Mental injury eligibility - Determining significant behavioural, cognitive or psychological dysfunction

The role of the IME

As an IME you do not have delegation to make decisions under the WIRC Act.

The role of an IME is to provide a quality, evidenced based clinical report, that allows readers to understand the basis upon which you have formed your opinion, and helps inform robust Agent decision making.

Mental injury eligibility requirements have changed

On 31 March 2024, changes to the Workplace Injury Rehabilitation and Compensation Act 2013 (WIRC Act)came into effect. These include changes to the eligibility criteria for mental injury compensation. These changes will deliver a more contemporary and sustainable WorkCover scheme that can continue to support Victorian workers in the future.

This information focuses on the new requirement that a mental injury:

• causes significant behavioural, cognitive or psychological dysfunction, and
• has been diagnosed by a medical practitioner in accordance with latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

These new tests only apply to mental injuries sustained on or after 31 March 2024.

Why this change has been made

The WorkCover scheme was designed in 1985 to primarily deal with physical injuries. As such, the claims eligibility and assessment measures were better aligned to physical injuries.

The introduction of significance in determining mental injury claim eligibility recognises that mental injuries are complex and often the cumulative impact of several factors. It requires that in addition to being capable of receiving a diagnosis under the DSM, the injury should demonstrate a level of interference with the worker's regular functioning to be compensable.

Further information on whether employment is the predominant cause of a worker’s mental injury can be found on the WorkSafe website.

How this change impacts IMEs

As an IME, you will be asked to provide your independent clinical opinion on:

• whether the mental injury causes significant behavioural, cognitive or psychological dysfunction, and
• if employment is a predominant cause.

Determining significant dysfunction

The significant dysfunction test is separate and additional to the requirement for diagnosis under the DSM. The significant dysfunction test is intended to identify those injuries that are significantly interfering with a worker's life.

‘Significant’ is not defined in the WIRC Act. As such, it takes its ordinary meaning – sufficiently great or important to be worthy of attention.

The evaluation of dysfunction is not carried out in a specific technical or formal way. It is done by applying common sense to the facts of the particular case. An injury that causes significant behavioural, cognitive or psychological dysfunction is unlikely to be a short-term injury or an injury that does not significantly impair a worker's function. It is expected that such injuries will go beyond everyday variations in mood, behaviour or thought patterns.

In this context ‘significant’ usually implies that symptoms are:

• Clinically meaningful.
  • The symptoms must cause noticeable impairment in important areas of functioning, such as social, occupational, or other significant aspects of life.
• Severe enough to require intervention.
  • Symptoms often need to reach a level that warrants clinical attention or treatment.
• Not attributable to other causes.
  • Symptoms are not better explained by other medical conditions, substance use, or non-pathological causes.

Evaluating if the mental injury has caused significant behavioural, cognitive or psychological dysfunction

You are being asked to form an opinion as to whether an injury diagnosed in accordance with the DSM has caused significant behavioural, cognitive or psychological dysfunction.

This can be established through consideration of:

• Information provided by the referrer, such as GP clinical records and circumstance investigation reports.
• Information provided by the worker during the assessment, such as:
  • their mental health history
  • details of their personal life
  • details of other work issues separate from the claimed event.