loss of VA combined with loss of VF Combine C and D for each eye See AMA4 Guides, page E Loss of OM (diplopia) Enter under worse eye See AMA4 Guides, section 803, Figure 3, page 217 Loss of VA, VF and OM For worse eye, combine E and F. For the other eye, transfer E to G. See AMA4 Guides, page F G Other ocular functions and disturbances Loss of VA, VF and OM and ocular dysfunction Convert both eyes to the visual system Convert the visual systems to whole person May combine 5%-10% impairment for an ocular abnormality or dysfunction if you believe it isn t adequately reflected in the VA, VF or diplopia testing (see AMA4 Guides, page 209, paragraph 3) Enter any rating you assess under the involved eye Justify in your report If an eye has additional impairment, combine G and H If not, transfer G to I See AMA4 Guides, page 322 See AMA4 Guides, Table 7, page 219 Convert J to whole person See AMA4 Guides, Table 6, page H I 33 J 31 K Cosmetic deformities Can allow for permanent cosmetic deformities causing up to 10% whole-person impairment See AMA4 Guides, page 222, section 8.5 Grand total Combine K and L See AMA4 Guides, page L 31 M Accident Compensation Corporation Page 15 of 29

16 The impairment relating attributed to the right eye injury is therefore 31% - 3% = 28% whole-person impairment after apportionment. Note that in this example an injury for a person with already compromised vision results in a higher impairment rating than if they had had normal vision beforehand. It is important to use the visual impairment worksheets in the ACC User Handbook to AMA4 (page 71), to support your rating and apportionment. Using prostheses in assessment A client s visual system is tested with glasses or corrective lenses if they usually wear them. However, the AMA4 Guides (page 9) also refer to the use of prostheses in assessments. A client who s lost an eye may wear a cosmetic prosthetic eye, which isn t considered to be a contact lens as it doesn t correct vision. As it can be removed easily, the client s impairment can be assessed without it. This attracts a cosmetic rating; the AMA4 Guides (page 222) allow up to 10% impairment in this case. Accident Compensation Corporation Page 16 of 29

17 6. Mental injury Background and context Historically two broad approaches have been used to apportion a client s total claimrelated impairment in relation to mental injury: 1. Focus on the covered mental injury or condition (eg post-traumatic stress disorder [PTSD]) and exclude from the current impairment any impairment not related to this condition. 2. Focus on the factors that led to cover (eg sexual abuse, genetics, upbringing). Deduct a proportion of the current impairment based on those factors contribution to the current state, including the covered injury where it s been caused by a number of factors. Both methods can be supported using the ACC User Handbook to AMA4. However, they can result in inconsistent and inequitable outcomes for clients owing to the different levels of assessed claim-related impairment that result, which can affect whether they qualify for entitlements, and the levels of those entitlements. The issue is all the more important given that mental and behavioural impairment assessments are by their nature relatively subjective. Apportioning for conditions Apportioning for conditions, which focuses on the covered mental Injury, is our confirmed approach to mental injury apportionment in impairment assessments. Under this approach: there s no apportionment of the covered mental injury. any impairments due to non-covered conditions, non-covered symptoms or behaviours (even when these don t meet a diagnostic threshold) are deducted. This approach can also be applied to rating behaviours and symptoms where the diagnostic criteria for a formal mental health condition that ACC has covered are no longer met. For example, if a client has previously received mental injury cover for a particular condition, and a new assessment finds that they don t have the condition or the condition no longer meets the full diagnostic criteria, symptoms related to the previously diagnosed condition might still continue. The impairment due to these symptoms can be rated in an assessment. Examples A client has cover for PTSD caused in part by sexual abuse in New Zealand and in part by earlier sexual abuse overseas. The client has another diagnosis (major depressive disorder), which isn t covered by ACC and pre-dated the sexual assault in New Zealand. The client s current presentation is thought to relate mainly to PTSD. Accident Compensation Corporation Page 17 of 29

18 How should the client s mental and behavioural impairment be rated and apportioned? As the PTSD is the covered injury, it shouldn t be apportioned even though the overseas event may have contributed to the cause. Cover for this episode of PTSD has been established. The current impairment rating determined by using Chapter 14 of the AMA4 Guides and the ACC User Handbook to AMA4, is thought to relate mainly to PTSD. There s no apportionment for PTSD, but some apportionment would be expected for the impairment that doesn t relate to PTSD (in this case the major depressive disorder). This can be achieved, as detailed on the Handbook (page 10), by deducting the impairment that existed before the PTSD from the current impairment rating, or alternatively by using your clinical judgement. It might be helpful to use mental and behavioural functional classifications (that is activities of daily living, social functioning, concentration, persistence and pace and adaptation and decompensation ) to justify the extent of apportionment for non-covered conditions PTSD Major Depressive Disorder Unimpaired In this case apportionment would be for the major depressive disorder component: 36% - 8% = 28%. In this example, what if the New Zealand sexual abuse was part of the overall background to the major depressive disorder, but not a material cause? The impairment rating is for the injury covered by ACC. If we don t cover the major depressive disorder, it should be apportioned. The impairment rating is not of the sexual abuse (the event) but of the covered injury condition resulting from it (in this example PTSD). Accident Compensation Corporation Page 18 of 29

19 When calculating a mental and behavioural impairment rating should I apportion only for diagnosed mental health conditions that aren t covered? In all physical and mental impairment assessments, apportionment is necessary when the impairment has been caused by multiple conditions. The current impairment is rated, then apportioned into covered and non-covered impairments. The non-covered impairment is deducted from the overall current impairment, leaving the injury-related component. In the case of mental and behavioural impairment, the apportionment should be for all impairment not arising from the covered condition. It may reflect non-covered conditions with a formal psychiatric diagnosis, but will also include factors that contribute to the overall mental and behavioural impairment rating and that are separate from the covered mental injury PTSD Major Depressive Disorder Unimpaired Poor Education In this example, the total impairment using the mental and behavioural tables relates to PTSD, major depressive disorder and poor education (considered to be separate from the PTSD and not causing it). The apportionment would be for major depressive disorder and poor education: 40% - 7% -7% = 26%. A client has cover for borderline personality disorder and polysubstance abuse, and while sexual abuse contributed to these conditions there were many other contributors. How should these be apportioned? If the impairment relates fully to borderline personality disorder and polysubstance abuse, the causal factors for these conditions should not be apportioned. If you Accident Compensation Corporation Page 19 of 29

20 believe there was impairment unrelated to the conditions, it should still be apportioned with an appropriate explanation. The referral letter doesn t detail an injury, but simply refers to the read code sexual abuse head nos (not otherwise specified). What should I rate? If you need help identifying the covered injury or extent of cover, contact the impairment assessment unit before you undertake the assessment or write your report. Not otherwise specified cases There are some cases where there is no clear specified mental injury accepted historically by ACC. This may relate to claims accepted under the 1972 or 1982 Accident Compensation Act, where cover was extended to the physical and mental consequences of injuries and accidents, or to historically accepted Sensitive claims under the 1992 Accident Rehabilitation and Compensation Insurance Act for mental or nervous shock. There may not be enough evidence for a psychiatrist who sees the client now to determine their diagnosis at the time cover was accepted. In these situations the clients are covered by ACC and have a right to apply for Independence Allowances for those covered injuries. If a client meets ACC s legislative requirements for an assessment or a reassessment of their impairment, we re legally required to make that happen. We ll refer the client to you for an assessment based on the cover granted when we first received their claim. If the cover at that time is unclear, we ll ask you to use your clinical experience to rate the effects of sexual abuse using the historical medical notes and a recently provided psychiatrist opinion. Example We have accepted a client s sensitive claim for sexual abuse. Historical counselling reports noted symptoms of PTSD, anxiety disorder and some borderline personality traits, but no relevant clinical opinion or diagnosis was sought at that time. A recent psychiatric assessment diagnosed major depressive disorder, with the psychiatrist noting that the abuse was not a material cause but one of several factors in the background to the depressive disorder. The recent assessment can t confirm from the historical notes that there was a previous diagnosis of PTSD, and if it was evident at that time, there are no longer any symptoms of PTSD. There are some borderline personality traits, but not enough for diagnosis. Given that there isn t enough information to establish that ACC made an error in providing cover when the claim was lodged and no evidence of a diagnosis by someone duly qualified, the client is entitled to have their current impairment level rated. Accident Compensation Corporation Page 20 of 29

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