Step 1: For each of the 6 ADLs, obtain a grading code for that activity using Table 16.1.
From Table 16.1 obtain a separate grading code for:
movement in bed;
transfers;
locomotion;
dressing;
personal hygiene; and
feeding.
Table 16.1 Combined male and female symbol
ACTIVITIES OF DAILY LIVING GRADING CODES
Code Description
NIL Independent, and can perform the task as well as peers do, or with minor difficulty only.
ONE Can complete the task independently, but with considerably more difficulty than peers have.
FOUR Requires some degree of personal assistance in order to perform the task.
SIX Requires extensive assistance in order to perform the task.
EIGHT Unable to contribute towards performance of the task. Completely dependent.
No age adjustment permitted for his table
Step 2: Add up the grading codes for each of the 6 ADLs.
Add up the 6 separate grading codes obtained from Table 16.1 for:
movement in bed;
transfers;
locomotion;
dressing;
personal hygiene; and
feeding.
Step 3: Using the sum obtained in Step 2, determine a functional impairment rating by applying Table 16.2.
Use the sum of the grading codes obtained in Step 2 to obtain an impairment rating from Table 16.2.
Functional Loss Table 16.2 Combined male and female symbol
LOSS OF FUNCTION: ACTIVITIES OF DAILY LIVING
Impairment Ratings Sum of Grading Codes
NIL 0
FIVE 1–2
TEN 3–4
TWENTY 5–6
THIRTY 7–8
FORTY 9–11
FIFTY 12–14
SIXTY 15–17
SEVENTY 18+
No age adjustment permitted for this table
Apply Chapter 19 (Partially Contributing Impairment) to make any necessary adjustment for non‑accepted conditions.
Apply Chapter 18 (Apportionment) to make any necessary adjustment for accepted conditions (or groups of conditions) other than the ones that are being assessed by the application of the ADLs tables.
Step 4: Determine an Other Impairment rating for the condition by applying Table 16.3.
Other Impairment Table 16.3 Combined male and female symbol
ACTIVITIES OF DAILY LIVING: OTHER IMPAIRMENT
Impairment Ratings Criteria
NIL No, or negligible, i.e. easily tolerated symptoms. Evidence of disease, but minimal interference with daily tasks. Feeling of good health most of the time. Normal or almost normal life expectancy in spite of disorders.
FIVE Daily (or almost‑daily) symptoms that are irritating and not easily tolerated, but which improve with medication. Some daily tasks performed inefficiently because of generalised lethargy.
TEN Daily (or almost‑daily) symptoms that are irritating and not easily tolerated. Treatment is not available, or is of little value, or gives only short remission. Noticeable loss of energy, leading to loss of efficiency and avoidance of some tasks previously easily performed. Decreased life expectancy. Five year survival less than 75% of normal.
TWENTY Intense daily (or almost daily) symptoms which are impossible to ignore, but that prevent few daily tasks. Decreased efficiency in most activities. Marked loss of energy leads to avoidance of many daily tasks, most of which can be completed but rapidly cause fatigue. Five year survival less than 50% of normal.
THIRTY‑ FIVE Five year survival less than 25% of normal.
No age adjustment permitted for this table
Step 5: Compare the ratings obtained in Steps 3 and 4. Take the higher rating.
The higher of the impairment ratings obtained in Steps 3 and 4 is the final impairment rating for the accepted conditions under assessment, based on ADLs.
CHAPTER 17
DISFIGUREMENT AND SOCIAL IMPAIRMENT
INTRODUCTION
This chapter is to be applied when assessing conditions that cause disfigurement and embarrassment.
Only one rating may be determined by applying this chapter for any condition or combination of conditions. The rating determined by applying this chapter is to be combined with any other ratings for the disfiguring condition or combination of conditions determined under other chapters.
Widespread skin conditions that cause avoidance of ordinary public places should also be assessed under Chapter 11 (Skin Impairment).
“Severe facial disfigurement” and “very severe facial disfigurement” are also mentioned in Chapter 24 (Degree Of Incapacity For Specific Disabilities).
Calculation of the impairment rating for disfigurement.
Follow the steps below to calculate the impairment rating due to disfigurement.
(Each step is elaborated in the following pages.)
STEP 1
Determine the impairment rating from Table 17.1 for the effect of all accepted conditions that cumulatively lead to disfigurement.
Page 184
STEP 2
If non‑accepted conditions have contributed to the disfigurement, apply Chapter 19 (Partially Contributing Impairment) to adjust the rating determined in Step 1.
Page 186
Step 1: Determine the impairment rating from Table 17.1 for the effect of all accepted conditions which cumulatively lead to disfigurement.
For the purposes of Table 17.1, the following definitions apply:
“disfiguring condition” means any noticeable condition that causes the sufferer embarrassment in ordinary public places and may include, but is not limited to, the following :
facial scarring;
exfoliative skin disorders;
disorders of gait or posture;
involuntary facial expressions, or unusual or grotesque involuntary bodily movements;
disorders of speech;
vile odours which cannot be overcome by the use of deodorants or the application of normal oral hygiene;
deficits of the visual field which may cause the veteran to lurch into people through not seeing them;
painful conditions which may cause the veteran to cry out involuntarily (for example, in response to a sudden pain in a joint); and
severe pruritic conditions which cause the veteran to scratch even though normal behaviour in a public place would recommend restraint.
“ordinary public places” includes suburban streets, shopping centres, public transport, theatres, clubs and many sporting venues, but does not include places where a great part of the skin is customarily bared such as swimming pools and beaches.
“avoidance” means the veteran feeling obliged as a result of embarrassment to restrict his or her use of public places to hours when few people are about, or to avoid totally use of public places at certain times, for example, when school children are likely to be about.
Functional Loss Table 17.1 Combined male and female symbol
DISFIGUREMENT
Impairment Ratings Criteria
NIL A visible condition that the veteran does not consider to be disfiguring. A noticeable condition that is not significantly disfiguring and which causes negligible or slight embarrassment such as some acne scars on face, or minor limps, or a slight stoop.
TWO A noticeable condition. For example, severe acne scars, a unilateral squint, an intermittent stutter or stammer. A noticeable condition which causes significant embarrassment and may cause avoidance of some normal activities. For example, an ungainly gait, a gross stoop, a persistent stutter or stammer, or an unsightly skin disorder.
FIVE A very noticeable condition which causes marked embarrassment to some people in ordinary social contacts and causes avoidance of some normal activities. For example, a severe skin disorder of the face and/or hands, or a gross and persistent stutter or stammer.
TEN A very noticeable condition which causes marked embarrassment and results in the avoidance of many normal activities. For example, moderate facial disfigurement. A severe and marked condition which causes embarrassment and causes much avoidance of many public places and social intercourse. For example, severe facial disfigurement.
FIFTEEN A particularly severe and marked condition which causes extreme embarrassment and results in avoidance of public places and social intercourse to as great a degree as possible. For example, very severe facial disfigurement.
Only one rating is to be selected from this table for any condition or group of conditions which contribute to disfigurement.
No age adjustment permitted for this table
Both the objective and subjective components of a disfiguring condition are to be taken into account when applying Table 17.1. The objective component is the actual physical and/or temporal extent of the disfiguring condition as perceived by others. The subjective component is the veteran’s own emotional and behavioural reactions to the disfigurement.
The two components will generally be aligned with one another. If the veteran has a noticeable condition that is objectively disfiguring but does not embarrass the veteran to the extent to which an average person of the same age, occupational and residential circumstances would be embarrassed, the assessment should be based on the average person’s degree of embarrassment. The veteran’s denial of his or her condition should not be taken into account when applying Table 17.1.
Step 2: If non‑accepted conditions have contributed to the disfigurement, apply Chapter 19 (Partially Contributing Impairment) to adjust the rating determined in Step 1.
If non‑accepted conditions have contributed to the disfigurement, Table 19.1 in Chapter 19 (Partially Contributing Impairment) is to be applied to adjust the impairment rating for the accepted conditions.
The rating obtained in this step (or in Step 1 if partially contributing impairment is not applicable) is the final rating for disfigurement, and is to be included in the final combining of all impairment ratings.
Part C: Impairment Ratings: Combining, Apportioning, Partially Contributing
CHAPTER 18
COMBINED VALUES CHART
INTRODUCTION
After impairment ratings have been obtained for all accepted conditions they must be combined to a single value known as the combined impairment rating. The combining is not to be done by simple addition but is to be done by applying Table 18.1 (Combined Values Chart). The values in Table 18.1 (Combined Values Chart) are derived from the formula:
Start formula, combined value of A and B equals, open square brackets, A plus B, open parentheses, 1 minus start fraction, A over 100, end fraction, close parentheses, close square brackets, rounded to nearest integer, end formula
where “A” and “B” are the impairment ratings to be combined.
This formula embodies a principle of combining ratings. The principle derives from the concept of whole person impairment (see page X). The following example illustrates the combining principle:
Example
Suppose a veteran has three accepted conditions. If the first assessed condition attracts 60 points the veteran will get a rating of 60. This rating implies that the whole person is 60% impaired. That leaves 40% to be further apportioned among other conditions. If the second condition assessed attracts 30 points, the total impairment rating will not be 60 + 30 = 90, but 60 + 12 = 72. The 12 represents 30% of the 40 that remained of the whole person after the initial 60 was awarded. Now the whole person of the veteran is 72% impaired. If the third condition assessed attracts 10 points, the total impairment rating will be 60 + 12 + 3 = 75. The 3 represents 10% of the 28 that remained of the whole person after 72 was awarded for the first two conditions. Now the whole person of the veteran is 75% impaired.
Combining two or more impairment ratings into a single value.
Follow the steps below to combine two or more impairment ratings into a single value (the combined impairment rating).
STEP 1
Take the highest (or equal highest) of the ratings to be combined. Find that rating in the column on the extreme left hand side of the chart in Table 18.1. The row in which this number is written is “The Row” for purposes of Step 3.
STEP 2
Take the next highest (or equal highest) of the ratings to be combined. Find that rating in the very bottom row of the chart. The column above this number is “The Column” for purposes of Step 3.
STEP 3
Find the intersection of The Row and The Column. The number written on the intersection is the combined value of the two ratings. If only two ratings are to be combined, then this figure is the “Combined Impairment Rating”.
STEP 4
This step is only to be used if more than two ratings are to be combined.<br>Take the result obtained in Step 3. Find that result in the column on the extreme left hand side of the chart. The row in which this number is written is “The Row” for purposes of Step 6.
STEP 5
Take the highest (or equal highest) of the remaining ratings to be combined. Find that rating in the very bottom row of the chart. The column above this number is “The Column” for purposes of Step 6.
STEP 6
Find the intersection of The Row and The Column. The number written on the intersection is the combined value of the three ratings. If only three ratings are to be combined, then this figure is the “Combined Impairment Rating”.
STEP 7
This step is only to be used if more than three ratings are to be combined.<br>To combine more than three ratings, reapply the instructions in steps 4, 5, and 6 to the remaining ratings. Always take the value obtained by performing Step 6 and combine that with the highest (or equal highest) of the remaining values. Continue until all ratings have been combined into a single value. This figure is the “Combined Impairment Rating”.
STEP 8
The individual impairment ratings for the various conditions being assessed are not to be rounded before they are combined using the chart in Table 18.1.<br>If the combined impairment rating is not a multiple of five, it should be rounded to the nearest multiple of five. (For purposes of the preceding sentence, “0” is a multiple of five.) Figures ending on “3” or “4” or “8” or “9” should be rounded up, figures ending on “1” or “2” or “6” or “7” should be rounded down. (This also applies when the only impairment rating a veteran obtains = 2. In that case the combined impairment rating = 0.)
Example
To combine 35 and 20, read down the extreme left hand side column of the chart in Table 18.1 until you come to the larger value, 35. In the very bottom row of the chart read from left to right until you come to 20. At the intersection of the row on which 35 is written, and the column above 20, is the number 48.
Therefore, 35 combined with 20 is 48. Due to the construction of this chart, the larger impairment value must be identified at the side of the chart.
Applying the formula to this example gives:
Start formula, 35 plus 20 times, open parentheses, 1 minus, start fraction, 35 over 100, end fraction, close parentheses, equals, 35 plus 20 times, open parentheses, 1 minus 0.35, close parentheses, equals, 35 plus 20, times 0.65 equals 35 plus 13, equals 48, end formula
Table 18.1 Combined male and female symbol
COMBINED VALUES CHART ‑ Part 1
A chart containing a range of values for a combined value assessment
No age adjustment permitted for this table
Table 18.1 (continued) Combined male and female symbol
COMBINED VALUES CHART ‑ Part 2
A second chart containing a range of values for a combined value assessment
No age adjustment permitted for this table
Table 18.1 (continued) Combined male and female symbol
COMBINED VALUES CHART ‑ Part 3
A third chart containing a range of values for a combined value assessment
No age adjustment permitted for this table
CHAPTER 19
PARTIALLY CONTRIBUTING IMPAIRMENT
INTRODUCTION
Partially contributing impairment is to be applied whenever an impairment is not due solely to the effects of accepted conditions.
How to apply partially contributing impairment
Follow the steps below to apply partially contributing impairment.
Use relevant medical evidence to determine if any non‑accepted conditions contribute to the impairment being assessed.
Step 2: Determine the relative contribution of the accepted and non‑accepted conditions.
The judgement of the relative contributions should be based on proper medical advice.
The contribution should be expressed in the form:
‘The accepted condition contributes “not at all”, “about one quarter”, “about one third”, “about half”, etc’.
If more than one accepted condition contributes to the relevant impairment rating, the contribution of the accepted conditions is to be treated as a single entity.
If more than one non‑accepted condition contributes to the relevant impairment rating, the contribution of the non‑accepted conditions may be treated as a single entity.
Step 3: Determine the impairment rating attributable solely to the accepted condition by applying Table 19.2 or Table 19.1.