Liability assessments for compensation claims

Liability assessments determine whether a condition was caused by, contributed to, or aggravated by ADF service. Medical providers play an important role in providing information about the diagnosis, onset of the condition, and any known causes or risk factors. DVA decision makers, who are known as ‘delegates’, make a decision on liability using medical information alongside other evidence.

Providing a diagnosis

For compensation purposes, DVA needs to identify the medical condition relevant to the claim and have this established by an appropriately qualified practitioner.

Practitioners should use routinely accepted diagnostic terminology, list the condition not the symptoms, and include the specific side of the body or anatomical location where relevant. Claims cannot be assessed for symptoms (e.g. pain), investigation findings, or disease manifestations such as heart failure.

Accepted medical terminology should be used in preference to lay terminology and acronyms. These may have multiple meanings and can lead to uncertainty in claim assessment.

For example:

The diagnostic process for a compensation claim should follow the normal clinical pathway for establishing a diagnosis. Where more than one diagnosed condition contributes to the veteran's symptoms, each condition should be identified separately.

For example, a veteran with chronic low back pain may have lumbar spondylosis and an inflammatory spondyloarthropathy. If both are clinically relevant, both diagnoses should be recorded separately.

Many symptoms (eg knee pain), signs (eg heart failure) and investigation results (eg renal impairment) are the common end point of multiple conditions. Clinical judgement is therefore required to identify the condition or conditions that best explains the veteran's presentation, noting that not all findings are clinically relevant.

Supporting diagnostic evidence

Here the medical practitioner is asked to explain how the diagnosis was established.

This may include:

• relevant history
• physical examination findings
• investigation results
• specialist assessment
• diagnostic reasoning.

Where available, attach copies of relevant:

• imaging reports
• pathology reports
• specialist correspondence.

This information assists DVA in confirming both the diagnosis and the timing of the condition.

Where there are no definitive diagnostic findings or investigations, or when there is conflicting or incomplete medical information, a brief explanation of the clinical reasoning should be included. An example of this is Irritable Bowel Syndrome, for which diagnosis is based largely on history and if necessary, exclusion of differential diagnoses.

Previously established diagnoses

Veterans may present with diagnoses that were established by another GP, specialist or by the health service with the Australian Defence Force. It is not necessary to reinvestigate the condition just to complete the compensation assessment. However, it is important to consider whether the original diagnosis explains all of the veteran’s current symptoms, and whether any new or alternative diagnoses are now relevant.

Comprehensive review by medical providers of clinical records used when the veteran was serving in the Australian Defence Force is not expected. DVA staff will review these documents to identify presentations, investigations, and diagnoses relevant to the claim.

When should providers organise further clinical investigations?

For most assessments, further investigations will not be necessary. If a clinical investigation is thought to be necessary, pre-approval from the DVA delegate is required.

Once pre-approval is granted, a DVA-issued Transaction Reference Number unique to this additional work will be issued directly to the imaging provider. For more information on how this works see DVA Quick Tips for Health Providers: Billing for Compensation Claims.

Providing onset dates

Two dates are particularly important for claim assessment:

Date of first symptom(s)

This is the earliest date that symptoms attributable to the specific condition were first experienced. The date should relate to the diagnosed condition itself, rather than to any symptom occurring in the same body region, or any earlier injury.

For example:

• For Osteoarthritis, provide the date for when the chronic osteoarthritic knee pain started rather than the veteran’s ACL injury 20 years prior.
• For lumbar spondylosis, provide the date lower back pain became persistent and impactful rather than the date of the lumbar disc injury during service.

It is uncommon for an exact date to be known for many chronic conditions and a reasonable estimate of the approximate month and year is sufficient.

Date of diagnosis

This is the date the condition was formally diagnosed such as when full diagnostic criteria were satisfied, or when confirmed by medical assessment or investigation.

Backdating of onset

For many conditions exact dates may not be available and were before the involvement of the current medical provider. Where this is the case, the closest month or year to onset date should be used.

Providers should avoid estimating dates solely to place the onset of a condition within a period of service as it is not necessary for a condition to have first arisen during service for it to be accepted, and assigning an arbitrary onset date without sufficient evidence can sometimes make the claim more difficult to assess.

However, where there is clear evidence from their history that symptoms first occurred during service and were attributable to the condition, providers should record this even if the symptoms were not reported or formally diagnosed at the time.  

Providing information about causation

When completing an assessment, medical providers should give their opinion regarding the known causes and identified risk factors of the condition that are relevant to the veteran.

For example, it may be helpful to identify:

• sporting injuries or other previous trauma
• occupational activities or exposures
• relevant medical comorbidities
• smoking and other risk factors
• non-modifiable risk factors (for example age and sex).

Where no cause or risk factor has been identified, this can be stated.

DVA considers a range of information sources when assessing causation, including legislative requirements and Statements of Principle (SoPs), where applicable. However medical practitioners are not expected to have knowledge of SoPs or compensation legislation. Medical practitioners should focus on the clinical assessment and DVA will assess this against the relevant legislation and SOPs as required.

Medical practitioners should avoid stating that a condition is ‘related to service’. Assessment of service contribution is the responsibility of the DVA delegate. Instead, medical practitioners should provide a clinical opinion regarding the causes and risk factors present for that veteran's diagnosed condition, which can include occupation activities and exposure, where relevant.

For example:

• Tinnitus contributed to by repeated exposure to loud noise from aircraft and weapons fire.
• Lumbar spondylosis caused by a lumbar disc prolapse around 2010 and significant manual labour roles.
• Lung cancer due to smoking and asbestos exposure from building demolitions.