Greater emphasis has been given throughout this Guide to functional loss as a basis for assessment. It is measured by reference to an individual’s performance efficiency compared with an average, healthy person of the same age and sex, in a set of defined vital functions. This is a means of compensating for the loss of ability to perform everyday functions.
Each table contains benchmark values, generally at intervals of five points. In some cases the range between nil and five includes a rating of two points. In some other cases intervals are greater than five points because lesser increments of impairment cannot be distinguished.
Each benchmark is a threshold value, that is, the rating applies only if the threshold is achieved or exceeded. Ratings are not to be rounded up to the next benchmark. Similarly, ratings between benchmark values contained in the tables are not to be interpolated.
In some tables more than one criterion is stated opposite a benchmark value. The different criteria are marked by dot points. Where more than one criterion is stated for a particular value, the condition being assessed has to satisfy one of the criteria in order to attract the impairment rating of that value.
Each chapter contains step‑by‑step instructions to be followed in the use and application of the tables.
Determining compensation payable
This Guide specifies the only way of determining the amount of compensation payable is by reference to the maximum compensation that can be paid. The maximum is specified in the Act as a weekly amount. It becomes payable only when a person’s impairment rating reaches 80 points.
The Guide includes tables that will give a compensation factor for different impairment and lifestyle ratings. Different tables are used for warlike and non‑warlike service and for peacetime service. The maximum compensation is multiplied by the compensation factor to give the weekly amount of compensation payable.
Medical impairment
Under this Guide medical impairment has two components:
(a) physical loss of, or disturbance to, any body part or system; and
(b) the resultant functional loss.
Whole person impairment
Medical impairment is expressed in impairment points, out of a maximum rating of 100. On this scale, zero corresponds to no impairment or negligible impairment from accepted conditions, and 100 points corresponds to death. Effectively, impairment points are percentages of the impairment of the whole person.
Loss of hearing, loss of taste, loss of smell, loss of a finger or of a toe as impairment for a single condition can be compensated for under this Guide only if a threshold value of 5 impairment points is reached. Any combination of loss from conditions that delivers a combined impairment of 10 or more will attract compensation.
Example
Loss of taste rated at 5 impairment points and mild reflux rated at 2 impairment points.
A payment for loss of taste is permitted but, since 5 plus 2 is 7 and does not reach the threshold of 10 impairment points, no other payment is made.
Loss of taste rated at 5 impairment points and reflux rated at 5 impairment points.
The reflux 5 points when combined with the loss of taste reaches the threshold of 10 impairment points and so payment is made on the basis of 10 impairment points.
Functional loss
Medical impairment is measured chiefly by loss of vital functions and is addressed in the twelve system specific chapters of this Guide, as follows:
Cardio‑Respiratory Impairment
Hypertension and Non‑Cardio Vascular Conditions
Impairment of Spine and Limbs
Emotional and Behavioural
Neurological Impairment
Gastro‑intestinal Impairment
Ear, Nose, and Throat Impairment
Visual Impairment
Renal and Urinary Tract Function
Sexual Function, Reproduction, and Breasts
Skin Impairment
Endocrine and Haemopoietic Impairment
Other Impairment
Other Impairment is the physical loss of, or disturbance to, any body part or system. This concept is extended in some chapters in this Guide to include discomfort, pain, poor prognosis and other, less tangible, effects of accepted conditions.
Lifestyle effects
Lifestyle effects are to be assessed by applying Chapter 22 of this Guide in accordance with that Chapter.
The Tables
Types of Tables
There are several different sorts of tables used in GARP V that remain common to both GARP V and this Guide. Basically these are various impairment tables, the lifestyle tables and the tables to deal with more complex matters.
However the MRCA requires the Commission to specify two particular tables that are not used in GARP V or the VEA. These are tables that arise from the method specified by the Commission to determine compensation payable for warlike and non‑warlike as distinct from peacetime service (see Tables 1 and 2 of Chapter 23). In addition the Commission must specify a method for determining compensation payable when a mixture of warlike (or non‑warlike) and peacetime service causes the whole person impairment
Gender Use
Some tables are for men only, some for women only, and others (the majority) are not gender specific. Each table is clearly marked in the top right hand corner:
the symbol
Venus (female) symbol
means that the table is only to be used for the assessment of female veterans;
the symbol
Mars (male) symbol
means that the table is only to be used for the assessment of male veterans;
the symbol
Combined male and female symbol
means that the table is used for either male or female veterans.
Age Adjustment
Some tables incorporate age dependent criteria. Some other tables have no such criteria and require subsequent age adjustment by applying tables provided for that purpose.
Each table is clearly marked in the bottom left hand corner with instructions on age adjustment for ratings derived from that table.
Conversion Factor Tables
The Commission is required by paragraph 67(1)(e) to provide methods that enable Lifestyle to be combined with Impairment to give compensation for each type of service by reference to the maximum compensation payable. These are set out as compensation factors in tables in Chapter 23 and include a different set of factors to be used for warlike and non‑warlike service and for other service as provided for in the Act (see subsection 67(2)).
Non‑system specific assessments
This Guide has chapters describing alternate methods of assessing certain conditions:
Chapter 13 — Negligible Impairment
Chapter 14 — Malignant Conditions
Chapter 15 — Intermittent Impairment
Chapter 16 — Activities of Daily Living
Chapter 17 — Disfigurement
Conditions and their sequelae
Only the clinical features of an accepted condition may be taken into account in making an assessment. If the accepted condition causes some other distinct and diagnosable condition (sequela), the symptoms of the sequela cannot be taken into account when assessing the original accepted condition.
Sequelae can only be assessed when they have been separately determined to be service related.
Applying the instructions
To the extent of any inconsistency between an instruction in this “How to use the Guide” and a specific instruction concerning a particular matter in this Guide, the specific instruction in this “How to use the Guide” is to apply to that particular matter.
Duration of assessment period or date of determination and commencement of periodic payment and permanent impairment and interim payments
Assessment can only be made by reference to the available medical and other material that, of necessity, relates to a particular point or period in time.
The assessment of the impairment and lifestyle ratings must be based on the Commission’s reasonable satisfaction on the available material. If there is a significant change in impairment during the course of an investigation a payment may still be made as an interim payment. Interim payments are made until the Commission is satisfied that the condition has stabilised at an impairment level.
If the condition worsens after the last payment is made the person may claim additional compensation for the worsening and further periodic payments or lump sums can be made.
Apportionment of impairment ratings
It is sometimes necessary, for an accepted condition, to compare an impairment rating derived from one table with an impairment rating derived from another table. When two or more conditions contribute to the impairment ratings from either or both tables, and comparison is necessary, the method called “apportionment” is to be applied before making the comparison.
Details of the application of apportionment are given in Chapter 20.
Apportionment between tables
If a condition can be rated using both a functional loss table and an “Other Impairment” table, only the higher of the two ratings is to be given to the veteran.
Paired organ policy
The paired organ policy applies to eyes, kidneys etc and is described in detail in Chapter 21 of this Guide.
Impairment for specific disabilities
The Act provides only for impairment and does not convert that rating into a degree of incapacity like the VEA requires. Instead the impairment and lifestyle ratings determine a factor, not a degree of incapacity. Incapacity applies to ability to perform military service or a civilian occupation. Therefore, Chapter 24, “Degree of incapacity for specific disabilities” of GARP V, has been omitted. Instead impairment ratings are based only on the Tables from Chapter 1 to 21 of this Guide.
MEDICAL IMPAIRMENT
PART A: SYSTEM SPECIFIC ASSESSMENT
CHAPTER 1
CARDIORESPIRATORY IMPAIRMENT
INTRODUCTION
Cardiorespiratory impairment results from conditions that affect the function of the heart or lungs. The procedures described in this chapter are to be applied in assessing most conditions of the heart and lungs, and will usually also be appropriate for conditions affecting the function of the thorax or diaphragm, lesions of the nerves that supply the muscles of respiration, and conditions such as anaemia. The principal exception is any condition which is predominantly intermittent in nature and which would be better assessed by applying Chapter 15 (Intermittent Impairment).
Different procedures (described in Chapter 2) are to be applied to assess hypertension and non‑cardiac vascular conditions (such as aortic aneurysm and varicose veins).
In general, cardiorespiratory impairment is to be measured by reference to exercise tolerance. Exercise tolerance is quantified in terms of METs (see pages 11–12). However, if a respiratory component is present, measurements of lung function, such as forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and maximal expiratory flow (MEF 25–75) are to be used in addition to exercise tolerance. FEV1 and FVC are to be measured by spirometry. For the purposes of assessment in accordance with this Guide, the terms “MEF 25–75” and “FEF 25–75” (forced expiratory flow between 25% and 75% of the vital capacity) are to be taken as equivalent.
The conversion of loss of exercise tolerance and measurements of lung function into an impairment rating is set out in Table 1.2 and Table 1.3.
Certain cardiorespiratory conditions cannot be rated by applying exercise tolerance. These include:
conditions that do not decrease exercise tolerance;
conditions that do not produce symptoms; and
intermittent conditions.
“Exercise tolerance” refers to a person’s ability to exercise from a cardiorespiratory point of view rather than to a person’s total ability to exercise. For example, a veteran who has osteoarthritis of both knees may be greatly limited in walking but may still be able to swim a considerable distance. Such a veteran would still have good exercise tolerance from a cardiorespiratory point of view, though total ability to exercise would be reduced.
A veteran whose ability to exercise has been significantly reduced by other conditions (such as musculoskeletal conditions or being grossly overweight), or who no longer has cardiac or respiratory symptoms on exercise, cannot always be given an appropriate impairment rating for reduced exercise tolerance. However, the need to apply Chapter 19 (Partially Contributing Impairment) should always be considered before disregarding exercise tolerance figures.
Calculation of the impairment rating for accepted cardiorespiratory conditions
Follow the steps below to determine the impairment rating for cardiorespiratory conditions:
(Each step is elaborated in the following pages.)
Step 1
Establish what cardiorespiratory conditions are present.
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Step 2
Assess the information that is available and decide whether it is reliable and sufficient.
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Step 3
Determine the impairment rating based on effort tolerance.
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Step 4
(Omit this step if no respiratory disease is present.)<br>Determine the impairment rating based on measurements of lung function.
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Step 5
Determine the total accepted cardiorespiratory functional impairment rating.
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Step 6
Consider the effects of cardiac failure (if any).
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Step 7
Moderate the total cardiorespiratory functional impairment rating to allow for effects of any non‑accepted conditions.
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Step 8
Determine whether any ratings from the relevant Other Impairment tables apply (Tables 1.7, 1.8, 1.9, 1.10).
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Step 1: Establish what cardiorespiratory conditions are present.
For the purpose of assessing cardiorespiratory impairment, both the accepted and the non‑accepted conditions are be taken into account. Both will affect the way in which cardiorespiratory functional impairment is calculated. (Their combined effect is taken into account in the application of Table 1.5 in Step 5.)
Any non‑accepted conditions are to be subsequently allowed for by applying Chapter 19 (Partially Contributing Impairment) — see Step 7.
When considering the question: ‘What cardiorespiratory conditions are present in this veteran?’, it is not appropriate to rely simply on a list of accepted conditions. Both previously claimed but rejected cardiorespiratory conditions and unclaimed cardiorespiratory conditions may also be present.
Step 2: Assess the information that is available and decide whether it is reliable and sufficient.
To make a reliable cardiorespiratory assessment, there should be an adequate medical history of the veteran’s cardiorespiratory conditions. In addition, there should be information relating to the veteran’s effort tolerance and, if any respiratory disease is present, there should also be one or more sets of spirometry or other physiological measurements of respiratory function. The criteria by which the evaluation of the information is to be made are set out below.
Medical history
An adequate history of the veteran’s illness and a description of the current symptoms and details of the current treatment should be available.
The history should be reviewed at the start of the cardiorespiratory assessment procedure to establish whether any major cardiorespiratory event (for example a myocardial infarction or bypass surgery) has occurred within the period of assessment.
An examination of the history will indicate whether any Other Impairment ratings (from Tables 1.7, 1.8, 1.9, 1.10) are applicable. For example, in the case of ischaemic heart disease, the history will reveal whether the veteran has had any myocardial infarctions, whether coronary bypass surgery has been performed and the outcome of any such surgery. In other cases, for example when respiratory disease is present, the current treatment will reveal whether any Other Impairment rating for cardiorespiratory conditions is applicable.
In long‑standing respiratory conditions, there will often be a disease complex present that is more extensive than that implied by the original diagnostic label. For example, asthma may lead to chronic obstructive respiratory disease and chronic bronchitis may lead to small airways disease. Such extensions of the disease process are to be assessed as part and parcel of the original condition unless there is clear reason why they should not be — for example, they have been determined to be non‑accepted conditions.
Effort tolerance
Effort tolerance information should always be obtained except if the veteran has a condition that renders the collection of reliable effort tolerance information impracticable.
Examples of conditions that may render the collection of reliable effort tolerance information impracticable include:
hemiparesis following a stroke;
quadriplegia or hemiplegia;
severe arthritis of the lower limbs; and
certain mental conditions such as dementia (in which the veteran’s ability to co‑operate or provide useful information may be restricted).
The date of the effort tolerance information used must be appropriate to the period of assessment: the effort tolerance information should be not more than six months older than the relevant time in the assessment period to which the information is to be applied.
Measurements of lung function
Spirometry should always be obtained if any condition affecting the function of the lungs is present unless it is not practicable or appropriate to perform spirometry because:
the veteran is very old or frail and cannot reasonably attend a clinic where spirometry can be performed; or
the veteran lives in a remote locality and cannot reasonably attend a clinic where spirometry can be performed; or
the veteran’s impairment from other accepted conditions is of such a degree that it would result in a combined impairment rating of at least 68 points.