Chapter 61 Medical Disability Retirement
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Chapter 61 Medical Disability Retirement

&#x/M00; 00;� 00;&#x/M00; 00;� 00;Chapter 61 - Attendance Allowance and Disability Living Allowance &#x/M00; 00; 00;&#x/M00; 00; 00;Contents &#x/M00; 00; 00;&#x/M00; 00; 00;General rules on entitlement Introduction Primary qualifying conditionsThe residence and presence and competency conditionsDay for payment of AA and DLA Provision of NINOMedical advice Customer Case Management Adult and Childrens Medical GuidanceReferrals to Medical Services Examination and report Failure to attend for examinationAA and DLA care component -

The day conditionRates of AA The night conditionHigher rateLower rate Vol 10 Amendment 34 June 2012

&#x/M00; 00;� 00;&#x/M00; 00;� 00;Rates of DLA care component Highest rateMiddle rateLowest rateChange of rateSpecial provisions AA and DLA care component - definitions Preparation of the cooked main mealily funcBreathingCleanliness and skin protectionDressing and undressing inkingGetting into or out of bedGoing to the toilet (elimination of waste products) HearingTaking medicationTurning over in bed Frequent or repeated Alternatives to attention or supervision Continual supervisionWatching over Frequent intervalsProlonged SubstantiaFallingRenal dialysisDay and night needsVol 10 Amendment 34 June 2012
&#x/M00; 00;� 00;&#x/M00; 00;� 00;Period throughout which &# portionSo severely disabled physically or Renal rate Lower rateUnable or virtuallyPhysical or mental disabRefusal or reluctance to walkSevere discomfort Relevance of stops and severe discomfortWalking with supportArtificial limbs and appliancesSwinging throughVirtually unable Danger to life or serious deterioration in healthVirtually unable to walk flow chartDLA mobility component - peoplDLA mobility component - severely visually impairedEvidence of visual acuity/visual Supersession of existing awardsDLA mobility component - deaf and blindAssessment of the degree of deafnessSeverely mentally impaired with severe behavioural problemsVol 10 Amendment 31 July 2011

&#x/M00; 00;� 00;&#x/M00; 00;� 00;Severely mentally impaired Arrested development or incomplete physical development of the brainArrested development or incomplete physical development

Arrested development or incomplete physical development

of the brain and schizophreniaof the brain and attention deficit hyperactivity disorderSevere impairment genceSevere impairment of social functioningSevere behavioural problemsEvidence of severe mental impairment or severe behavioural problemsSeverely mentally impaired with severe behavioural problems flow chartLower rate DLA mobility component The need for guidance or or anxiety Guidance or supervision Special hosBenefiting from enhanced facilities for locomotionDLA mobility component - invalid carriage usersInvalid Vehicle Scheme beneficiary over 65Attendance allowanceExtension to the qualifying periodPeriod for which AA is payDisability living allowance DLA care componentcomponentThe qualifying period and prospective test on or around age 16 ModificationsVol 10 Amendment 31 July 2011
&#x/M00; 00;� 00;&#x/M00; 00;� 00;Special cases &#x/M00; 00; 00;&#x/M00; 00; 00;Terminally ill (special rules cases) Conditions of Qualifying period AA and DLA care componentPeriod of awardcomponent Claim on behalf of a terminally ill person made by a third partyClaim received for a child under 16DLA care componentRenal dialysis componentPoints for considerationAssessment of care needsCare substantially in excessAttention or supervision at school ........................................................…….Nocturnal Encopresis and Assessment of Quality and quantity of supervision and Living Allowance - people 65 years old or over New claimsRenewal claims Revisions or SupersessionsDLA care component Highest and middle rate Lowest rateEffect of these conditionsDLA mobility component Higher rate Lower rate Vol 10 Amendment 31 July 2011
&#x/M00; 00;� 00;&#x/M00; 00;� 00;DLA mobility component - award of DLA care component Claims and awards DLA claims with evidence of one component onlyAdvance claims and awardsInterchange of claims Movement between ratesPeriod of award Rules on payability Hospitals and similar institutions General rule Exception to the general rule - first 28 (or 84) days Modifications to the general rule - the DLA mobility component Motability agreements The Motability SchemeExemption from general ruAgreements under the Wheelchair ScRate of benefit payable Hospices hospiceCare homes other than hospitals and hospices from 6.10.03 IntroductionCommunity Care arrangements Group homes - England and Wales onlyDirect payments General ruleExceptions to the general rulePeople with homes to sell or who await other release of fundsVol 10 Amendment 31 July 2011

&#x/M00; 00;� 00;&#x/M00; 00;� 00;Meaning of “living in accommodation”Meaning of “costs of any qualifying services”Meaning of “whole cost” Meaning of “privaMeaning of “care home” Meaning of “privately fostered child” in EnglWar pensioners and civilians in relevant accommodationWhether the claimant is in a similar institution to a hospital or

a care home Establish where the cllivingCare homes funded by NHS component DLA care component and AAPayment during periods in hospital or a care home

overChildren under 16Calculation of the periodDays of admission and discharge

HospitalsCare homesDays of transferEntitlement begins during period in hospital or a care home Entitlement begins before admission - payability on readmissionPayment at daily rateConditions for payment at daily ratePeriod payable at daily rateAbsence more than 28 days Application of daily rate provisionsDischarge before 28 day period endsDischarge after 28 day period endsOther restrictions on payability and exclusions ImprisonmentVol 10 Amendment 34 June 2012
&#x/M00; 00;� 00;&#x/M00; 00;� 00;Overlapping benefits AA or DLA (care)component Adjustment Split payments of DLAActs relating to people with disabilities and Acts relating to young

people, education or trainingAppendix Assessment of the % degree of disablement Application of the general rule for people in hospital on or before Appendix Rates of benefit (AA) Appendix Rates of benefit (DLA)Appendix Appendix Vol 10 Amendment 34 June 2012
Chapter 61 - Attendance Allowance and Disability Living Allowance General rules on entitlement

Introduction 61001 AA is a benefit designed to help severely disabled people who need attention from another person supervision from another person another person to watch over them.61002 There is only one AA component made with two rates which are the higher rate and the lower rate.Severely disabled people may be entitled to either of these rates.

The rate depends on the level of attention, supervision or watching over a person needs1 SS CB Act 92, s 64 61003 - 61007

DLA 61008 DLA is a benefit that depends on a person’s need for care and help with mobility arising from a disability.It is the functional deficiency, physical or mental and whether

care needs

mobility needs both care and mobility needs which result from the functional disability satisfy any of the entitlement conditions1 R(DLA) 3/06; 2 SS CB Act 92, s 72(1)(a) to (c) & 73(1)(d) Example Amy, aged nine, has behavioural problems and learning difficulties.Medical evidence indicates mental health problems but there is no diagnosis as to the disabilities which Amy suffers.The DM accepted that, despite no diagnosis, Amy Vol 10 Amendment 33 February 2012
was unable to control her behaviour and was at risk of substantial danger requiring continual supervision throughout the day.The DM accepted that the supervision Amy required was substantially in excess of a nine year old who does not have Amy’s disability.61009 DLA is made up of two components.

These are

the care component and the mobility component.

A disabled person may be entitled to one or both components.See guidance in DMG 61603 for claims with evidence of one component only.

61010 There is a range of disability conditions relating to care and mobility needs.Satisfying any one of the conditions gives entitlement.

61011 There are three rates of the DLA care component and two rates of the DLA mobility component.

The rate of benefit payable depends on which of the disability conditions are satisfied.Primary qualifying conditions

61012 The three primary qualifying conditions which apply to AA and DLA are

and residence, presence and competency and disability.Although there is no formal order of consideration of these conditions, if either of the first two are not satisfied, then the third need not be considered.

Age 61013 To be entitled to AA a person must be

aged 65 or over and not entitled to DLA Note: From 6.12.18 the age condition will be that a person has reached pensionable age.

See DMG Chapter 75 for guidance on the meaning of pensionable age.1 SS CB Act 92, s 64(1); SS (DLA) Regs, Sch 1, para 7; 2 Pensions Act 07, s 13(3); 3 SS CB Act 92, s 64(1) 61014 To be entitled to DLA a person must be

under 65 years of age and Vol 10 Amendment 33 February 2012
in the case of the lower rate of the mobility component, aged five or over (see DMG 61251 et seq) the higher rate of the mobility component, aged three or over (five years or over before 09.04.01).Note: From 6.12.18 the age condition will be that a person must be under pensionable age.See DMG Chapter 75 for guidance on pensionable age
chapter 61 medical disability retirement
.1 Pensions Act 07, s 13(3); 2 SS CB Act 92, s 75(1) The residence and presence and competency conditions

61015 To become entitled to AA or DLA a person must satisfy the residence and presence conditions, and competency condition, under UK law (see DMG Chapter 07).Day for payment of AA and DLA 61016 AA is a weekly benefit payable on Mondays unless it is linked with another benefit and the DM arranges for it to be paid on that benefit’s paydayThere are also circumstances when AA can be paid daily (see DMG 61881 et seq).

1 SS (C&P) Regs, reg 22(3) & Sch 6

DLA 61017

DLA is a weekly benefit, payable on Wednesdays, unless it is combined with another benefit and the DM arranges for it to be paid on that benefit’s payday1 SS (C&P) Regs, reg 22(3) & Sch 6

61018 The amount payable is the total of the care component and mobility component awarded.It is normally paid four weekly (see DMG 61017 for exceptions).But in certain cases it can be paid on a daily basis (see DMG 61881 et seq).

61019 Following the transition from AA to DLA, former AA recipients retain the right to weekly payments and Monday paydays.If DLA is combined with another benefit, it is paid at the same interval as the other benefit.Vol 10 Amendment 33 February 2012

Provision of NINO 61020 For AA and DLA there is a specific requirement for a claimant to provide sufficient information or evidence to establish their NINO.See DMG Chapter 02 for full guidance.1 SS A Act 92, s 1(1A) & (1B) Vol 10 Amendment 33 February 2012
Medical advice

Customer Case Management Adult and Childrens Medical Guidance 61021 General information on the likely care and mobility needs arising from the more commonly occurring medical conditions can be found in the Customer Case Management Adult and Childrens Medical Guidance.61022 The Medical Guidance is available to all DMs.They are produced by Medical Policy in consultation with

the DLA Advisory Board and many organizations representing disabled people and health professionals.61023 The Medical Guidance provides information which can help the DM to understand the evidence provided on claims.It is also useful in helping the DM to decide when and from whom to seek further medical advice.References to the Medical Guidance will be made in this Chapter.

Referrals to Medical Services 61024 If the DM has difficulty in interpreting the medical evidence the case may be referred to Medical Services for advice.In the event of an appeal, the advice should be put before the tribunal for comment.

DMs should consider the guidance in DMG Chapter 03 when giving consideration to a medical opinion.

Where the Medical Services advice conflicts with the claimed needs, the DM should consider whether further evidence needs to be obtained.

Medical Services have no authority to determine claims and cannot advise directly on whether a person satisfies one of the disability tests.61025

Before submitting a case to Medical Services, the DM should be clear on why help is needed.Examples of cases where Medical Services may help are where there is a discrepancy between the description of the effects of a particular condition in the Medical Guidance and any evidence submitted by the claimant Vol 10 Amendment 34 June 2012
there are inconsistent statements in the claim pack there is a corroborative statement which is inconsistent with claimed needs the medical condition does not appear in the Medical Guidance a prognosis is needed to help in determining duration of award there is doubt as to what type of further evidence may be needed.

61026 Any request for medical advice should normally contain

a brief explanation of the problem and a list of the evidence and any authorities consulted.All sources of reference should be shown.This indicates to Medical Services how far the DM has progressed in the investigations.

61027 The questions should refer specifically to the effects of the medical conditions in each individual case.General inquiries about disability needs arising from a particular medical condition should be avoided where possible.General advice may not always be relevant and may be misleading.

Examination and report

61028 If the evidence in the claim form and advice from Medical Services is still insufficient to decide the disability questions, the DM may request further evidence such as a report from the GP's or hospital's records request a HCP examination reportNote: The DM may request other reports, for example from a physiotherapist, as necessary 1 SS Act 98, s 19(1)(a) 61029 Reports will be provided by a HCP approved by the Secretary of State.A HCP is a registered medical practitioner registered nurse registered occupational therapist or physiotherapistmember of such other regulated profession as prescribed.

Note: For the purposes of no other professions have been prescribed as HCPs at present.

1 SS Act 98, s 39(1); 2 Health Act 1999, s 60; 3 NHS Reform & Health Care Professions Act 2002, s 25(3);

SS Act 98, s 39(1) Vol 10 Amendment 34 June 2012

&#x/M00; 00;� 00;&#x/M00; 00;� 00;Failure to attend for examination

61030 The DM must decide the claim or revise the decision against the person if the DM refers the person to a Medical Adviser or HCP (see DMG 61028) and the person fails to attend for examination without good cause.

Note: Further information on medical evidence can be found at DMG Chapter 01.1 SS Act 98, s 19(3) 61031 - 61050

Vol 10 Amendment 28 June 2010
AA and DLA care component

AA and DLA care component - the disability conditions 61051 To satisfy the disability conditions for AA, a person must needattention from another person supervision from another person another person to watch over them.

1 SS CB Act 92, s 64(2) & (3) 61052 To satisfy the disability conditions for the DLA care component, a person

must needattention supervision watching over as in DMG 61051 cannot prepare a cooked main meal even if they have the ingredients1 SS CB Act 92, s 72(1)(b) & 72(1)(c); 2 s 72(1)(a)(ii) The day condition

61053 The day condition is satisfied if a person is so severely disabled physically or mentally that, they require from another person

frequent attention throughout the day in connection with bodily functionscontinual supervision throughout the day in order to avoid substantial danger to themselves or others1 SS CB Act 92, s 64(2)(a); s 72(1)(b)(i); 2 s 64(2)(b), s 72(1)(b)(ii) 61054 The night condition is satisfied if a person is so severely disabled physically or mentally that, at night they require prolonged or repeated attention in connection with bodily functions from another personanother person to be awake for a prolonged period or at frequent intervals for the purpose of watching over them in order to avoid substantial danger to themselves or others1 SS CB Act 92, s 64(3)(a), s 72(1)(c)(i); 2 s 64(3)(b); s 72(1)(c)(ii) Vol 10 Amendment 32 October 2011
Rates of AA 61055 AA is payable at the higher rate if a person satisfies

the day condition and the night condition or is terminally ill (see DMG 61491 et seq)1 SS CB Act 92, s 65(3) Lower rate

61056 AA is payable at the lower rate if a person satisfies either the day condition or the night condition1 SS CB Act 92, s 65(3) 61057 - 61060

Rates of DLA care component

Highest rate 61061 The highest rate is awarded to people who are so severely disabled physically or mentally that they satisfy the day condition (DMG 61053) and the night condition (DMG 61054)1SS CB Act 92, s 72(4)(a) Middle rate 61062 The middle rate is awarded to people who are so severely disabled physically or mentally that they satisfy the day condition (DMG 61053) the night condition (DMG 61054)1 SS CB Act 92, s 72(4)(b) Lowest rate

61063 The lowest rate is awarded to people who are so severely disabled physically or mentally that they need attention from another person for a significant portion of the day in connection with their bodily functions (whether during one period or a number of periods)they cannot prepare a cooked main meal for themselves even if they have the ingredients (provided they are 16 years old or over).1 SS CB Act 92, s 72(1)(a)(i); 2 s 72(1)(a)(ii) Vol 10 Amendment 32 October 2011

61064 A person may be awarded only one of the rates.If a person

has satisfied the disability condition at a lower rate for three months and then begins to satisfy the conditions for a higher rate

only the lower rate is payable until the conditions for a higher rate component have been satisfied for three months1 SS CB Act 92, s 72(4) Example A woman makes a claim on 6 February.She has satisfied the conditions for the middle rate for over three months.On 8 January, her condition has deteriorated and the conditions for the highest rate are now satisfied.

The DM awards the middle rate from 6 February and the highest rate from 8 April.

Special provisions 61065 Special provisions apply for people who are

terminally ill (see DMG 61491 et seq) under 16 years of age(see DMG 61520 et seq) undergoing renal dialysis (see DMG 61220 et seq).

1 SS CB Act 92, s 72(5); 2 s 72(1A); 3 SS (DLA) Regs, reg 7 61066 - 61080

Vol 10 Amendment 32 October 2011
AA and DLA care component - definitions

Preparation of the cooked main meal 61081 The “main meal test” determines a person’s ability to perform key daily tasks.It is a hypothetical test to calibrate the severity of a person’s disability.It is not a test of cooking ability or of the person’s ability to survive or enjoy a reasonable diet without assistance.

It is a measurement of a person’s physical and mental capacity to carry out complex functions.A cooked main meal means a meal for one person freshly cooked on a traditional cooker.Note: This applies to the lowest rate of the DLA care component only.

1 Moyna v.Secretary of State; R(DLA) 7/03 61082 The definitive interpretation of the cooking test is now that
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