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Chapter G1: Work capability assessment

Contents
G1001:Introduction
Definitions
G1012:Meaning of a health care professional
G1013:Meaning of claimant

When is a work capability assessment carried out
G1020:Initial and routine assessments
G1021:Exceptions
When is a work capability assessment not carried out
G1030:Claimant with weekly earnings: the in work gateway
G1034:What if a work capability assessment cannot be carried out
G1035:Claimant already has LCW or LCWRA
G1040:Claimant found not to have LCW or LCWRA
G1050:Application of the work capability assessment
G1060:Use of prostheses, aids and appliances
G1063:General application
G1065:Aid or appliance prescribed or advised
G1067:Aid or appliance not prescribed or advised
G1075:Information requirements
G1076:The questionnaire
G1081:The medical report
G1093:Second or subsequent referrals
G1096:Failure to return the questionnaire
G1097:The Secretary of State's duty
G1098:Has the questionnaire been sent
G1099:Has the correct amount of time passed
G1100:Good reason
Vol 8 Amendment 12 October 2012
G1101:Questionnaire returned before good reason considered
Medical examination
G1105:General
G1106:Failure to attend or submit to a medical examination
G1108:The Secretary of State's duty
G1113:Has notice been sent
G1114:Have seven days passed
G1115:Has the appointment been cancelled
G1116:Good reason
G1117:Failure to submit
G1121:Good reason
G1125:Consideration of good reason
G1128:Good reason - some scenarios

Chapter G1: Work capability assessment

G1001 Introduction

The WCA is an assessment of the extent to which a claimant with a specific disease
or bodily or mental disablement is capable, or is incapable, of carrying out specified
activities (1).
1 UC Regs, reg 39(2) & (3); reg 40(2)(a); Sch 6 & 7
Important
note:
The WCA for UC is only as described above. It does not include
being treated as having LCW or LCWRA. It is not the same as the description of the
WCA for ESA in DMG Chapter 42, and ADM Chapter U2, as the end to end medical
process, including whether the claimant can be treated as having LCW or LCWRA.
In practice the process of referral to Medical Services remains the same.

G1002

The question of whether a claimant has LCW or LCWRA is relevant in order to determine
1. if the LCW or LCWRA element can be included in the UC award (1) and
2. what work-related requirements group the claimant falls into (2) and
3. which income and work allowance deduction is applicable (3) and
4. where the claimant is also eligible for receipt of the carer element, which
element is payable (4).
See ADM Chapter F5 for guidance on work capability elements, Chapter J2 for
guidance on work-related requirements groups, Chapter E2 (Awards and maximum
amount of UC) for guidance on income and work allowance deductions, and Chapter
F6 for guidance on the carer element.

1 UC Regs, reg 27; 2 WR Act 12, s 13(3) & 19-22; 3 UC Regs, reg 22; 4 reg 29(4)

G1003

The WCA will normally be completed during the relevant period during which the
LCW or LCWRA element is not included in the UC award. See ADM Chapter F5
(Work capability elements) for guidance on the relevant period.

G1004

Claimants who are treated as having LCW or LCWRA do not have to undergo the
WCA (1). See ADM Chapters G2 (LCW) and G3 (LCWRA) for further guidance.

1 UC Regs, reg 39(1)(b) & 40(1)(b)

G1005 G1020

A UC claimant may already have been assessed for LCW and LCWRA for the
purposes of ESA. Where
1. it has been determined that the claimant has LCW or LCWRA following an
assessment under ESA legislation (1) and
2. a claim for UC is made while the determination in 1. is current
the claimant does not have to undergo a separate WCA for the purposes of UC (2).
See G1020 2. for when a further WCA may be required. See ADM Chapter U2 for
guidance on assessing LCW and LCWRA for ESA.
Note: In this Chapter references to ESA are to new style ESA (2). See ADM Chapter
M1 (Pathfinder Group - claims for UC) for guidance on the meaning of new style
ESA.

1 ESA Regs 13, reg 15 & 30; 2 UC Regs, reg 39(1)(a) & 40(1)(a)(ii); 2 UC (TP) Regs, reg 2(1)

G1006

The DM should note that where a claimant is treated as having LCW or LCWRA
under ESA legislation (1), they are not automatically treated as having LCW or LCWRA
for the purposes of UC (2). This is because the conditions are not identical. The DM
should check why the claimant has been treated as having LCW or LCWRA for
ESA. If the ESA condition which is satisfied is the same as a UC condition, the DM
may determine that the claimant is treated as having LCW or LCWRA for the
purposes of UC.
1 ESA Regs 13, reg 16, 21, 22, 31 & 32; 2 UC Regs, Sch 8 & 9

Example

Kelly is entitled to ESA. She is treated as having LCW as she is pregnant, and is
entitled to MA. Her pregnancy is progressing normally, and she has no health
problems. She claims UC. Kelly cannot be treated as having LCW for the purposes
of UC.

G1007

As part of the assessment, claimants may be required to complete a questionnaire (2)
(see G1075 et seq) and if necessary attend a medical examination (3) (see G1105 et
seq). If they fail without a good reason to do either, they can be treated as not having
LCW and LCWRA (4).
Note: This does not apply to claimants who are treated as having LCW or LCWRA (1)
(see ADM Chapters G2 and G3).
1 UC Regs, reg 39(1)(b) & 40(1)(b); 2 reg 43(1); 3 reg 44(1); 4 reg 43(3) & 44(2)

[G1008-G1011]

Definitions

G1012 Meaning of a health care professional G1082

A HCP means (1)
1. a registered medical practitioner or
2. a registered nurse or
3. a registered occupational therapist or physiotherapist (2).
1 UC Regs, reg 2; 2 Health Act 99, s 60

G1013 Meaning of claimant

Claimant means a single claimant or each of joint claimants (1).
1 WR Act 12, s 40

[G1014-G1019]

When is a work capability assessment carried out

G1020 Initial and routine assessments G1005 G1093

A WCA may be carried out when
1. the DM has to determine whether the claimant has LCW or LCWRA for the
first time (1) (but see G1005 where the claimant has already been assessed for
ESA) or
2. there has been a previous determination that the claimant has or is treated as
having LCW or LCWRA, and the DM wishes to determine whether
2.1 there has been a relevant change of circumstances in the claimant's
physical or mental condition or
2.2 the previous determination was made in ignorance of, or based on a
mistake as to, some material fact (2).
1 UC Regs, reg 41(1)(a); 2 reg 41(1)(b)

G1021 Exceptions

A WCA is not normally carried out where (1)
1. the claimant has weekly earnings (2) - see G1030 et seq for further guidance or
2. it was previously determined that the claimant did not have LCW or LCWRA (3)
- see G1040 et seq for further guidance.
1 UC Regs, reg 41(1); 2 reg 41(2) & (3); 3 reg 41(4)

[G1022-G1029]

When is a work capability assessment not carried out

G1030 Claimant with weekly earnings: the in work gateway G1021

Normally a claimant who is in work earning above the relevant threshold (see G1033) is
1. not entitled to a work capability element (1) and
2. not subject to work-related requirements (2).
Unless any of the exceptions in G1032 apply, the WCA is not carried out, so
entitlement to a work capability element cannot be considered (3).

1 UC Regs, reg 27; 2 reg 90; 3 reg 41(2) & (3)

G1031

The in work gateway allows claimants who are working, but are at risk of not being
able to do so, where they
1. are disabled and entitled to AA, DLA, PIP or AFIP or
2. start work after being assessed as having LCW or LCWRA
to be assessed or reassessed under the WCA. If they have LCW or LCWRA, the
work capability element will continue to be included in the UC amount until the next
WCA is due, or there is a specific reason to carry out a fresh assessment.
Note: DMs should note that this does not apply to ESA. A UC claimant may have
LCW for the purposes of UC, even though for ESA they may be treated as not
having LCW because the work is not exempt work. See ADM Chapter V3 for
guidance on exempt work.

G1032 G1030 G1034

Where the claimant has weekly earnings (1) that are equal to or above the relevant
threshold (see G1033), a WCA cannot be carried out unless
1. they are entitled to (2)
1.1 AA (3) or
1.2 DLA (4) or
1.3 PIP (5) or
1.4 AFIP (6) or
2. the WCA is to review a previous LCW or LCWRA determination made for the
purposes of ESA or UC (7) - see G1035 for further details.
Note: See ADM Chapter J2 (Work-related requirements groups) for guidance on
calculation of weekly earnings.
1 UC Regs, reg 2 & 90(6); 2 reg 2 & 41(2)(a); 3 SS CB Act 92, s 64, 104, 105, 111 & Sch 8, para 4 & 7(2);
WR Act 12, s 64(3)(a); Personal Injuries (Civilians) Scheme 83, art 14, 15, 16, 43 or 44;
4 SS CB Act 92, s 71; 5 WR Act 12, Part 4; 6 AF & RF (Comp Scheme) Order; 7 UC Regs, reg 41(2)(b)

G1033 G1030 G1032

The relevant threshold is the amount the claimant would be paid at the highest NMW
hourly rate for 16 hours a week (1). See ADM Chapter H3 (Earned income: employed
earnings) for NMW rates.
1 UC Regs, reg 41(3); National Minimum Wage Regs 99, reg 11

G1034 What if a work capability assessment cannot be carried out G1036

Where
1. a WCA cannot be carried out as in G1032 (1) and
2. the claimant cannot be treated as having LCW or LCWRA (2)
the claimant is treated as not having LCW (3). But see G1036 for where this does not
apply.
Note: See ADM Chapter G2 for where a claimant is treated as having LCW, and
ADM Chapter G3 for where a claimant is treated as having LCWRA.
1 UC Regs, reg 41(2); 2 reg 39(4) or 40(4); 3 reg 41(2)

G1035 Claimant already has LCW or LCWRA G1032

If a claimant in work has already been assessed as having LCW or LCWRA,
whether for the purposes of UC or ESA (1), a further WCA may be carried out in order
to consider again whether the claimant has LCW or LCWRA (2). Any work capability
element continues to be included in the UC amount unless and until it is determined
that the claimant does not have LCW or LCWRA.

1 ESA Regs, Parts 4 & 5; UC Regs, Part 5; 2 reg 40(2)(b)

G1036 G1034

The DM may consider that a further WCA is not required, for example where the
claimant's work does not give rise to a doubt as to whether they still have LCW. In
this case the claimant is not treated as not having LCW and G1034 does not apply.

Example

Nigel is entitled to UC including the LCW element. He has LCW because he has
significant difficulties communicating verbally with strangers due to deafness, as he
cannot lip read. Nigel starts office work, earning 16 x the NMW every week. The DM
establishes that the job is in the family business where Nigel is not required to deal
with anyone other than his family. The DM decides that a further WCA is not
required, and Nigel's UC award continues to include the LCW element.

[G1037-G1039]

G1040 Claimant found not to have LCW or LCWRA G1021

Where it has been determined that the claimant does not have LCW following
application of the WCA under UC or ESA legislation, a WCA may not be carried out
unless there is evidence to suggest that
1. the determination was based on ignorance of, or mistake as to, some material
fact or
2. there has been a relevant change of circumstances in the claimant's physical
or mental condition, for example where there is a new or worse condition (1).
1 UC Regs, reg 41(4)

[G1041-G1049]

Application of the work capability assessment

G1050

The WCA is an assessment of the extent of a claimant's ability to perform specified
activities because of their physical or mental condition (1). The performance of
activities is measured by descriptors2. The test is the ability to perform any work or
work-related activity, not a specific occupation.

1 UC Regs, reg 39(3)(a) & 40(2); Sch 6 Column 1 & Sch 7 Column 1; 2 Sch 6 Column 2 & Sch 7 Column 2

G1051

If a descriptor applies as a direct result of treatment provided by a registered medical
practitioner for a specific disease, illness or disablement, it is treated as applying as
a result of that disease, illness or disablement (1).

1 UC Regs, reg 42(3)

G1052

See ADM Chapter G2 for guidance on the assessment of whether a claimant has
LCW, and Chapter G3 for guidance on the assessment of whether a claimant has
LCWRA.

[G1053-G1059]

G1060 Use of prostheses, aids and appliances

A claimant is assessed
1. as if fitted with or wearing any prosthesis with which they are normally fitted
(such as an artificial limb) or normally wear and
2. as if wearing or using any aid or appliance which is normally, or could
reasonably be expected to be, worn or used (such as a hearing aid)1.

1 UC Regs, reg 42(2)

G1061 G1062

The DM should apply the following principles:
1. where a claimant normally uses an aid or appliance, they must be assessed
as if they were using it
2. if an aid or appliance has been prescribed or recommended by a person with
appropriate expertise, the claimant must be assessed as using it unless it
would be unreasonable for them to use it
3. if a claimant does not use an aid or appliance, and it has not been prescribed
or recommended, the claimant must be assessed as if using it if
3.1 it is normally used by people in the same circumstances acting
reasonably and
3.2 it would be reasonable for the claimant to use it.

G1062

Where
G1061 3. applies, the DM must explain how an aid or appliance would help
the claimant.

G1063 General application

The test of normal use of an aid or appliance applies to the assessment of all of the
physical activities in the WCA (1). It is not restricted to those activities that make
specific reference to aids or appliances.

1 UC Regs, reg 42(2)

G1064

Four of the LCW physical activities (1) refer specifically to the use of aids. Activity 1
(mobilising), Activity 7 (understanding communication), Activity 8 (navigation), and
Activity 9 (continence), all refer to aids that are normally or could reasonably be
used. The DM should apply the test in a way that displays consistency between the
WCA as a whole and the assessment of each descriptor in particular.
1 UC Regs, Sch 6, Part 1

G1065 Aid or appliance prescribed or advised

The DM should establish whether the claimant normally uses an aid or appliance,
and if not, whether the use of it has been prescribed or advised.

G1066

If the claimant does not have an aid or appliance which they have been prescribed
or advised to use, the DM should establish
1. whether it would help the claimant
2. why they are not using one
3. whether the explanation is reasonable.

Example 1

Billy has been advised by his GP to use a walking stick to help with balance
problems when walking and standing. He states that he doesn't like the idea of a
walking stick because it makes him look old. The DM considers that it would be
reasonable to expect Billy to use a walking stick, and assesses LCW and LCWRA
as if he is using it.

Example 2

Annie lives in a one bedroom apartment on the upper storey of a two storey block.
There is no lift. She has been advised by her GP that a wheelchair would help her to
mobilise over longer distances and that a wheelchair could be provided on request.
Annie states that she could not get a wheelchair into her apartment, and could not
store a wheelchair, either in her apartment or elsewhere. The DM considers that it
would not be reasonable to expect Annie to use a wheelchair, and assesses LCW
and LCWRA without it.

G1067 Aid or appliance not prescribed or advised

The DM must consider all the circumstances in order to determine whether it would
be reasonable to assess the claimant as using an aid or appliance that has not been
prescribed or that they have not been advised to use.

G1068

Factors include whether
1. the claimant possesses the aid or appliance
2. the claimant was given specific medical advice about managing their
condition, and it is reasonable for them to continue following that advice
3. the claimant would be advised to use an aid or appliance if they raised it with
the appropriate authority such as a GP or occupational therapist (advice may
only be given on request)
4. it is medically reasonable for them to use an aid or appliance
5. the health condition or disability is likely to be of short duration
6. an aid or appliance is widely available
7. an aid or appliance is affordable in the claimant's circumstances (people are
not routinely required to buy equipment where it can be prescribed.)
8. the claimant is able to use and store the aid or appliance
9. the claimant is unable to use an aid or appliance due to their physical or
mental health condition, for example they are unable to use a walking stick or
manual wheelchair due to a cardiac, respiratory, upper body or mental health
condition.

Example 1

Miranda has significantly reduced mobility due to arthritis of the right hip and is on
the waiting list for a hip replacement. She uses a walking stick to help with balance,
but this does not enable her to walk any further than 200 metres before she
experiences pain. She has not been advised to use a wheelchair. The HCP advises
that she has no other health problems, and in their opinion based on clinical
experience, would be provided with a manual wheelchair if she asked her consultant
about this. If she had a wheelchair, she would be able to mobilise over longer
distances. The DM decides that it would be reasonable, having considered all
relevant factors, for Miranda to use a manual wheelchair, and that none of the
Activity 1 descriptors apply.

Example 2

Gary has problems standing due to a condition which affects his balance. He would
normally be helped by the use of a walking stick. However, the HCP advises that due
to arthritis of the hands, Gary would have difficulty using a stick because he has
reduced grip. The DM determines that it would not be reasonable to assess Gary
taking a walking stick into account.

G1069

Where it is considered that the claimant should be assessed using an aid or
appliance they do not have, the DM must give a clear explanation of how it could
help the claimant. In the majority of cases the HCP will give advice on their use in
the medical report. If not, or if the advice is not clear, the DM should seek further
advice as to how reasonable it is to expect the claimant to use or benefit from the aid
or appliance.

G1070

The aid or appliance must be relevant to the activity being assessed. For example,
when assessing activity 5, manual dexterity, it is not appropriate to consider the use
of devices, such as a grabber, which substitute for the hands, other than prosthetic
hands.

G1071

DMs are additionally reminded that some activities and descriptors specify that the
person must be assessed without the help of another person.

[G1072-G1074]

G1075 Information requirements G1007

The information required to determine whether a claimant has LCW or LCWRA is
1. any information relating to the descriptors that may be requested in the form
of a questionnaire and
2. any additional information that may be requested (1).
1 UC Regs, reg 43(1) & Sch 6 & 7

G1076 The questionnaire

Where the DM is satisfied there is sufficient information to determine whether a
claimant has LCW or LCWRA without the questionnaire, that information will not be
required (1).

1 UC Regs, reg 43(2)

G1077

Claimants who are treated as having LCW (see ADM Chapter G2) are not required
to complete a questionnaire for the purposes of determining LCW, but will be
required to provide information relating to the descriptors for LCWRA unless they are
also treated as having LCWRA (see ADM Chapter G3).

G1078

The questionnaire is designed for the claimant to give as much information about
their condition, how it affects them in their daily functioning, and how they manage
their condition.

G1079

Medical services
1. scrutinises evidence regarding a claimant's condition and gives an opinion as
to whether
1.1 they are treated as having LCW or LCWRA
1.2 in second or subsequent referrals they actually have LCW or LCWRA
without requiring a medical examination
2. provides impartial medical advice on request.

G1080

Medical services is responsible for gathering any information required to support the
WCA process. This includes
1. sending the questionnaire (form UC (50))
2. sending a reminder if the claimant does not reply within three weeks
3. deciding if further medical evidence is required from the claimant's GP or
health care professional.

G1081 The medical report

Medical services provides an independent medical opinion on the claimant's
condition, functionality and their ability to perform activities related to work. They do
not provide a diagnostic examination. The focus is on a claimant's abilities rather
than their disabilities. HCPs should provide relevant information and good
justification for their recommendations with regard to LCW and LCWRA.

G1082

In the main, medical reports are completed electronically. There is no requirement
for the report (form UC (85)) to be signed by the examining HCP (1). However the report
must identify the status of the HCP, i.e. whether he or she is a doctor, a registered
nurse, or a registered occupational therapist or physiotherapist as in G1012.

1 R(IB) 7/05

G1083

The personalised summary statement forms part of the report form where that is
produced electronically, and is also produced as a separate form. It is part of the
evidence considered by the DM when making determinations as to whether the
claimant has LCW or LCWRA.

G1084

The personalised summary statement is a statement of facts and findings made by
the HCP, and is personal to the claimant. It gives the HCP the opportunity to
1. justify their recommendation on the LCW and LCWRA activities and
descriptors and
2. explain where the recommendation conflicts with the claimant's view of their
condition.

G1085

The personalised summary statement should refer to all of the claimant's health
conditions, and consider the combined impact where multiple conditions are present.
This should reflect the consensus of medical opinion. It should not introduce new
information not already in the report form.

[G1086-G1089]

G1090 The questionnaire, the medical report, and any other medical evidence obtained by
medical services, are referred to the DM to consider whether the claimant has LCW
or LCWRA. There may be differences between the answers from the claimant and
the HCP.

Example

On the questionnaire Kevin indicates he can walk on level ground but cannot walk
200 metres. He also indicates on the form that he can walk about 50 metres before
he has to stop due to severe pain. On the medical report the HCP should collect
more evidence to identify the actual distance the claimant can walk and the amount
of pain and discomfort experienced and how that affects the daily functioning.
The DM then considers the merit of each answer and any other evidence. As with all
evidence DMs have to decide what weight to give to the content of the medical
report.
Note: The report should be read as a whole and any concerns over inconsistent or
improbable entries addressed before a determination of LCW or LCWRA is made.

G1091

There should be no changes made to the content of the medical report other than of
a very minor nature e.g. a typing error, and these are to be carried out by the same
HCP who completed the original wherever possible. It is permissible for another
approved HCP to make the amendment, having consulted the author of the original
report, for example to avoid unnecessary delay. However the HCP making the
amendment should make it clear that it has been made following consultation. Any
other additions or alterations should be provided in a separate document.

G1092

The medical report includes an opinion of a HCP approved by the Secretary of State
on whether any prescribed exceptional circumstances apply. The DM should
consider that opinion when deciding whether a claimant can be treated as having
LCWRA if they do not satisfy the test from the descriptors (1) (see ADM Chapter G3).
1 UC Regs, reg 40(1)(b) & (4) & Sch 9 para 5

G1093 Second or subsequent referrals

The medical report also includes advice on the period of time that should pass
before a claimant is reconsidered for the next WCA process. This advice is given in
all cases but the DM can determine afresh whether the claimant still has LCW in
prescribed circumstances (see G1020 et seq). This may be at a different time from
the advice given on the medical report.

G1094

In second and subsequent referrals medical services will
1. provide confirmation of the assessments which reach or exceed the threshold
to satisfy LCW or LCWRA or
2. arrange for a HCP to examine all claimants who do not reach the threshold and
provide a medical report on their ability to perform the specified activities or
3. provide a recommendation on whether the claimant has LCWRA.

G1095

Not all claimants require an assessment in subsequent referrals. Medical services
decides if LCW or LCWRA can be assessed on scrutiny of the available evidence.

G1096 Failure to return the questionnaire G1101

A claimant is treated as not having LCW or LCWRA for failure to return the
questionnaire without a good reason (1) if the Secretary of State can show that
1. the questionnaire was sent and
2. a further request was sent at least three weeks after the first letter and at least
one week has passed since then (2) and
3. a good reason has not been given or accepted for delay beyond the period
stated in 2. above.
1 UC Regs, reg 43(3); 2 reg 43(4)

G1097 The Secretary of State's duty

The DM needs to make sure that the Secretary of State has complied with the duty
set out in the legislation (1) to send the questionnaire and the reminder to the claimant.
The DM can accept that it has been sent if there is a record of its issue and no
indication that it was not properly addressed, stamped and posted.
1 Inte Act 78, s 7

G1098 Has the questionnaire been sent

Care must be taken to identify the date the questionnaire was sent. The date of its
issue is only an indication of the date on which it was posted. The DM should
consider whether the questionnaire actually left the issuing office and was put into
the external mail on the date recorded (1).
1 R(IB) 1/00

G1099 Has the correct amount of time passed

The correct period of time must have passed since the first questionnaire was sent.
The period of time starts on the day after the questionnaire is sent and ends at
midnight on the last day provided for. If the questionnaire is posted to the claimant's
last known address, the date on which it is sent is the date it was posted (1).
1 UC, PIP, JSA & ESA (D&A) Regs, reg 3(2)

Example

A questionnaire was sent to Jack on 7.10.13. A reminder is due and sent on
29.10.13. If he still does not return the questionnaire, the first day on which the DM
can consider whether he should be treated as not having LCW is 6.11.13.

G1100 Good reason

If the DM concludes that the Secretary of State has complied with the duty set out in
the legislation, they may then go on to consider whether the claimant had a good
reason for their failure to return the questionnaire (1) (see G1125 et seq).
1 UC Regs, reg 43(3)

G1101 Questionnaire returned before good reason considered

As in G1096, the law imposes time limits on the Secretary of State in relation to the
sending of the questionnaire and the reminder. However, there is no law imposing a
time limit on the claimant for the return of the questionnaire. Sometimes the
questionnaire is returned after the time limit imposed on the Secretary of State but
before the DM has considered whether there was a good reason for the earlier
failure to return the questionnaire. In these circumstances, the determination cannot
be made because it cannot be held that the claimant has failed to return the
questionnaire. Instead, normal WCA action should resume.

Example

A questionnaire was sent to Jayne on 1.7.14. This was not returned so a reminder
was sent to her on 23.7.14. If the questionnaire is not returned, the first day on which
the DM could consider making a determination treating Jayne as not having LCW is
31.7.14. The DM obtains the case on 11.8.14 to make the determination, but notes
that the questionnaire had been received in the office on 6.8.14. The DM cannot
make the determination treating Jayne as not having LCW because she has not
failed to return the questionnaire. Instead, normal WCA action resumes.

[G1102-G1104]

Medical examination

G1105 General G1007

Claimants may be called to attend a medical examination by a HCP approved by the
Secretary of State where it has to be determined whether they have LCW or
LCWRA (1). The purpose of the medical examination is to enable the DM, with the
benefit of a medical opinion, to determine whether a claimant meets the threshold
for LCW or LCWRA.
1 UC Regs, reg 44(1)

G1106 Failure to attend or submit to a medical examination

Claimants can be treated as not having LCW or LCWRA if
1. they fail without a good reason to attend for or submit to a medical
examination (1) and
2. they
2.1 had at least seven days' notice of the examination or
2.2 agreed to accept a shorter period of notice (2).

1 UC Regs, reg 44(2); 2 reg 44(3)

G1107

Medical services
1. where possible contacts the claimant by telephone to arrange an appointment
for the examination and
2. keeps a detailed record of the date, time and place of the examination agreed
with the claimant and
3. issues written notice to confirm the arrangement (unless the claimant has
agreed to accept a shorter period of notice).

G1108 The Secretary of State's duty G1112 G1116 G1121

Unless the claimant has agreed to accept a shorter period of notice, when
considering whether a claimant should be treated as not having LCW or LCWRA,
the DM has to be satisfied that the Secretary of State has complied with the duty set
out in the legislation (1), that
1. a written notice was sent and
2. the notice included the time and place of the examination and
3. the notice was sent at least seven days before the date of the examination
and
4. the examination had not been cancelled.

1 UC Regs, reg 44(3)(a)

G1109

If, after calculating the period of time which passed between the date the written
notice was sent and the time of the examination, the DM decides that seven days
had not elapsed (1), they should consider whether the claimant has agreed to accept a
shorter period of notice whether given in writing or by telephone. If there is no
evidence that the claimant had agreed to accept a shorter period of notice the
claimant cannot be treated as not having LCW.

1 UC Regs, reg 44(3)(a)

G1110

Where the claimant has agreed to accept a shorter period of notice the DM
considers the appropriate amount of time agreed between medical services and the
claimant (1). Medical services always send a confirmation of the date, time and venue
of the appointment whether or not this has been agreed in a telephone call with the
claimant.

1 UC Regs, reg 44(3)(b)

G1111

Only one rescheduled appointment can be offered during a WCA referral. If the
claimant cannot attend the rescheduled appointment, medical services will record
that the claimant has failed to attend. The DM will have to consider the reasons why
the claimant cannot attend and consider whether this was because of a good reason
(see G1125 et seq).

G1112

If the DM cannot confirm that the provisions in G1108 were met, the claimant cannot
be treated as not having LCW or LCWRA.
Note: Medical services can provide evidence of notification for requests from DMs
who are considering revision or supersession of disallowance determinations and
preparing appeal responses.

G1113 Has notice been sent

The DM needs to be sure that the claimant has been sent notice. The DM can
accept that it has been sent if there is a record of its issue and no indication that it
was not properly addressed, stamped and posted (1). In addition the DM should make
sure that the notice was in writing and included the time and place of the medical
examination unless the claimant had agreed to accept a shorter period of notice.
Medical services always send a confirmation of the date, time and venue of the
appointment whether or not this has been agreed in a telephone call with the
claimant.
1 Inte Act 78, s 7

G1114 Have seven days passed

Where there is no evidence that the claimant agreed to accept a shorter period of
notice, the DM needs to be sure that the correct period of notice has been given.
The DM has to decide when the notice was sent. The day after is day one. Seven
clear days of notice have to pass before the date of the examination (1).
1 R(IB) 1/00

Example 1

A letter giving the time and place of a medical examination is prepared and placed in
the post tray at 3pm on Friday 1st. Because of the timing of the internal post
collection it does not reach the post room until Monday lunchtime and leaves the
office in the external mail on Monday at 5pm. The appointment is timed for Monday
11th. The recipient does not attend. It is not possible to treat the claimant as not
having LCW because if Tuesday 5th is Day one, Monday 11th is Day seven and they
have not received seven days clear notice.

Example 2

A letter giving the time and place of a medical examination leaves the office on
Wednesday 6th. The appointment is timed for Thursday 14th. The recipient does not
attend. Subject to good reason the claimant is treated as not having LCW because
Thursday 7th is Day one, Thursday 14th is Day eight and they have received at least
seven days clear notice.

G1115 Has the appointment been cancelled

Claimants cannot fail to attend the medical examination if the appointment had
already been cancelled by medical services. The DM should investigate any
indications that the claimant had made contact with the issuing office before the time
of the examination. This is so that they can satisfy themselves that the appointment
had been left open for the claimant.

G1116 Good reason

If the DM concludes that the Secretary of State has complied with the duty set out in G1108they may go on to consider whether the claimant had a good reason for their
failure to attend to medical examination.

G1117 Failure to submit

Where a claimant attends a WCA but fails to participate in the process the
assessment is terminated. This may happen where a claimant
1. refuses to be examined or
2. poses a threat to staff or others or
3. shows inappropriate or threatening behaviour or
4. shows intoxication from alcohol or substance abuse or
5. is persistently uncooperative.

G1118

Medical services will record a full and detailed account of the claimant's behaviour
and refer to the DM to decide whether the claimant should be treated as not having
LCW or LCWRA due to a failure to submit to an examination.

G1119

If a claimant makes it clear after going to the examination that they will not be
medically examined then that constitutes a failure to submit to an examination (1).

1 R(IB) 1/01

G1120

A claimant fails to submit to an examination not only by refusing to be examined but
also if that claimant seeks to impose as a condition of being examined a term which
would render the examination useless for the purpose for which it is required.

Example

The claimant requests the medical report should not be passed to a layman,
including a DM, insisting on complete confidentiality. By imposing such a condition
the examination becomes useless for the purposes for which it was required and the
claimant is failing to submit to an examination.

G1121 Good reason

If the DM concludes that the Secretary of State has complied with the duty set out in G1108they may go on to consider whether the claimant had a good reason for their
failure to submit to a medical examination (see G1125 et seq).

[G1122-G1124]

G1125 Consideration of good reason G1100 G1111 G1121

The claimant will have been asked to give the reasons for not complying with the
Secretary of State's request for information or to attend or submit for examination.
The DM should bear in mind the guidance about considering evidence in ADM
Chapter A1 (Principles of decision making and evidence).

G1126

The onus of proving good reason lies with the claimant who fails to comply. The test
of good reason is whether the DM judges the reason for non-return or non-
attendance or failure to submit to be reasonable and likely on the balance of
probabilities.

G1127

The DM may determine that a claimant is treated as not having LCW if
1. they have failed to
1.1
return the questionnaire or
1.2. attend or submit for examination and
3. they have
3.1
not replied to enquiries or
3.2
given an explanation that does not amount to a good reason.

G1128 Good reason - some scenarios

Any reasons given for the non-return of the questionnaire should be judged on the
balance of probabilities. Whether the reasons for delay amount to good reason
depends upon whether the DM considers, for example,
1. it was reasonable not to return the questionnaire on this occasion or
2. if non receipt by the office or claimant was more probable than not.

G1129

If a claimant says that they were too ill to attend because of the nature of their
disability, the DM should ask for evidence to support this. If the claimant is usually
able to get out, for example to the doctor or hospital, good reason should only be
accepted if it is unreasonable to expect the claimant to have attended on that
occasion. Exceptionally, a claimant may be examined at home if they are unable to
travel.

G1130

A claimant may say they were too ill to attend because of a condition unrelated to
their disability, for example they may say that they had flu at the time of the
appointment. If the DM accepts the evidence, the claimant has a good reason for
their non-attendance.

G1131

Good cause (or reason) was not accepted in a case where a claimant had tried to
avoid attending several examinations by submitting final certificates. In the particular
circumstances the final certificate was irrelevant because it was replaced by an open
statement which included the day of the examination (1).

1 R(S) 12/59

G1132

If the claimant contends that they did not receive the notice of the appointment, DMs
should satisfy themselves that the notice was sent. The DM should give
consideration to the date on which the written notice was posted, the time sufficient
to show whether or not it would have been collected from the post box, the address
to which it was posted and whether by first or second class post. The DM should
also be satisfied the letter has not been returned undelivered.

G1133

The DM will normally need better evidence of the address to which it was posted
than a later computer generated print out showing the address on the file at that later
date. If there is no evidence to show whether first or second class post was used the
DM should assume that second class post was used. If it was sent it can be
assumed it was delivered unless there is evidence to the contrary.

G1134

Where the claimant says the postal difficulties are specific to them or their address,
all of their circumstances are to be given fair consideration. They will have to show
that they have done enough to ensure as far as is reasonably possible that they
receive their mail, special care may be expected in the cases of accommodation
addresses and premises in multiple occupation.

G1135

Sometimes it may be right to reject a claimant's allegation of non-receipt where the
excuse extends to a number of letters, or is coupled with suspicious circumstances,
or if the non-receipt of mail is selective so that only certain letters are not received.
However the uncontradicted evidence of the non-receipt of a single letter in plausible
circumstances, such as the communal delivery of mail to particular premises where
another person went through the mail before the claimant had a chance to do so
may establish a good reason.

G1136

DMs can see all changes of address and when the changes were effective from in
the relevant medical services computer system to help them decide where the
questionnaire was sent and when.

G1137

If a claimant attends but refuses to have a physical examination, for example
because of genuinely held religious beliefs, the DM should normally accept a good
reason unless it is evident that the refusal is based on a prejudice against or distaste
for the examination rather than because of a particular belief (1) .

1 R(S) 9/51

G1138

It is possible for the DM to consider that a claimant did not have a good reason for
failure to submit to an examination because of drunkenness, drug abuse or other
problem behaviour. However if the behaviour is a symptom of the stated medical
condition such as alcoholism, rather than an isolated occurrence, the claimant may
have a good reason.

G1139

If a claimant did not attend for medical examination because a consultant advised
that attendance was not necessary, that does not show a good reason for failing to
attend for medical examination. Irrespective of the claimant's medical advisor's
opinion as to LCW or LCWRA, a claimant is obliged to abide by the rules for
claiming benefit.

G1140

A failure to comply with a notice to attend a medical examination will usually be
deliberate, except in cases where, through mental illness or disablement, the
claimant is unable to make a choice between attendance and non-attendance. The
question is whether there is a good reason for the deliberate failure to comply with
the notice.

[G1141-G1999]