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Chapter U2: ESA Limited capability for work and Limited capability for work-related activity

Contents
U2001:Introduction
U2002:Benefits affected
U2005:Scope of this chapter and definitions
U2006:Meaning of a health care professional
U2007:Meaning of claimant
U2008:Determination of limited capability for work
Certain claimants to be treated as having
U2017:limited capability for work
U2018:Certain conditions
U2020:Terminally ill
U2023:Cancer treatment
U2029:Meaning of relevant infection or contamination
U2030:Pregnant women
U2040:Hospital patient
U2046:Future admission to hospital
U2047:Planned admission postponed
U2048:Planned admission cancelled
U2049:Receiving regular treatment
U2059:Claimants treated as having limited capability for work throughout a day
U2067:Night shift workers
Qualifying young claimants to be treated as having limited capability for work in
U2074:certain circumstances
U2091:Evidence and information for limited capability for work
U2092:Evidence
U2093:Self-certification
U2095:Doctor's statements
U2097:Other evidence
U2101:Information
Limited capability for work assessment
U2111:Introduction
U2126:Application of the assessment
U2142:Second or subsequent referrals
U2147:Determining limited capability for work afresh
U2151:Qualifying conditions
U2154:Calculation of score
U2160:Use of prostheses, aids and appliances
U2163:General application
U2165:Aid or appliance prescribed or advised
U2167:Aid or appliance not prescribed or advised
U2171:Determination of the limited capability for work assessment
U2185:Exceptional circumstances
U2186:Uncontrolled or uncontrollable disease
U2187:Medical evidence
U2188:Substantial risk
U2190:Meaning of substantial risk
U2194:Risk at work
Treated as having limited capability for work until assessment
U2201: is carried out
U2202:Conditions
U2206:Further claim after determination that claimant does not have LCW

Gap in medical evidence
U2208:Contact with claimant not lost
U2214:Contact lost with claimant

Treated as not having limited capability for work
U2221:General
U2222:Failure to return the questionnaire
U2228:The Secretary of State's duty
U2229:Has the questionnaire been sent
U2230:Has the correct amount of time passed
U2231:Good cause
U2232:Questionnaire returned before good cause considered
Failure to attend or submit to a medical examination
U2241:General
U2244:The Secretary of State's duty
U2249:Has notice been sent
U2250:Have seven days passed
U2251:Has the appointment been cancelled
U2252:Good cause
U2253:Failure to submit
U2257:Good cause
U2261:Consideration of good cause
U2265:General considerations
U2266:Claimant's state of health
U2268:Nature of claimant's disability
U2270:Previous WCA attended
U2271:Repeated failures
U2280:Good cause - some scenarios
Certain claimants to be treated as not having limited capability for work
U2300:Member of Her Majesty's Forces
U2301:Training course
U2303:Medical evidence ends

Medical evidence ceases before appeal heard
U2307:contact with claimant lost
U2308:Appeal allowed

Medical evidence ceases before appeal heard
U2330:contact with claimant not lost
U2332:Appeal allowed
U2333:Appeal withdrawn, struck out or dismissed
U2340:Detention in legal custody
U2350:Claimant does not have LCW for the purposes of UC
Claimants who are treated as not entitled to ESA by reason of working
U2360:to be treated as not having limited capability for work
U2363:Date of determination
Evidence of limited capability for work after determination that a claimant
U2370:does not have limited capability for work

Limited capability for work-related activity
U2380:General

Claimant treated as not having limited capability for work-related activity . U2385
U2390:Determination of limited capability for work-related activity

Certain claimants treated as having limited capability
U2395:for work-related activity
U2397:Information required for determining capability for work-related activity
U2402:Failure to provide information
U2410:Claimants who may be called for examination
U2415:Consideration of good cause

Determination of whether a claimant has limited capability
U2425:for work-related activity
U2440:Second or subsequent referrals
U2444:Determining limited capability for work-related activity afresh
Explanation of treatments .................................................................... Appendix

Chapter U2: ESA Limited capability for work and Limited capability for work-related activity

U2001 Introduction

The WCA describes the end to end medical process comprising of two elements to
help the DM decide
1. whether a claimant has LCW and is entitled to ESA
2. whether a claimant who has LCW
2.1
also has LCWRA and is entitled to the support component or
2.2
does not have LCWRA and is entitled to the WRAC.

U2002 Benefits affected

Whether a claimant has LCW and LCWRA must be determined using the following
guidance.

U2003

A determination on whether a claimant
1. has or does not have or
2. is to be treated as having or not having
LCW for entitlement to any benefit, allowance or advantage is conclusive for other
decisions on any other benefit, allowance or advantage for the same period where
LCW is relevant to entitlement to that benefit, allowance or advantage (1).

1 UC, PIP, JSA & ESA (D&A) Regs, reg 40(1)

U2004

The benefits and allowances affected include ESA (1), JSA (2) and NI credits (3).
1 ESA Regs 13; 2 WR Act 07, Sch 3, 12(6); 3 SS (Credits) Regs, reg 8B

U2005 Scope of this chapter and definitions

This chapter contains guidance on

Determination of LCW (see U2008)

Certain claimants to be treated as having LCW (see U2017)

Evidence and Information required for determining LCW (see U2091)

LCW assessment (see U2111)

Exceptional circumstances (see U2185)

Treated as having LCW until assessment (see U2201)

Treated as not having LCW (see U2221)

LCWRA (see U2380).

U2006 Meaning of a health care professional

A HCP means (1)
1. a registered medical practitioner or
2. a registered nurse or
3. a registered occupational therapist or physiotherapist (2).
1 ESA Regs 13, reg 2; 2 Health Act 1999, s 60

U2007 Meaning of claimant

Claimant means a person who has claimed ESA (1).
1 WR Act 07, s 24(1)

U2008 Determination of limited capability for work U2005

To be entitled to ESA a claimant must have LCW (1). This means that the claimant's
capability for work is limited by their physical or mental condition and it is not
reasonable to require them to work (2).

1 WR Act 07, s 1(3)(a); 2 s 1(4)(a) & (b)

U2009

The question of LCW must be decided first in the WCA process as this determines
entitlement to benefit. This is normally by questionnaire and face to face assessment
at a medical. This part of the WCA process is referred to as the LCW assessment.

U2010

A claimant can be treated as having LCW pending a determination of LCW provided
certain conditions are satisfied (1) (see U2201 et seq).

1 ESA Regs 13, reg 26

U2011

Certain claimants are treated as having LCW and do not have to undergo the LCW
assessment (1) (see U2018). However some claimants who do not have to be
assessed for LCW will still have to be assessed for LCWRA (see U2380 et seq).
1 ESA Regs 13, reg 16, 21 & 22

[U2012-U2016]

U2017 Certain claimants to be treated as having limited capability for work U2005 U2399

A claimant is treated as having LCW if the claimant
1. satisfies certain conditions (1) (see U2018) or
2. is a hospital patient (2) (see U2040) or
3. is receiving certain treatments (3) (see U2049) or
4. has LCW for part of a day (4) (see U2059) or
5. has exceptional circumstances (6) (see U2185).
1 ESA Regs 13, reg 16; 2 reg 21; 3 reg 22; 4 reg 23; 5 reg 25

U2018 Certain conditions U2011 U2017 U2019 U2115

Claimants are treated as having LCW and do not have to undergo the LCW
assessment if any of the circumstances in U2019 apply to them (1) unless they are
treated as not having LCW because they are working (2) (see U2360 et seq).

1 ESA Regs 13, reg 16; 2 reg 37

U2019 U2018 U2030 U2032 U2102 U2126 U2147 U2362

For the purposes of U2018 the circumstances are that the claimant (1)
1. is terminally ill (see U2020 et seq)
2. is
2.1 receiving
or
2.2 likely to receive or
2.3 recovering from
treatment for cancer by way of chemotherapy or radiotherapy and the DM is
satisfied that the claimant should be treated as having LCW (see U2023 et
seq)
3. is known or reasonably suspected to be a carrier, or to have been in contact
with a case, of a relevant infection or contamination and
3.1 is excluded or abstains from work in accordance with a request or
notice in writing in accordance with legislation or
3.2 is otherwise prevented from working in accordance with legislation (see U2029)
4. is a pregnant woman (see U2030 et seq)
4.1 where there is a serious risk of damage to her health or to the health of
her unborn child if she does not refrain from work or
4.2 who is in the MAP and is entitled to MA or
4.3 whose EWC or ADC has been certified (2) on any day in the period
4.3.a
beginning with the first day of the 6th week before the EWC or
the ADC, whichever is earlier and
4.3.b ending on the 14th day after the ADC
if she would have no entitlement to a MA or SMP were she to make a
claim in respect of that period
5. satisfies any of the descriptors in the LCWRA activities about
5.1 conveying food or drink to the mouth or
5.2 chewing or swallowing food or drink (3)
6. is entitled to UC and it has previously been determined following assessment
under UC rules that they have LCW (6).
1 ESA Regs 13, reg 16; 2 SS (Med Ev) Regs, reg 2(3); 3 ESA Regs 13, reg 30(2), (3) & (6) & Sch 3, para 15 or 16;
6 reg 16(1)(h); UC Regs, Part 5

U2020 Terminally ill U2019

"Terminally ill" is defined as a claimant who is suffering from a progressive disease
and death in consequence of that disease can be reasonably expected within six
months (1).

1 ESA Regs 13, reg 2

U2021

Claimants claiming under special rules are terminally ill as diagnosed by a GP or
other HCP.

U2022

A claimant who is terminally ill and has made
1. a claim expressly on the ground of being terminally ill or
2. an application for supersession or revision expressly on the ground of being
terminally ill
is entitled to the support component or WRAC without the assessment phase having
ended (1).
1 ESA Regs 13, reg 7(1)(a)

U2023 Cancer treatment U2019 U2025 U2025 U2395

A claimant can be treated as having LCW if (1)
1. they are
1.1 receiving treatment for cancer by way of chemotherapy or radiotherapy
or
1.2 likely to receive treatment as in 1.1 within six months after the date of
the LCW determination or
1.3 recovering from treatment as in 1.1 and
2. the DM is satisfied that the claimant should be treated as having LCW and
LCWRA.

1 ESA Regs 13, reg 16(b)

U2024

The claimant is asked in the questionnaire (form ESA (50)) to ensure that their HCP
completes page 20 of the form, giving details of the diagnosis, treatment including
how long it is likely to last, and the expected recovery period, as well as an opinion
on the effects on the claimant's ability to work. The claimant is asked to complete
the form as normal if other health conditions are present.
Note: See U2222 et seq for guidance on when the claimant does not return the
questionnaire.

U2025

The DM should take into account the debilitating effects of the treatment in U2023 1.
when considering whether the claimant should be treated as having LCW. The
presumption is that claimants who fall within U2023 1. will be treated as having
LCW, where the cancer treatment has work limiting side effects, and those effects
are likely to limit all forms of work.

Example 1

Martin is diagnosed with cancer of the oesophagus, and has a course of
chemotherapy to reduce the size of the tumour. Once the treatment starts, Martin
becomes too ill to work, and claims and is awarded ESA. He is referred for the
WCA. In the ESA (50), Martin's oncologist states that the chemotherapy will continue
for 3 months, after which it is hoped to remove the tumour surgically. He will
probably require a course of radiotherapy after that. The treatment so far has left
Martin feeling very tired, nauseous and weak, as well as giving him difficulties with
speaking, eating and drinking. The HCP recommends that Martin is treated as
having LCW for 9 months, before referring for a further WCA to see if Martin's
condition has improved. The DM accepts the advice, and determines that Martin has
LCW.

Example 2

Jay has exploratory surgery as a day patient to remove a lump in his groin. He is
diagnosed with non-Hodgkin's lymphoma. He starts a course of chemotherapy, and
is awarded UC after the second treatment leaves him unable to work.
Jay is referred for the WCA. In the ESA (50), his oncologist says that Jay will have up
to 8 chemotherapy treatments by injection every three weeks. Jay is often too weak
to get out of bed as a result of the treatment. He has loss of sensation in his hands
and feet, and is prone to falling. He has twice been admitted to hospital for treatment
for dehydration due to vomiting and diarrhoea. If the side effects continue, the
chemotherapy treatment may stop and be replaced by radiotherapy over a longer
period. He is likely to take at least six months to recover from the chemotherapy.
Medical advice is that Jay should be treated as having LCW, with a review after a
year. The DM accepts the advice.

Example 3

Heather is diagnosed with primary breast cancer following a mammogram. She is
admitted to hospital for surgery to remove the tumour, and is required to stay in
hospital for 24 hours or longer. She claims and is awarded ESA. Heather is referred
for the WCA. On the ESA (50), Heather's oncologist states that Heather will start a
course of radiotherapy in about 4 weeks. The radiotherapy will be likely to make her
very tired for several months as the treatment progresses, and after it has ended.
The HCP recommends that Heather should be treated as having LCW for 6 months,
with a further review to check on progress. The DM determines that Heather is
treated as having LCW.

Example 4

Rachel has difficulties with mobility, standing and sitting and reaching as a result of
generalised arthritis. A small spot on her nose is diagnosed as a melanoma or skin
cancer. The melanoma is surgically removed under local anaesthetic. She claims
and is awarded ESA.
Rachel is referred for the WCA. Her GP completes the statement in the ESA (50) to
say that Rachel had facial pain, bruising and swelling for two weeks after the
surgery. She will be referred for a single session of radiotherapy, but this is unlikely
to affect her ability to work. Rachel completes the rest of the questionnaire to give
details about how her arthritis affects her ability to work.
Rachel is required to attend for medical examination. The HCP is of the opinion that
Rachel does not satisfy any of the LCW descriptors, and should not be treated as
having LCW, because although she is due to have radiotherapy treatment, this is not
likely to have any debilitating effects. The DM accepts the advice, and determines
that Rachel does not have, and is not treated as having, LCW.

[U2026-U2028]

U2029 Meaning of relevant infection or contamination U2019

The following definitions apply (1):
1. in Scotland, the term "contamination" is the same as defined in legislation (2).
2. in England and Wales, the term "infection or contamination" shall be read in
accordance with legislation (3).
3. in Scotland, the term "infectious disease" is the same as defined in
legislation (4).
4. in England and Wales, the term "relevant infection or contamination" means
4.1 any incidence or spread of infection or contamination, in respect of
which certain legislation applies (5), for the purpose of preventing,
protecting against, controlling or providing a public health response
4.2 any disease, food poisoning, infection, infectious disease or notifiable
disease to which certain legislation applies (6).
5. in Scotland, the term "relevant infection or contamination" means
5.1 any infectious disease or exposure to an organism causing that
disease, or
5.2 contamination or exposure to a contaminant to which certain legislation
applies (7).
1 SS (IW) (Gen) Regs, reg 11(2); ESA Regs 13, reg 16(2); 2 Public Health etc (Scotland) Act 2008, s 1(5);
3 Health and Social Care Act 2008, s 45A(3); 4 Public Health etc (Scotland) Act 2008, s 1(5);
5 Public Health (Control of Disease) Act 1984, Part 2A; 6 Public Health (Aircraft) Regulations 1979,
reg 9 & Public Health (Ships) Regulations 1979, reg 10; 7 Public Health etc (Scotland) Act 2008, s 56 to 58

U2030 Pregnant women U2019

A pregnant woman can be treated as having LCW in certain circumstances (1) (see U2019 4.).

1 ESA Regs 13, reg 16(d), (e) & (f)

U2031

"Sickness of pregnancy", which can also be described as "emesis", "hyperemesis",
"hyperemesis gravidarum", or "morning sickness", comes within the definition of a
disease. This condition usually occurs between the 29th and 34th weeks before the
EWC but can also be accepted outside that period when it may include a
complication in the pregnancy.
Note: "Pregnancy" itself does not come within the definition of a disease.

U2032

Unless a woman can be treated as having LCW because of pregnancy as in U2019
4., she should provide other evidence of LCW, for example
1. a complication in the pregnancy or
2. a medical condition not related to pregnancy.

[U2033-U2039]

U2040 Hospital patient U2017 U2041 U2042 U2102 U2126 U2147 U2362

Claimants are treated as having LCW where they are
1. undergoing medical or other treatment as a patient in a hospital or similar
institution or
2. recovering from treatment as in 1. and the DM is satisfied that the claimant
should be treated as having LCW (1).

1 ESA Regs 13, reg 21(1)

U2041

Where a claimant attends a residential programme of rehabilitation for the treatment
of drug or alcohol abuse, they are regarded as undergoing treatment as in U2040 (1).

1 ESA Regs 13, reg 21(2)

U2042

A claimant is regarded as undergoing treatment as in U2040 1. only where they have
been advised by a registered medical practitioner to stay for a period of 24 hours or
longer following that treatment (1). This applies even if the claimant disregards that
advice and returns home.
1 ESA Regs 13, reg 21(3)

Example

Sarah is admitted to hospital for surgery involving a general anaesthetic. She was
told before the surgery that she should bring a night bag in case she has to stay
overnight. Sarah's surgery goes well, and she is discharged the same day. As Sarah
was not advised to stay overnight, she cannot be treated as having LCW. Sarah will
need to be assessed for LCW in the normal way by completing a questionnaire and
attending for medical examination if necessary.

U2043

"Day of recovery" means a day on which a claimant is recovering from treatment as
a patient in a hospital or similar institution and the DM is satisfied that the claimant
should be treated as having LCW on that day (1).

1 ESA Regs 13, reg 21(4)

U2044

A hospital patient can be treated as having LCW even if admitted only for
investigation of symptoms unless the investigation reveals that admission was due to
another factor such as a personality disorder (1).

1 R(S) 1/58; R(S) 6/59

[U2045]

U2046 Future admission to hospital U2047

Where
1. on consideration of all the evidence after application of the WCA, the DM is of
the opinion that the claimant would not have, or would not be treated as
having, LCW and
2. the HCP advises that the claimant is about to go into hospital for treatment
within 21 days of the medical examination
the DM should defer making a determination as to whether the claimant has LCW
until it is confirmed that the claimant has become a hospital in-patient.

U2047 Planned admission postponed

If
1. the claimant is not admitted to hospital as planned and
2. a new date for admission is provided and
3. the claimant continues to provide evidence of LCW (see U2092 et seq)
the DM should continue to defer making a determination on LCW as in U2046.

U2048 Planned admission cancelled

Where a planned admission to hospital is cancelled and no new date is proposed,
the DM should determine whether the claimant has LCW as normal.

U2049 Receiving regular treatment U2017 U2050 U2051 U2052 U2054 U2056 U2102 U2126 U2147 U2362

Claimants are treated as having LCW when they
1. receive
1.1. regular weekly treatment by way of haemodialysis for chronic renal
failure or
1.2. treatment by way of plasmapheresis or
1.3. regular weekly treatment by way of total parenteral nutrition for gross
impairment of enteric function (1) and
2. satisfy the condition in U2052 (2)
unless they are treated as not having LCW because they are working (3) (see U2360 et
seq).

1 ESA Regs 13, reg 22(1); 2 reg 22(2); 3 regs 37

U2050

An explanation of the treatments in U2049 is in the Appendix to this Chapter.

U2051 U2057

Subject to U2052 a claimant referred to in U2049 is to be treated as having LCW
during any week in which that claimant is engaged in treatment or has a day of
recovery from that treatment (1).

1 ESA Regs 13, reg 22(1)

U2052 U2049 U2051 U2053 U2054

Claimants who receive the treatment in U2049 1. are only treated as having LCW
from the first week of treatment where they have no fewer than
1. two days of treatment or
2. two days of recovery from that treatment or
3. one day of treatment and one day of recovery from that treatment
but the days of treatment or recovery or both need not be consecutive (1).

1 ESA Regs 13, reg 22(2)

U2053

The condition in U2052 must be satisfied during the period of the current claim for
ESA. Where the condition was satisfied before the date of the current claim, and is
not satisfied at the date of that claim, the claimant cannot be treated as having LCW
under the regular treatment rules.

Example

Bill is receiving radiotherapy on one day a week, with a further day for recovery from
the treatment. The treatment is changed so that he no longer needs a recuperation
period. His SSP expires, and he claims ESA. He cannot be treated as having LCW
because his regular treatment is only once a week. Later his condition deteriorates,
and the radiotherapy treatment again means that he needs a subsequent day to
recover. He is treated as having LCW from the first week after the date of claim in
which he has two days of treatment including the day of recovery. Bill continues to
be treated as having LCW as long as the treatment lasts, even if it reduces to one
day.

U2054

There are no linking rules for periods of regular treatment. If
1. a claimant has been treated as having LCW as in U2049 and
2. entitlement to ESA ends (for example because the treatment ends) and
3. a further award of ESA is made from a later date when treatment begins again
the claimant must satisfy the condition in U2052 again before they can be treated as
having LCW.

U2055

U2056

A "day of recovery" means a day on which the claimant is recovering from any of the
forms of treatment listed at U2049 and the DM is satisfied the claimant should be
treated as having LCW on that day (1).

1 ESA Regs 13, reg 22(3)

U2057 U2365

Where a claimant is
1. in receipt of ESA and
2. treated as having LCW as per U2051 and
3. working on any day during a week when he is receiving regular treatment or
recovering from it
the work does not affect the claimant's entitlement to ESA (1). But the claimant is only
paid ESA for the days of receiving or recovering from treatment if they are not days
of work (2) (see ADM Chapter V1 for further guidance).

1 ESA Regs 13, reg 40; 2 reg 102

[U2058]

U2059 Claimants treated as having limited capability for work throughout a day U2017 U2060

If a claimant
1. has LCW at the start of a day but becomes capable later that day or
2. is capable of work at the start of the day but develops LCW during the day
the whole day is treated as a day of LCW if no work is done on that day (1).
Note: The exception to this would be where the night shift worker provision applies
(see U2067).

1 ESA Regs 13, reg 23

U2060

The guidance at U2059 applies where there is a sudden onset of, or recovery from,
an incapacitating condition. It does not provide that a claimant with a variable
condition that incapacitates them for part of each day has LCW throughout the whole
of every day.

U2061

When DMs determine that a claimant has LCW they can consider if this provision
applies to treat the claimant as having LCW for the day at the beginning or end of
the period of illness.

U2062

Even if a claimant is treated as having LCW under this provision any work that they
do on that day or on another day in that week may mean that they are to be treated
as not having LCW. A day cannot be a day of LCW if they have undertaken work on
that day (1). The normal rules for exempt work (2) apply.
Note:
For guidance on exempt work see ADM Chapter V3.
1 ESA Regs 13, reg 23; 2 reg 39

Example

If a claimant works 9am to 5pm from Monday to Friday, and on the Wednesday has
an accident at work at 11am resulting in them being unable to continue with that
day's work this will not be treated as a day of LCW. The first day of LCW will be the
day following the accident if they do not return to work on that day.

[U2063-U2066]

U2067 Night shift workers U2059 U2364

Night shift workers are claimants who work for a period of employment which begins
on one day and extends over midnight into the next day. It is necessary to establish
how many hours are worked before and after midnight. The hours of work on any
other occasion are not relevant (1).

1 R(I) 31/55

U2068

The day on which the lesser hours are worked is treated as a day of LCW if (1)
1. a claimant works on a night shift for a continuous period over midnight and
2. the claimant has LCW for the rest of that day.

1 ESA Regs 13, reg 24(1)

U2069

The second day of a night shift is treated as a day of LCW if (1)
1. the hours before and after midnight are equal and
2. the night shift is at the beginning of the PLCW.

1 ESA Regs 13, reg 24(2)(a)

U2070

The first day of the shift is treated as a day of LCW if (1)
1. the hours before and after midnight are equal and
2. the night shift is at the end of a PLCW.

1 ESA Regs 13, reg 24(2)(b)

U2071

The provisions do not apply to claimants whose employment lasts for more than 24
hours on either side of midnight (1). For example, it would not apply to continuous
employment from 6 pm on Monday to 2 am on Wednesday. In this example the
Wednesday cannot be treated as a day of LCW.

1 R(U) 18/56

U2072

A night worker paid by the shift is normally paid for a meal break and this should be
included in the calculation of the total time worked.

U2073

A night worker paid by the hour is not normally paid for a meal interval. This should
be deducted from the shift hours to arrive at the actual hours worked. The shift is still
regarded as one continuous period of employment because the meal break is a
normal break.

U2074 Qualifying young claimants to be treated as having limited capability for work in certain circumstances

To help satisfy the condition relating to youth claimants can be treated as having
LCW for days on which they are entitled to SSP (1) (see ADM Chapter U1).
1 ESA Regs 13, reg 29

[U2075-U2090]

U2091 Evidence and information for limited capability for work U2005

Information or evidence is needed to determine whether a claimant has LCW (1).
1 ESA Regs 13, reg 17

U2092 Evidence U2047 U2202 U2303

Evidence of LCW should be provided for the day or days of LCW until the claimant
has undergone the LCW assessment. Evidence may be (1)
1. self-certification (2) (see U2093) or
2. a statement from a doctor (3) (see U2095) or
3. if it is unreasonable to require such a statement, other evidence which is
sufficient to show that the claimant is limited by their physical or mental
condition and it is not reasonable to expect them to work because of some
specific disease or bodily or mental disablement (4).
1 ESA Regs 13, reg 17(1)(a); 2 SS (Med Ev) Regs, reg 5; 3 reg 2(1); 4 reg 2(1A)

U2093 Self-certification U2092

Evidence of LCW for a spell of less than eight days, or for the first seven days of a
longer spell, may be self-certification. Self-certification is only appropriate for the first
seven days of a PLCW.
Note: Where PLCWs link (see ADM Chapter U1), a claimant can self-certify for the
first seven days of each PLCW even if they are treated as a continuation of an
earlier PLCW (1).

1 SS (Med Ev) Regs, reg 5(1)

U2094

A self-certificate is (1)
1. a declaration made in writing by the claimant, in a form approved by the
Secretary of State or
2. a verbal declaration by the claimant in such cases where the DM allows (for
example where the claim to ESA is made by telephone).
Note:
It should include the information that they have been unfit for work from a date
or for a period. It may also include a statement that the claimant expects to continue
to be unfit for work.
1 SS (Med Ev) Regs, reg 5(2)

U2095 Doctor's statements U2092

A doctor's statement is a statement given in writing by a doctor. They are made on
an approved form (1).

1 SS (Med Ev) Regs, reg 2(1) & Sch 1, Pt 2

[U2096]

U2097 Other evidence

Evidence other than on an approved form or from a registered medical practitioner
can be accepted (1) if
1. it is unreasonable to require a doctor's statement and
2. the evidence shows that the claimant is unfit for work because of a disease or
disablement.

1 SS (Med Ev) Regs, reg 2(1A)

U2098

The DM decides what is reasonable in each case. For example, evidence from
alternative therapists such as chiropractors, osteopaths, etc can be accepted if the
claimant is usually treated by them as well as, or instead of, a GP.

U2099

Depending on the circumstances (1) a declaration that a claimant is incapable of
following a particular occupation and is receiving non-medical treatment such as
Christian Science treatment (i.e. treatment through prayer) may be sufficient proof of
LCW.

1 R(S) 9/51

U2100

An employer's certificate which only confirms absence from work is not sufficient
evidence (1).
1 R(S) 13/51

U2101 Information

The DM can ask for any additional information to help determine whether a claimant
has LCW (1).

1 ESA Regs 13, reg 17(1)(c )

U2102 U2117 U2171 U2225

Any information relating to the claimant's ability to perform certain activities (1) may be
requested in the form of a questionnaire (2) unless
1. there is already sufficient information to determine the question (3) or
2. a claimant is to be treated as having LCW (4) because they
2.1
satisfy certain conditions (see U2019) or
2.2
are a hospital patient (see U2040) or
2.3
receive certain treatments (see U2049).
1 ESA Regs 13, reg 15 & Sch 2; 2 reg 17(1)(b); 3 reg 17(2); 4 reg 17(3)

[U2103-U2110]

Limited capability for work assessment

U2111 Introduction U2005 U2209 U2372

The LCW assessment is the part of the WCA process that assesses LCW. It will
normally be completed during the assessment phase of ESA (1) and determines
entitlement to benefit beyond the assessment phase.

1 WR Act 07, s 8(1) & (2)

U2112

Whether a claimant's capability for work is limited by their physical or mental
condition and the limitation is such that it is not reasonable to require that claimant to
work is determined on the basis of a LCW assessment (1).

1 ESA Regs 13, reg 15(1)

U2113

Satisfying the LCW assessment depends on the ability to perform certain functions (1).

1 ESA Regs 13, reg 15(2)

U2114

When assessing the extent of the claimant's LCW, it is a condition that the
claimant's inability to perform (1)
1. physical
descriptors (2) arises
1.1 from a specific bodily (i.e. physical) disease or disablement or
1.2 as a direct result of treatment by a registered medical practitioner for
such a condition and
2. mental
descriptors (3) arises
2.1 from a specific mental illness or disablement or
2.2 as a direct result of treatment by a registered medical practitioner for
such a condition.
1 ESA Regs 13, reg 15(5); 2 Sch 2, Part 1; 3 Sch 2, Part 2

Example 1

Brian suffers from rheumatoid arthritis in his hands and knees, and claims ESA. In
the questionnaire Brian states that due to cognitive and mental impairment he has
difficulty with learning tasks, awareness of hazards and completing personal actions.
At the medical examination, Brian explains that the high level of painkillers he takes
for his arthritis makes him too tired to concentrate. The HCP advises that Brian is
mentally disabled by the medication, but not sufficiently to satisfy any mental health
descriptors. Brian scores 6 points for mobility problems.

Example 2

Rita is injured in an accident which leaves her with significant mobility problems and
facial scarring. Rita also suffers from depression and social anxiety disorder as a
result of the accident. Meeting people outside her immediate family brings on a
panic attack, so she avoids this. She scores 6 points for mobility problems arising
from her physical health condition, and 9 points for coping with social engagement
arising from her mental health condition.

Example 3

Ailsa suffers from mechanical back pain. She states that she has difficulties with
mobilising as well as getting about unless she has someone with her. The HCP
advises that Ailsa's need for assistance with getting about is only due to her physical
problems. The DM determines that Ailsa does not score any points for mental health
descriptors.

U2115 U2116

Certain claimants can be treated as having LCW without undergoing the LCW
assessment (see U2018).

U2116

Claimants who are not treated as having LCW as in U2115 and so have to undergo
the LCW assessment can be treated as having LCW pending actual assessment,
provided certain conditions are satisfied (1) (see U2201 et seq).

1 ESA Regs 13, reg 26

U2117

As part of the assessment, claimants who are not treated as having LCW may be
required to complete a questionnaire (see U2102) and if necessary attend a medical
examination. If they fail without good cause to do either, they can be treated as not
having LCW (1) (see U2221 et seq).

1 ESA Regs 13, reg 18 & 19

U2118 U2180

A claimant will have LCW if, by adding the points scored against any descriptor, a
score of at least 15 points is reached (1) (see U2157).
1 ESA Regs 13, reg 15(3)

[U2119-U2125]

U2126 Application of the assessment

The questionnaire is not required (1) if the claimant
1. satisfies certain conditions (2) (see U2019) or
2. is a hospital patient (3) (see U2040) or
3. receives certain treatment (4) (see U2049) or
4. the DM is satisfied that there is sufficient information to decide whether a
claimant has LCW without it.
All other claimants will be sent the questionnaire (ESA (50)) during the assessment
phase of their award of ESA.

1 ESA Regs 13, reg 17; 2 reg 16; 3 reg 21; 4 reg 22

U2127

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.

U2128

Medical services will
1. scrutinise evidence regarding a claimant's condition and give an opinion as to whether
1.1 they are treated as having LCW
1.2 in second or subsequent referrals they actually have LCW without
requiring a LCW assessment
2. provide impartial medical advice on request.

U2129

Medical services are responsible for gathering any information required to support
the WCA process. This includes
1. sending the questionnaire (ESA (50))
2. sending a reminder if the claimant does not reply within 28 days
3. deciding if further medical evidence is required from the claimant's GP or
HCP.

U2130

Medical services will arrange for a HCP to provide an opinion on LCW on either an
1. ESA (85) if the claimant has been examined or
2. ESA (85)A if the claimant has not been examined.

U2131

Medical services will provide 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. Their 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.

U2132

In the main, medical reports will be completed electronically. There is no
requirement for the report to be signed by the examining HCP (1). However the report
must identify the status of the HCP, i.e. whether he/she is a doctor or a registered
nurse.

1 R(IB) 7/05

U2133

The personalised summary statement forms part of the report form ESA (85) where
that is produced electronically, and is also produced as a separate form ESA (85)(S). It
is part of the evidence considered by the DM when making determinations as to
whether the claimant has LCW, and if so, whether they have LCWRA.

U2134

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.

U2135

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 form ESA (85).

[U2136-U2137]

U2138 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.
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 to
determine an overall score. 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 is made.

U2139

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.

U2140

A claimant may not have returned a questionnaire. The DM can proceed without it if
satisfied that there is sufficient information for a determination to be made whether
the claimant has LCW without it (1). For example the claimant is considered to be in a
vulnerable group, i.e. there is a diagnosis of a mental health condition. A decision to
treat as not having LCW due to non-return of the questionnaire would not be made
but the claimant referred for assessment.

1 ESA Regs 13, reg 17(2)

U2141

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
LCW if they do not satisfy the test from the descriptors (1) (see U2191 et seq).
1 ESA Regs 13, reg 25

U2142 Second or subsequent referrals

[See ADM memo ADM 21 14] 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 U2147). This may be at a
different time to the advice given on the medical report.

U2143

In second and subsequent referrals medical services will
1. provide confirmation of the assessments which reach or exceed the threshold
to satisfy LCW 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 they fall into the support group criteria
(see guidance in U2351 et seq).

U2144

Not all claimants require a LCW assessment in subsequent referrals. Medical
services will decide if LCW can be assessed on scrutiny of the available evidence.

U2145

However it may be necessary to call the claimant for examination on subsequent
referrals to assess LCWRA (see U2444).

[U2146]

U2147 Determining limited capability for work afresh U2142 U2148

[See ADM memo ADM 21 14] Where it has been determined that a claimant
1. has
LCW
or
2. is treated as having LCW
2.1 in certain conditions (see U2019) or
2.2 as a hospital patient (see U2040) or
2.3 due to receiving certain regular treatment (see U2049) or
2.4
in exceptional circumstances (see U2185) or
the DM can determine afresh whether the claimant still has LCW (1).

1 ESA Regs 13, reg 15(7)

U2148

U2147 applies where (1)
1. the DM wishes to determine whether there has been a relevant change of
circumstances in relation to the claimant's physical or mental condition or
2. the DM wishes to determine whether the previous determination was made in
ignorance of, or based on a mistake as to some material fact or
3. at least 3 months have passed since the date of the previous determination.
1 ESA Regs 13, reg 15(8)

[U2149-U2150]

U2151 Qualifying conditions

The LCW assessment is an assessment of the extent of a claimant's LCW because
of some specific bodily disease or disablement, a specific mental illness or
disablement or as a direct result of treatment provided by a registered medical
practitioner for such a disease or disablement to perform specified activities1. The
performance of activities is measured by descriptors the points from which have to
reach a set total for the claimant to have LCW (2). If the required number of points is
not reached the claimant does not have LCW. The test is the ability to perform any
work, not a specific occupation.

1 ESA Regs 13, reg 15(2) & Sch 2, Column 1; 2 reg 15(3) & Sch 2, Column 2

[U2152]

U2153

The level of each activity is measured by points. Part 1 contains activities
characterising physical function which are broken down into descriptors. Part 2
contains activities characterising mental, cognitive and intellectual function which are
also broken down into descriptors. The extent to which a claimant can or cannot
carry out an activity is determined by which descriptor applies to that claimant.

U2154 Calculation of score

Where a claimant meets a descriptor points will be awarded corresponding to that
descriptor.

U2155 U2156

Where more than one descriptor specified for an activity applies to a claimant, only
the descriptor with the highest score in respect of each activity which applies can be
counted (1).

1 ESA Regs 13, reg 15(6)

U2156

Other than as in U2155, there is no scoring limitation based on the claimant's
specific disease or bodily disablement. So, for example, a claimant who cannot walk
up and down 2 steps even with the support of a handrail because of their defective
sight can score points both for the activity of vision and that of walking (1).

1 R(IB) 3/98

U2157 U2118

A claimant has LCW when
1. one or more of the descriptors in the physical disabilities (1) or mental, cognitive
and intellectual functions (2) apply and
2. a total is reached of at least 15 points (3) from the descriptors
2.1 specified in Part 1 or
2.2 specified in Part 2 or
2.3 in both categories.
1 ESA Regs 13, Sch 2, Part 1; 2 Sch 2, Part 2; 3 reg 15(3)

[U2158-U2159]

U2160 Use of prostheses, aids and appliances U2392

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 ESA Regs 13, reg 15(4)

U2161 U2162

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.

U2162

Where
U2161 3. applies, the DM must explain how an aid or appliance would help
the claimant.

U2163 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 ESA Regs 13, reg 15(4) & Sch 2, Part 1

U2164

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 ESA Regs 13, Sch 2, Part 1

U2165 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.

U2166

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.

U2167 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.

U2168

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.

U2169

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.

U2170

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

U2171 Determination of the limited capability for work assessment

The DM determines whether the assessment is satisfied from
1. the questionnaire if one is available (see U2102) and
2. a statement from the GP (1) if one is available and
3. the medical report of the claimant's ability to perform the specified functions
and
4. the personalised summary statement and
5. any other relevant evidence.

1 SS (Med Ev) Regs, reg 2(1)

U2172

The normal principles apply to considering the evidence (see ADM Chapter A1).

U2173

The LCW assessment does not have to be satisfied in respect of each day (1). A
claimant should satisfy the test throughout a period. A claimant whose condition
varies from day to day and who would easily satisfy the LCW assessment on three
days a week and would nearly satisfy it on the other four days might have LCW for
the whole week.

1 R(IB) 2/99

U2174

A claimant may have long periods of illness separated by periods of remission
lasting some weeks, during which he or she suffers no significant disablement; such
a claimant might have LCW during the periods of illness but not have LCW during
the periods of remission. This is so even if the periods of illness are longer than the
periods of remission (1).

1 R(IB) 2/99

U2175

The test of whether a claimant cannot perform an activity is not whether or not they
are physically incapable of performing it. Matters such as pain, discomfort and
repeatability are taken into account. A claimant is not capable of carrying out an
activity if they can only do so with severe pain or, if having done it once, they are
unable to repeat it for hours or days. The extent of a claimant's ability to repeat the
activity in a single stretch and of the intervals at which the claimant would be able to
repeat the performance should be identified. A decision can then be made on
whether the claimant can perform the relevant descriptor with reasonable regularity.

U2176

There is no specific requirement that a claimant must be able to perform the activity
in question with "reasonable regularity". Even so regard should be had to some such
concept. The real issue is whether, taking an overall view of the claimant's limited
capability to perform the activity in question, they should reasonably be considered to
be incapable of performing it. The fact that they might occasionally manage to
accomplish it, would be of no consequence if, for most of the time, and in most
circumstances, they could not do so (1).

1 R(IB) 2/99

U2177

Where relevant descriptors are expressed in terms that the claimant "cannot"
perform the activity, one should not stray too far from an arithmetical approach that
considers what the claimant's abilities are most of the time (1).

1 R(IB) 2/99

U2178

Descriptors which state that "none of the above apply" to their ability to carry out the
activity or where they do not apply mean that the claimant has no problem
performing the activity or has less of a problem than would satisfy any of the other
descriptors for that activity.

Example

Activity 1 descriptor (e) is "None of the above applies". Descriptor (d) is "Cannot,
unaided by another person, either
(i)
mobilise more than 200 metres on level ground without stopping in order to
avoid significant discomfort or exhaustion; or
(ii)
repeatedly mobilise 200 metres within a reasonable timescale because of
significant discomfort or exhaustion."
"None of the above applies" means the claimant has no mobilising problem, or less
of a problem than would satisfy the penultimate descriptor 1(e) and would score no
points for that activity.

U2179

Where a descriptor refers to a claimant being able to use a tool or implement, the
use referred to is the use to which the tool or implement is normally put. The activity
relates to hand function and is intended to reflect the ability to manipulate objects in
order to carry out work-related tasks.

Example

Ability to use a pen or pencil is intended to reflect the physical use of the object not
reflect a claimant's level of literacy. The same concept applies to the use of a
computer keyboard or mouse.

U2180

The DM should decide which descriptor applies to each activity. Provided the
determination is sufficiently supported by evidence, for each activity the DM can
select the descriptor from the medical report (ESA (85)), the evidence provided by the
claimant (including the ESA (50) questionnaire), or a different descriptor. Satisfaction
of the test is decided on the total number of points from the final selection of
individual descriptors (see U2118).

U2181

The DM must record the final scores for each descriptor and the reasons for the
decision. Guidance on burden of proof is in ADM Chapter A1.

U2182

If the required number of points is not reached a claimant does not have LCW (1).
1 ESA Regs 13, reg 15(3)

[U2183-U2184]

U2185 Exceptional circumstances U2005 U2017 U2147 U2362

Claimants who do not satisfy the LCW assessment by having enough points must be
treated as having LCW (1) if they
1. are suffering from a life threatening disease for which
1.1 there is medical evidence (see U2187) that the disease is
uncontrollable, or uncontrolled by a recognised therapeutic procedure
and
1.2 in the case of a disease that is uncontrolled, there is a reasonable
cause for it not to be controlled by a recognised therapeutic procedure
or
2. are suffering from some specific disease or bodily or mental disablement and,
by reasons of such disease or disablement, there would be a substantial risk
(see U2188) to the mental or physical health of any person if they were found
not to have LCW unless they are treated as not having LCW because they are
working (2) (see ADM Chapter V3).
1 ESA Regs 13, reg 25; 2 reg 37

U2186 Uncontrolled or uncontrollable disease

There should be evidence that the disease is either uncontrolled or uncontrollable.
The DM should establish that there is a reasonable cause for it not being controlled
by medication or other recognised therapeutic procedure.

U2187 Medical evidence U2185

Medical evidence means evidence (1)
1. from a HCP approved by the Secretary of State and
2. from any HCP, hospital or similar institution or
3. that constitutes the most reliable evidence available in the circumstances.
Note: This definition does not apply to U2303 - U2304.
1 ESA Regs 13, reg 25(4)

U2188 Substantial risk U2185 U2396

A claimant is treated as having LCW (1) if
1. they are
suffering from some specific disease or bodily or mental disablement
and
2. as a result, there would be a substantial risk (see U2190) to the mental or
physical health of the claimant or anyone else if they were found not to have
LCW.
But see U2189 for where this does not apply.

1 ESA Regs 13, reg 25(2)(b)

U2189 U2188

The claimant cannot be treated as having LCW if the risk could be significantly
reduced by
1. reasonable adjustments being made to the claimant's workplace or
2. the claimant taking medication prescribed by their GP to manage their
condition (1).
1 ESA Regs 13, 25(3)

Example 1

Khaled suffers from back pain, and claims ESA. His previous employment was office
work. Khaled argues that he satisfies the substantial risk rules, as he cannot sit at a
desk for lengthy periods without exacerbating his condition. The DM determines that
the risk to his health could be alleviated by reasonable adjustments to his
workstation, such as a desk which can rise and fall to allow working in standing and
sitting positions, and taking breaks away from his workstation. The DM determines
that Khaled cannot be treated as having LCW.

Example 2

Lucy is at risk of potentially fatal anaphylactic shock if she comes into contact with
products containing latex, which is a risk at work and in the journey to and from
work. There is no suggestion that she satisfies any of the descriptors. The DM
determines that the risk could be substantially reduced if Lucy carried an adrenaline
auto-injector which has been prescribed for her, and a medical alert bracelet.

U2190 Meaning of substantial risk U2188

`Substantial' is not defined and should be given its ordinary meaning. What amounts
to `substantial' is a question which must be determined using all the available
evidence and taking account of all the circumstances.

U2191 U2141

The substantial risk can be to the claimant or to any other person. For example, the
claimant's mental health may be such that they may self-harm or self-neglect or may
be violent to others.

U2192

A claimant's anxiety or concern about their ability to cope with the demands of work
or a return to work alone does not constitute a substantial risk.

U2193 U2303

Substantial risk must be determined, not only in the context of work undertaken or in
the workplace itself, but also the journey to and from work (1).
1 Charlton v Secretary of State for Work and Pensions [2009] EWCA Civ 42; R(IB) 2/09

U2194 Risk at work

The judgment states that the DM must consider whether a substantial risk arises in
the light of the work which the person might be expected to perform in the workplace
he might find himself in. In making this assessment, the DM need only identify a
broad range of duties that the person could be capable of, taking into account any
training given, the person's aptitude and their disease or disablement.

Example 1

Peter is 27 years old and suffers from alcohol dependency syndrome. He has never
worked and says that his condition prevents him from undertaking any kind of work.
The DM identifies that Peter could undertake straightforward and unstructured,
unskilled work without substantial risk to himself or any person. The DM need not
identify a particular type of work that Peter could be capable of.

Example 2

Phillip is 22 years old and has recently been diagnosed as suffering from epilepsy.
Since the age of 18 he has worked as a roofer and scaffolding erector. Phillip says
that if he were to return to this work, his health would be at substantial risk as he was
often expected to work at great height. The DM determines that Phillip could now
undertake closely supervised, indoor or outdoor work, at ground level without risk to
himself or any person. The DM need not identify a particular type of work that Phillip
could be capable of.

[U2195-U2200]

U2201 Treated as having limited capability for work until assessment is carried out U2005 U2010 U2116 U2362 U2373

A claimant can be treated as having LCW until such time as it has been determined
whether the claimant (1)
1. has LCW or
2. is to be treated as having LCW or
3. is to be treated as not having LCW because they fail without good cause to
provide the required information for the LCW assessment or to attend or
submit for examination (see U2221 et seq)
unless they are treated as not having LCW because they are working (2) (see ADM
Chapter V3).
1 ESA Regs 13, reg 26(1); 2 reg 37

U2202 Conditions

Where there is evidence of LCW (see U2092 et seq) and U2203 does not apply the
claimant is treated as having LCW (1) until
1. actual assessment or
2. they are treated as having LCW or
3. they are treated as not having LCW because they fail without good cause to
3.1 provide the information in the questionnaire or
3.2 attend for or submit to a medical examination.

1 ESA Regs 13, reg 26(2)(a); SS (Med Ev) Regs, regs 2 & 5

U2203 U2202 U2204 U2206

A claimant is not treated as having LCW if in the six months preceding the date of
claim it has been determined that the claimant did not have LCW or was treated as
not having LCW because of a failure without good cause to provide the required
information or to attend or submit for examination unless
1. the claimant is suffering from some specific disease or bodily or mental
disablement from which the claimant was not suffering at the time of that
determination or
2. a disease or bodily or mental disablement from which the claimant was
suffering at the time of that determination has significantly worsened or
3. a claimant who was treated as not having LCW for failure to provide
information has since provided the information requested by the DM (1).
Note: Where the FtT dismisses an appeal against a decision which includes a
determination that a claimant does not have LCW, the date of the LCW
determination is still that made by the DM.
1 ESA Regs 13, reg 26(2)(b)

Example

On 27.11.13 the DM decides to terminate Kamla's award of ESA when she is found
not to have LCW following application of the WCA. The decision is not changed after
mandatory reconsideration, and Kamla is awarded ESA pending the outcome of her
appeal.
Kamla's appeal is dismissed on 8.10.14, and her award of ESA is terminated from
16.10.14 as she is treated as not having LCW. On 28.10.14 Kamla makes a further
claim for ESA, providing evidence of the same health condition. As the last
determination that she did not have LCW was dated 27.11.13, and this is more than
6 months before the date of claim, Kamla is treated as having LCW, and referred for
a further WCA.

U2204 U2370

The conditions at U2203 do not apply where a claimant has made and is pursuing an
appeal against a decision that the claimant does not have LCW after application of
the WCA and that appeal has not yet been determined by a FtT (1). See ADM Chapter
U7 for detailed guidance.
Note: This guidance does not apply where the claimant makes a further appeal to
the UT against a FtT decision.

1 ESA Regs 13, reg 26(3); TCE Act 07, s 3(1)

U2205

Advice can be obtained from medical services on whether the reason for LCW is
new or the previous medical condition has significantly worsened if this is not clear
from the available evidence.

U2206 Further claim after determination that claimant does not have LCW U2373

If the claimant cannot be treated as having LCW because U2203 applies, their claim
cannot be decided until the LCW assessment is carried out.

U2207

The DM may already have sufficient information with which to carry out the LCW
assessment. This could include the medical report from a previous HCP
examination, medical evidence provided to support the new claim and any other
evidence received by the DM which is relevant to the new claim.
Gap in medical evidence

U2208 Contact with claimant not lost U2306

If a claimant fails to provide doctor's statements in the period pending a
determination of LCW, and contact with the claimant has not been lost, payment of
benefit may be suspended (1) (see ADM Chapter A4 for further guidance on
suspension of the payment of benefit).

1 UC, PIP, JSA & ESA (D&A) Regs, reg 44

U2209 U2330 U2333

In such cases, the DM must apply the WCA in the normal way (see U2111 et seq).

U2210

The test may need to be applied on the balance of probabilities using all the
available evidence, including evidence from the previous claim where appropriate.
For example, it might not be possible to refer the claimant for medical examination
where they have returned to work or claimed JSA. Where there is little or no
evidence, the DM may draw adverse inferences. Advice should be sought from
medical services in cases of doubt. Insufficient evidence does not mean that the
WCA cannot be applied.

U2211

Where a claimant stops submitting the required medical evidence this does not
count as a change of circumstances to justify a decision to supersede the
entitlement decision. The DM can suspend paying the claimant benefit because of
the failure to provide medical evidence but cannot conclude they are not entitled to
ESA without carrying out the WCA (1). The determination on LCW gives the grounds
for supersession, not the lack of medical evidence.

1 R(IB) 1/05

U2212

This applies even in cases where the claimant is treated as not having LCW
because they fail to return the questionnaire or fail to attend or submit for
examination.

Example 1

Graham is treated as having LCW while submitting doctor's statements. On 1.12.14
medical evidence expires and despite reminders no further medical evidence is
received. Graham asks for the LCW assessment to be applied. The questionnaire is
issued on 17.12.14 but is not returned. A reminder is issued on 8.12.14. On 4.2.15
the DM determines that Graham is treated as not having LCW from 15.1.15. They
also make a determination that for the period from 2.12.14 to 14.1.15 the claimant
scores 0 points for the purposes of the LCW assessment and does not have LCW.
The decision awarding ESA or credits is superseded to terminate entitlement from
2.12.14.

Example 2

Lois is treated as having LCW while submitting doctor's statements. On 1 November
medical evidence expires and after reminders Lois writes to say that she resumed
work on 5 November. The DM determines that for the period between 1 and 5
November the claimant scored 0 points for the purposes of the LCW assessment
and does not have LCW.

U2213 U2306 U2330 U2333

In all cases the effective date of the supersession to end entitlement to ESA or
credits is the date from which the claimant does not have LCW (1). This is because the
later determination about LCW showed there had been a change of circumstances
when the claimant was no longer treated as having LCW (2).
1 UC, PIP, JSA & ESA (D&A) Regs, Sch 1, para 4; 2 ESA Regs 13, reg 26

U2214 Contact lost with claimant

For cases where medical evidence ceases and contact with the claimant is lost, see U2285 et seq.

[U2215-U2220]

Treated as not having limited capability for work

U2221 General U2005 U2117 U2201

A claimant can be treated as not having LCW if
1. they fail without good cause to provide information, attend or submit to
examination (1) (see U2222 et seq)
2.
they are certain claimants who
2.1 have a day of sick absence from duty recorded by the Secretary of
State for Defence (2) (see U2300)
2.2 are attending a training course for which a training allowance or
premium is paid (3) (see U2301)
2.3 cease to supply medical evidence (4) (see U2303 et seq)
2.4 are disqualified for receiving ESA during a period of imprisonment or
detention in legal custody (5) (see U2340)
3. they are not entitled to ESA by reason of working (6) (see ADM Chapter V3).
1 ESA Regs 13, reg 18 & 19; 2 reg 27(1); 4; 3 reg 27(2); 4 reg 28(1); 5 reg 95; 6 reg 37

U2222 Failure to return the questionnaire U2024 U2221

A claimant can be required to
1. provide certain information asked for by the DM including the return of the
questionnaire (see U2224) and
2
attend and submit to a medical examination for the LCW assessment (see U2241)
If they fail without good cause to do either, claimants are treated as not having
LCW (1).

1 ESA Regs 13, reg 18 & 19

U2223

Before a claimant can be treated as not having LCW, the DM has to be satisfied that
the prescribed conditions are met. These include the way in which the information or
attendance was requested and the amount of notice given.

U2224 U2222

A claimant who is subject to the LCW assessment can be asked to provide
information (1) relating to their ability to perform certain activities (2). This information is
usually asked for by sending the claimant a questionnaire.

1 ESA Regs 13, reg 17(1)(b); 2 Sch 2

U2225

The questionnaire is not required in certain circumstances (1) (see U2102). All other
claimants will be sent the questionnaire.

1 ESA Regs 13, reg 17(3)

U2226

It is not appropriate to treat a claimant as not having LCW for non-return of the
questionnaire if a claimant fails to return the form but the DM has exercised
discretion to proceed without it (1).

1 ESA Regs 13, reg 17(2)

U2227

A claimant is treated as not having LCW for failure to return the questionnaire
without good cause if the Secretary of State can show that
1. the questionnaire was sent and
2. there is no response after four weeks to the first request for the information (1)
from the day following the date of issue and
3. a further request was sent at least three weeks after the first letter and at least
one week has passed since then (2) and
4. good cause has not been accepted for delay beyond the period stated in 2.
and 3. above (3).
1 ESA Regs 13, reg 18(2)(a); 2 reg 18(2)(b); 3 reg 18(1)

U2228 The Secretary of State's duty U2232

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

U2229 Has the questionnaire been sent U2406

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

U2230 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 5.11.14. A reminder is due and sent on
27.11.14. 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 5.12.14.

U2231 Good cause

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 good
cause for their failure to return the questionnaire (1) (see U2261).
1 ESA Regs 13, reg 20

U2232 Questionnaire returned before good cause considered U2406

As in U2228 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 good cause 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 7.5.14. This was not returned so a reminder
was sent to her on 29.5.14. 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
6.6.14. The DM obtains the case on 18.6.14 to make the determination, but notes
that the questionnaire had been received in the office on 12.6.14. 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.

[U2233-U2240]

Failure to attend or submit to a medical examination

U2241 General U2222 U2256

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 (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.

1 ESA Regs 13, reg 19(1)

U2242

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

1 ESA Regs 13, reg 19(2); 2 reg 19(3)

U2243 U2244 U2412

Medical services will contact the claimant by telephone to arrange an appointment
for the examination and will keep a detailed record of the date, time and place of the
examination agreed with the claimant. Written notice will be issued to confirm the
arrangement. The claimant can agree to accept a shorter period of notice than
seven days.

U2244 The Secretary of State's duty U2248 U2252 U2257

Unless the claimant has agreed to accept a shorter period of notice whether given in
writing or by telephone (see U2243 and U2246), when considering whether a
claimant should be treated as not having LCW, 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 ESA Regs 13, reg 19(3)

U2245

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 ESA Regs 13, reg 19(3)

U2246 U2244

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 ESA Regs 13, reg 19(3)

U2247

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 customer has failed to attend. The DM will have to consider the reasons why
the claimant cannot attend and consider good cause (see U2261 et seq).

U2248

If the DM cannot confirm that the provisions in U2244 were met, the claimant cannot
be treated as not having LCW.
Note: Medical services can provide evidence of notification for requests from DMs
who are considering revision or supersession of disallowance determinations and
appeal submissions.

U2249 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
whether given in writing or otherwise. 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

U2250 Have seven days passed

Where there is no evidence that the claimant agreed to accept a shorter period of
notice whether in writing or otherwise, 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 3 pm 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 into the external mail on Monday at 5 pm. 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 cause 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.

U2251 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.

U2252 Good cause

If the DM concludes that the Secretary of State has complied with the duty set out in U2244they may go on to consider whether the claimant had good cause for their
failure to attend to medical examination (see U2261).

U2253 Failure to submit

Where a claimant attends a LCW assessment 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.

U2254

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

U2255

If a claimant makes it clear that they will not be medically examined then that
constitutes a failure to submit to an examination. Going to the examination but
refusing to be examined constitutes attendance but is a failure to submit (1).

1 R(IB) 1/01

U2256

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 (see U2241) and the claimant is failing to submit to an examination.

U2257 Good cause U2412

If the DM concludes that the Secretary of State has complied with the duty set out in U2244they may go on to consider whether the claimant had good cause for their
failure to submit to a medical examination (see U2261).

[U2258-U2260]

U2261 Consideration of good cause U2231 U2247 U2252 U2257 U2268 U2417

When a claimant fails to return the questionnaire or fails to attend or submit to
examination, consideration of good cause includes
1. whether the claimant was outside GB at the relevant time and
2. the claimant's state of health at the relevant time and
3. the nature of any disability the claimant has (1).
Note:
The list is not exhaustive (see U2262 et seq for further guidance on good
cause).

1 ESA Regs 13, reg 20

U2262 U2261

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 evidence, including corroboration,
in ADM Chapter A1.

U2263

The onus of proving good cause lies with the claimant who fails to comply. The test
of good cause 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. See ADM Chapter A1 for guidance. The DM needs to ascertain the
precise facts and apply the concept of "good cause".

U2264

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
2. they have not replied to enquiries or the reasons given do not amount to good
cause.General considerations

U2265

When considering whether the claimant showed good cause, the DM should ensure
that they fully explain how they made their determination by recording
1. findings about the claimant's state of health at the time and the nature of their disability
2. what evidence was considered
3. what findings were made on the evidence
4. what steps they took to contact the claimant
5. whether the claimant is vulnerable
6. whether there were previous failures and whether good cause was accepted
7. the reasons for their determination on good cause.

U2266 Claimant's state of health

The claimant may state that they were unable to attend a face-to-face assessment
due to the state of their health on the date of the appointment (see ADM U2282).
Claimants may have difficulty in producing further medical evidence to support their
statement, as GPs are not obliged to provide this. Failure to provide such evidence
is not of itself a reason for refusing to accept that good cause was shown.

U2267

The DM should consider whether the stated health problem prevented the claimant
from contacting Medical Services to re-arrange the appointment. The DM should
also consider the nature of the claimant's health condition and whether it could
reasonably have lead to the claimant being, for example, incapacitated, forgetful,
confused, unmotivated or too anxious to comply with the process because of their
health condition.

Example 1

Luke has an appointment for an examination on 5.8.13. He contacts Medical
Services to say that he cannot attend as he has flu, and arranges another
appointment for 19.9.13. Luke fails to attend the new appointment. He returns the
BF (22)3 form explaining that the reason he did not attend was because he still had flu.
Luke's recent fit note shows low back pain as the reason for LCW. The DM
determines that good cause was not shown. Flu is incapacitating but usually only
lasts for a week where there are no complications. It was unlikely that he still had flu
since the previous appointment, and in any event it should not have prevented him
from contacting Medical Services.

Example 2

Katie has an appointment for an examination on 2.10.13, but fails to attend. She
states on the BF (22)3 form that she woke up on the day of the appointment with
severe dental pain, and had to wait in the dentist's surgery for an emergency
appointment. She required root canal treatment, and was prescribed a 5 day course
of antibiotics for an infected wisdom tooth. As a result she was unable to attend the
appointment. The DM accepts that good cause was shown for the failure to attend.

U2268 Nature of claimant's disability

DMs are reminded that the nature of the claimant's disability is a factor that must be
taken into account when considering whether good cause is shown (see ADM
U2261). The DM should make every effort to ensure that all sources of evidence are
considered before making a determination on good cause. Evidence about the
claimant's health may be obtained from
1. form BF (22)3 (good cause enquiry form)
2. any fit notes supplied
3. ESA (1) claim form
4. ESA (50) questionnaire where one is available
5. any evidence previously submitted that is relevant
6. ESA (85) report where one is available.

U2269

This may be particularly relevant in cases where the claimant has
1. mental health conditions affecting memory or concentration
2. a learning difficulty, for example where this affects comprehension
3. medication which affects memory or concentration
4. a sensory impairment, such as being registered blind.

Example 1

Jack claims ESA. His fit note states that he has problems with his feet. Jack fails to
return form ESA (50), and did not give any reasons for this failure. The award of ESA
was terminated. Jack's social worker returned the form which had been completed
for him, and explained that Jack had significant difficulties understanding
correspondence, and often delayed seeking help as he panicked. Good cause is
accepted, and ESA is reinstated.
Jack then fails to attend an examination on 24.9.13, and does not reply when the
BF (22)3 form is issued. The evidence in the questionnaire is that Jack has severe
learning difficulties. He has limited literacy skills and lives alone. The DM accepts
that Jack had good cause for failure to attend the examination, as due to the nature
of his disability he is unable to comply with the process. The DM determines that
Jack is likely to need ongoing support for his benefit claims and refers for
consideration of appointee action. They also request that Medical Services arranges
a home visit.

Example 2

Tamara is required to attend for an examination on 13.9.13. She rings the
examination centre and says that she is due to attend an out-patient clinic at the
same time. She is offered and accepts a further appointment for 24.9.13, which she
fails to attend.
Tamara does not return form BF (22)3, or respond to attempts to phone her. There is
no evidence in the claim form, fit note or ESA (50) which indicates that her health
condition is likely to impact her ability to attend the appointment. The DM determines
that Tamara did not have good cause for the failure to attend, and treats her as not
having LCW.

Example 3

Alex claims ESA, stating that he suffers from agoraphobia, anxiety and depression.
He does not return the questionnaire. Alex contacts Medical Services to ask for a
home visit after being asked to attend the examination centre. The appointment is
rearranged, and he is advised to get a supporting letter from his GP. Alex fails to
attend an examination 15.8.13. In the BF (22)3 form he states that his GP had told him
he would fax a letter to the examination centre requesting a home visit. He had no
copy of the letter, and was struggling to keep organised. There is no information on
the Medical Services computer system about a request for home visits, but the DM
has no reason to doubt Alex's explanation. The DM accepts that Alex had good
cause for his failure to attend. The DM also asks Medical Services to arrange a
home visit.

U2270 Previous WCA attended

The fact that the claimant has previously attended the WCA and been found to have
LCW is not sufficient reason that good cause has not been shown for a subsequent
failure to attend. The DM should consider each case on its merits.

Example

Lorraine, who has mental health problems, is placed in the SG following previous
application of the WCA. She is referred for a further WCA 18 months later, and does
not return the questionnaire. She also fails to attend for examination.
In response to the BF (22)3 form, Lorraine's CPN says that due to the strength of the
medication taken for several years for paranoid schizophrenia, Lorraine often forgets
to carry out daily tasks or attend appointments. The fact that Lorraine had previously
managed to attend for examination despite her memory problems is not of itself
sufficient to show that there was no good cause for the current failure.

U2271 Repeated failures

Where a claimant repeatedly fails to attend an examination, and good cause is
accepted, the DM should consider the previous reasons given critically. It may be
appropriate to require further evidence to support any explanation for the
subsequent failure. Wherever possible the DM should contact the claimant to
discuss the importance of attendance.

U2272

However, the fact that good cause was previously accepted is not a reason for
concluding that the claimant should be aware of the requirement to attend a
subsequent appointment. The same reasons for the failure may continue to
demonstrate that good cause is shown, such as in the case of a claimant who has a
long term mental health problem, who can only intermittently comply with the
processes necessary to manage their benefit claim due to effects of their condition
and its treatment.

Example

Viktor failed to attend for an examination. He did not respond to the BF (22)3 form, and
his ESA award was terminated. He subsequently provided evidence that on the day
of the appointment he had a panic attack on his way to the assessment centre. He
was taken to hospital, and discharged later in the day. The DM accepts that good
cause was shown, and ESA is reinstated.
Viktor fails to attend the subsequent appointment. He replies on the BF (22)3 form,
saying that he had a panic attack and felt unable to leave the house on the day of
the appointment, and was too anxious to explain this at the time. The DM accepts
that good cause was shown, and asks Medical Services to consider a home visit.

U2273

The DM may wish to consider whether it would be possible to ensure that the
claimant does not fail to attend future appointments, where the nature of the
claimant's health condition is the reason for good cause being accepted, and the
health condition is likely to be long term. For example, if the evidence shows that the
claimant is not capable of arranging their own affairs, is appointee action
appropriate? Should a home visit be recommended?

[U2274-U2279]

U2280 Good cause - 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 cause
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.

U2281

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 cause 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.

U2282 U2266

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 shown good cause
for their non-attendance.

U2283

Good cause 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

U2284

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.

U2285 U2214

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.

U2286

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.

U2287

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 a particular premises
where another person went through the mail before the claimant had a chance to do
so may establish good cause.

U2288

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.

U2289

If a claimant attends but refuses to have a physical examination, for example
because of genuinely held religious beliefs, the DM should normally accept good
cause 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

U2290

It is possible for the DM to consider that a claimant did not have good cause 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 good cause.

U2291

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

U2292

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

U2293 U2417

A claimant who fails to attend an examination for LCWRA can only be treated as not
having LCWRA. A claimant cannot be treated as not having LCW if their failure was
to not attend or participate in the LCWRA part of the WCA.

[U2294-U2299]

Certain claimants to be treated as not having limited capability for work

U2300 Member of Her Majesty's Forces U2221

A claimant who is or has been a member of HMF (1) is treated as not having LCW on
any day which is recorded by the Secretary of State for Defence as a day of sickness
absence from duty (2). See ADM Chapter U1 for guidance on the meaning of HMF.
1 ESA Regs 13, reg 2; 2 reg 27(1)

U2301 Training course U2221 U2302

A claimant is treated as not having LCW on any day on which they (1)
1. attend a training course and
2. are paid a training allowance or premium under certain provisions (2).

1 ESA Regs 13, reg 27(2); 2 E&T Act 73, s 2(1); Enterprise & New Towns (Scotland) Act 1990, s 2(3)

U2302

The guidance at U2301 does not apply
1. where the ESA claim is made for a period which begins after the claimant
ceased attending the training course or
2. where any training allowance or premium paid to the claimant is paid for the
sole purpose of travelling and meal expenses incurred as part of the training
1
course .
1 ESA Regs 13, reg 27(3)

U2303 Medical evidence ends U2187 U2221 U2307

A person may be treated as not having LCW (1) if
1. they have supplied medical evidence in accordance with legislation (2) and
2. the period covered by that medical evidence has ended and
3. the Secretary of State has requested further medical evidence and
4. the person has not, within six weeks
4.1 supplied further medical evidence or
4.2 otherwise made contact with the Secretary of State to indicate that they
wish to have the question of LCW determined.
Note: The definition of medical evidence at U2193 does not apply. See U2092 for
further guidance.

1 ESA Regs 13, reg 28(1); 2 reg 28(2); SS (Med Ev) Regs, reg 2 or 5

U2304 U2187

The six week period begins on
1. the date of the Secretary of State's initial request for further medical evidence
or
2. the day after the date on which the period covered by the medical evidence
has ended
whichever is the later (1).

1 ESA Regs 13, reg 28(1)(d)

U2305

If at the end of the six weeks no further medical evidence is received, or the claimant
does not contact the DWP, the DM should treat the claimant as not having LCW
from the day after the medical evidence expires. The decision is effective from the
date of the change (1), which is the date from which the claimant is treated as not
having LCW.
1 UC, PIP, JSA & ESA (D&A) Regs, Sch 1, para 4

Example

Victor's current medical certificate provides him with evidence of LCW up to and
including 19.5.14. A reminder that further medical evidence will be required is issued
on 12.5.14. The six weeks period ends on 30.6.14, and Victor does not contact the
DWP by then. He is treated as not having LCW from 20.5.14, the day after the
medical evidence ends.

U2306 U2307

Where the person
1. fails to provide further medical evidence and
2. asks for LCW to be determined
the DM should continue to follow the guidance in U2208 - U2213.

Example

William is covered by a doctor's statement up until 5.7.14. On 15.7.14 the local office
receives a letter from him stating that he became fit enough to start work on 14.7.14.
The DM may accept this as a request from William for his LCW to be determined for
the period from 6.7.14 to 12.7.14.

U2307 Medical evidence ceases before appeal heard - contact with claimant lost U2308

Where
1. a claimant is entitled to ESA pending an appeal and
2. medical evidence ceases and
3. the claimant does not respond to reminders requesting further medical evidence
the DM should consider whether the guidance at U2303 - U2306 about treating the
claimant as not having LCW and terminating the award applies (1).
1 ESA Regs 13, reg 28

U2308 Appeal allowed

Where
1. an award is terminated as in U2307 and
2. the FtT allows the appeal
the DM should award arrears of ESA as appropriate up to the date of the termination
of the pending appeal award (1).
1 ESA Regs 13, reg 87(7) & (8)

[U2309-U2329]

U2330 Medical evidence ceases before appeal heard - contact with claimant not lost

Where
1. a claimant is entitled to ESA pending an appeal and
2. medical evidence ceases and
3. the claimant states that he is unable to provide further medical evidence but
wishes LCW to be determined
the guidance at U2209 - U2213 about determining LCW does not apply while the
appeal is awaiting hearing. This is because the claimant cannot be referred for a
WCA unless they have a new or worse health condition - see ADM Chapter U7.

U2331

Payment of ESA should be suspended pending the outcome of the appeal (1).
1 UC, PIP, JSA & ESA (D&A) Regs, reg 44

U2332 Appeal allowed

Where the appeal is allowed, the suspension should be lifted and the guidance at
ADM Chapter U7 (ESA award made pending appeal) applied as normal.

U2333 Appeal withdrawn, struck out or dismissed

Where the appeal is withdrawn, struck out or dismissed, the guidance at U2209 U2213should be applied.

Example

Karen has been entitled to ESA since 6.10.14 pending an appeal against the
decision terminating her award of ESA following application of the WCA. On 15.3.15
medical evidence expires, and Karen states that she is unable to supply further
doctor's statements. The DM suspends payment of ESA. Karen does not make a
claim for another benefit.
On 26.6.15 Karen's appeal is dismissed. The DM treats Karen as not having LCW
from 6.7.15, and also determines that for the period 16.3.15 - 5.7.15, on the balance
of probabilities she scores 0 points for the purposes of the WCA. The award of ESA
is terminated from 16.3.15.

[U2334-U2339]

U2340 Detention in legal custody U2221

A claimant is to be treated as not having LCW if disqualified for receiving ESA during
a period of imprisonment or detention in legal custody if that disqualification is for
more than six weeks (1). Payment of ESA is suspended from the first day of
imprisonment or detention in legal custody. If a decision is subsequently made to
disqualify the claimant for receiving ESA, that decision will apply from the first day of
imprisonment or detention in legal custody. Therefore, unless it is for a period of six
weeks or less, the claimant will be treated as not having LCW from the first day of
imprisonment or detention in legal custody.
Note: See ADM Chapter U6 for guidance on disqualification for imprisonment or
detention in legal custody.
1 ESA Regs 13, reg 95

Example

Kenneth is detained in legal custody on 1.10.14 and payment of his ESA is
suspended. On 3.12.14 the DM decides that Kenneth should be disqualified for
receiving ESA from 1.10.14 because he has been sentenced to a period of
imprisonment for a period exceeding six weeks. There is also a determination that
Kenneth is treated as not having LCW from 1.10.14.

[U2341-U2349]

U2350 Claimant does not have LCW for the purposes of UC

A claimant is treated as not having LCW where
1. in the six months preceding the date of the ESA claim it has been determined
that the claimant did not have LCW following application of the WCA and
2. it appears to the DM that
2.1 the determination was not based on ignorance of or mistake as to a
material fact and
2.2 there has been no relevant change of circumstances in the claimant's
physical or mental health condition since the UC LCW determination
was made (1).
1 ESA Regs 13, reg 27(4)
U2351 - U2359

U2360 Claimants who are treated as not entitled to ESA by reason of working to be treated as not having limited capability for work U2018 U2049

For guidance on the effect of working on a claim or an award of ESA see ADM
Chapter V3.

U2361 U2362

Claimants who are treated as not entitled to ESA by reason of working are treated as
not having LCW (1).

1 ESA Regs 13, reg 38(1)

U2362

The guidance at U2361 applies even if it is determined that the claimant has or is to
be treated as having LCW because they (1)
1. satisfy certain conditions (2) (see U2019) or
2. are a hospital patient (3) (see U2040) or
3. are receiving certain treatments (4) (see U2049) or
4. have exceptional circumstances (5) (see U2185) or
5. satisfy the conditions pending assessment (6) (see U2201).
1 ESA Regs 13, reg 38(2); 2 reg 16; 3 reg 21; 4 reg 22; 5 reg 25; 5 reg 26(2)

U2363 Date of determination

Where a claimant is in receipt of ESA the determination to treat someone as not
having LCW applies to the whole week during which the work is done. However that
person is only treated as not having LCW on the days on which they actually work in
the week in which they
1. first have LCW (1) or
2. start or return to work (2).

1 ESA Regs 13, reg 37(4)(a); 2 reg 37(4)(b)

U2364

See U2067 for guidance on the day or days in a week on which a night shift worker
works (1)

1 ESA Regs 13, reg 37(6)

U2365

See U2057 et seq for guidance on the effect of work on claimants who are receiving
or recovering from regular treatment.

[U2366-U2369]

U2370 Evidence of limited capability for work after determination that a claimant does not have limited capability for work

A claimant may make a new claim and provide medical statements after the DM has
determined that they do not have LCW. The DM, if possible, applies the LCW
assessment. But see U2204 if the claimant makes an appeal against the decision
which embodies the determination that they do not have LCW following application
of the WCA.

U2371

The DM may already have sufficient information with which to carry out a new LCW
assessment. This could include
1. medical evidence from the previous medical examination
2. medical evidence provided to support the new claim and
3. any other evidence received by the DM relevant to assessment of LCW on the
new claim.

U2372

If the DM considers there is sufficient information they should carry out the LCW
assessment (see U2111).

U2373

If the DM considers there is insufficient information to carry out the LCW
assessment they should consider whether the claimant can be treated as having
LCW until the LCW assessment is carried out (1) (see U2201 - U2206).
1 ESA Regs 13, reg 26

[U2374-U2379]

Limited capability for work-related activity

U2380 General U2005 U2011

A determination has to be made whether a claimant who has LCW also has LCWRA
at the end of the assessment phase (1).

1 WR Act 07, s 9(1) & (2)

U2381

Where it is determined a claimant has LCW the claimant will receive an ESA
component during the main phase of ESA entitlement. Which component they
receive depends on whether or not they also have LCWRA.
Note: See ADM Chapter V1 for guidance on amounts payable.

U2382

Claimants with the most severe illnesses or disabilities who have LCWRA will
receive the support component (1) and are in the no work-related requirements group (2).
They may participate in work-related activity on a voluntary basis if they so wish.
Note: See ADM Chapter U4 for guidance on work-related requirements groups.

1 WR Act 07, s 2(2); 2 s 11(3)(a)

U2383

Claimants who do not have LCWRA will receive the WRAC (1). These claimants may
fall into the
1. work-focused interview requirement only group (2) or
2. work-focused interview and work preparation requirements group (3).
Note: For further guidance see ADM Chapter U4. See Chapter U5 for guidance on
work-related requirements.
1 WR Act 07, s 2(3); 2 s 11(3)(b); 3 s 11(3)(c)

U2384

U2385 Claimant treated as not having limited capability for work-related activity

A claimant is treated as not having LCWRA where
1. in the six months preceding the date of the ESA claim it has been determined
that the claimant did not have LCWRA following application of the WCA for
the purposes of UC and
2. it appears to the DM that
2.1 the determination was not based on ignorance of or mistake as to a
material fact and
2.2 there has been no relevant change of circumstances in the claimant's
physical or mental health condition since the UC LCWRA determination
was made (1).
1 ESA Regs 13, reg 31(3); UC Regs, Part 5

[U2386-U2389]

U2390 Determination of limited capability for work-related activity

Whether a claimant's capability for work-related activity is limited by the claimant's
physical or mental condition and the limitation is such that it is not reasonable to
require the claimant to undertake such activity is determined if one or more of the
descriptors are met (1).

1 ESA Regs 13, reg 30(1) & Sch 3

U2391

A descriptor applies to a claimant if that descriptor applies to the claimant for the
majority of the time or on the majority of the occasions on which the claimant carries
out or attempts to carry out the activity described by that descriptor (1).

1 ESA Regs 13, reg 30(2)

U2392

A claimant will be assessed as if wearing any prosthesis with which they are fitted or
wearing or using any aid or appliance which they normally wear or use (1). See U2160
et seq for detailed guidance.
1 ESA Regs 13, reg 30(3)

[U2393-U2394]

U2395 Certain claimants treated as having limited capability for work-related activity U2399

A claimant is treated as having LCWRA if
1. they are terminally ill (1) or
2. they are
2.1 receiving
or
2.2 likely to receive or
2.3 recovering from
treatment for cancer by way of chemotherapy or radiotherapy (see U2023 et
seq)2 or
3. in the case of a woman, she is pregnant and there is a serious risk of damage
to her health or the health of her unborn child if she does not refrain from
work-related activity (3)
4. they are entitled to UC and it has determined that they have LCWRA following
assessment under UC rules (4)
5. they were previously entitled to ESA including the support component and
5.1 the previous award ended other than because they were found not to
have LCW and
5.2 on a further claim for ESA, the PLCWs link (5) - see ADM Chapter U1
(Conditions of entitlement) and Chapter V1 (Amounts) for further
details.
1 ESA Regs 13, reg 2 & 31(1)(a); 2 reg 31(1)(b); 3 reg 31(1)(c)

4 reg 31(1)(d); UC Regs, Part 5; 5 ESA Regs 13, reg 7(3)(a), 32 & 86

U2396 U2428

A claimant who does not have LCWRA is treated as having LCWRA if
1. the claimant suffers from some specific disease or bodily or mental
disablement and
2. by reasons of such disease or disablement, there would be a substantial risk
(see U2188) to the mental or physical health of any person if that claimant
were found not to have LCWRA (1).
1 ESA Regs 13, reg 31(2)

U2397 Information required for determining capability for work-related activity

The information required to determine whether a claimant has LCWRA is (1)
1. any information relating to the descriptors that may be requested in the form
of a questionnaire and
2. any additional information as may be requested.

1 ESA Regs 13, reg 33(1)

U2398

Where the DM is satisfied there is sufficient information to determine whether a
claimant has LCWRA without the questionnaire that information will not be required (1).
For example the claimant is considered to be in a vulnerable group, i.e. there is a
diagnosis of a mental health condition. A decision to treat as not having LCWRA due
to non-return of the questionnaire would not be made but the claimant referred for
assessment.

1 ESA Regs 13, reg 33(2)

U2399

Certain claimants who are treated as having LCW (see U2017 et seq) 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 U2395).

U2400

Medical services are responsible for gathering any information required to support
the WCA process. This includes
1. sending the questionnaire (ESA (50) or ESA (50)A)
2. sending a reminder if the claimant does not reply within three weeks.
Note:
This could be any such additional information as the DM requires to determine
whether a claimant has LCWRA (1).

1 ESA Regs 13, reg 33(1)

U2401

It will not be necessary to obtain completion of an ESA (50)A for LCWRA in every case
where the claimant has already provided information on an ESA (50) for LCW. The
HCP should obtain additional information regarding the descriptors at the medical
examination for LCW in order to provide an opinion on LCWRA (see U2426).
Note:
There will be no need for a medical examination if medical services can give
an opinion on the basis of paper evidence that the claimant is, or is not, in the
support group. If both LCW and LCWRA can be assessed from the same piece of
evidence then there is no need to obtain further information.

U2402 Failure to provide information

A claimant is treated as not having LCWRA if
1. the questionnaire was sent and
2. there is no response after four weeks to the first request for the information (1)
from the day following the date of issue and
3. a further request was sent at least three weeks after the first letter and at least
one week has passed since then (2) and
4. good cause has not been accepted for the delay beyond the period stated in
the 2. and 3. above (3).

1 ESA Regs 13, reg 34(2)(a), 2 reg 34(2)(b), 3 reg 34(1)

U2403

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

U2404

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 good
cause for their failure to return the questionnaire (1) (see U2415).

1 ESA Regs 13, reg 36

U2405

Any reasons given for the non-return should be judged on the balance of
probabilities. Whether the reasons for delay amount to good cause 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.

U2406

See U2415 et seq for guidance on good cause where a claimant fails to return a
questionnaire for a determination of LCWRA. The general principles in U2229 U2232to be considered when determining LCW also apply to LCWRA.
Note:
A claimant who fails to provide information for LCWRA can only be treated as
not having LCWRA. A claimant cannot be treated as not having LCW if their failure
was to not provide information in respect of the LCWRA part of the WCA.

[U2407-U2409]

U2410 Claimants who may be called for examination

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 or not they have LCWRA (1).

1 ESA Regs 13, reg 35(1)

U2411 U2414

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

1 ESA Regs 13, reg 35(2); 2 reg 35(3)

U2412

The general principles in U2243 - U2257 to be considered when determining LCW
also apply to LCWRA.
Note: A claimant who fails to attend or submit for examination for LCWRA can only
be treated as not having LCWRA. A claimant cannot be treated as not having LCW if
their failure to attend or submit for examination was in respect of the LCWRA part of
the WCA.

U2413

Where a claimant fails without good cause to attend or submit for examination the
claimant can be treated as not having LCWRA (1) (see U2414).

1 ESA Regs 13, reg 35(2)

U2414 U2413

If the DM concludes that the Secretary of State has complied with the duty set out in U2411they may go on to consider whether the claimant had good cause for their
failure to attend or submit to a medical examination (see U2415).

U2415 Consideration of good cause U2404 U2406 U2414

When a claimant fails to provide information or to attend or submit to an
examination, consideration of good cause includes
1. whether the claimant was outside GB at the relevant time and
2. the claimant's state of health at the relevant time and
3. the nature of any disability the claimant has (1).

1 ESA Regs 13, reg 36

U2416

The onus of proving good cause lies with the claimant who fails to comply. The test
of good cause is whether the DM judges the reason for non-attendance or failure to
attend or submit to examination to be reasonable and likely on the balance of
probabilities. See ADM Chapter A1 for guidance. The DM needs to ascertain the
precise facts and apply the concept of "good cause".

U2417

See U2261 - U2293 for further guidance on consideration of whether a claimant has
good cause. This guidance is general on the principles of good cause and applies to
consideration of both LCW and LCWRA.
Note: A claimant who fails to return information, attend or submit for an examination
for LCWRA can only be treated as not having LCWRA. A claimant cannot be treated
as not having LCW if their failure was to not return information, attend or participate
in the LCWRA part of the WCA.

U2418

Where there is no evidence of good cause or the reasons provided are not accepted
as good cause, the DM should determine that the claimant is treated as not having
LCWRA.

[U2419-U2424]

U2425 Determination of whether a claimant has limited capability for work-related activity

The DM determines whether a claimant has LCWRA from
1. the questionnaire if one is available and
2. a statement from the GP if one is available and
3. the medical opinion from the HCP including the personalised summary
statement and
4. any other relevant evidence.

U2426 U2401

HCPs should provide relevant information and good justification for their
recommendations with regard to LCWRA on a medical report form on either an
1. ESA (85) if the claimant has been examined for LCW and the recommendation
is that the claimant does not have LCWRA or
2. ESA (85)A if the claimant
2.1 has not been examined or
2.2 has been examined for LCW and the recommendation is that the
claimant has LCWRA or
2.3 is treated as having LCW and has been called for examination for
assessment of LCWRA only.
Note: For the purposes of 2.2 if LCWRA is identified at examination the DM will get
two reports: an ESA (85) for LCW and an ESA (85)A for LCWRA.

U2427

In the main, medical reports will be completed electronically. There is no
requirement for the report to be signed by the examining HCP (1). However the report
must identify the status of the HCP, i.e. whether he/she is a doctor or a registered
nurse.

1 R(IB 7/05)

U2428

The medical report includes an opinion of a HCP 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 for LCWRA from the descriptors (1) (see U2396).

1 ESA Regs 13, reg 31(2)

U2429

The normal principles apply to considering the evidence. Guidance is in ADM
Chapter A1.

[U2430-U2439]

U2440 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 or can be
treated as having LCWRA in prescribed circumstances (see U2444). This may be at
a different time to the advice given on the medical report.

U2441

In second and subsequent referrals medical services will provide a recommendation
on whether a claimant has LCWRA.

U2442

Not all claimants require a WCA in subsequent referrals. Medical services will decide
if LCW can be assessed on scrutiny of the available evidence; however it may be
necessary to call the claimant for examination on subsequent referrals to assess
LCWRA.

U2443

Medical conditions can improve with treatment or they may decline. Depending on
the outcome of future assessments claimants who are placed in the WRAG may be
removed from that group and placed in the support group and vice versa.

U2444 Determining limited capability for work-related activity afresh U2145 U2440 U2445

Where it has been determined a claimant
1. has
LCWRA
or
2. is treated as having LCWRA or
3. is treated as not having LCWRA
the DM can determine afresh whether the claimant still has or is to be treated as
having LCWRA (1).

1 ESA Regs 13, reg 30(4)

U2445

The guidance at U2444 applies where (1)
1. the DM wishes to determine whether there has been a relevant change of
circumstances in relation to the claimant's physical or mental condition or
2. the DM wishes to determine whether the previous determination was made in
ignorance of, or based on a mistake as to some material fact or
3. at least three months have passed since the date of the previous
determination.
1 ESA Regs 13, reg 30(5)

[U2446-U2999]

Appendix
Explanation of treatments
Plasmapheresis
Plasmapheresis is a process by which harmful substances can be removed from the
bloodstream. Blood is taken from the person's vein, and the fluid part (plasma)
containing the harmful substance is separated from the blood cells and removed.
The blood cells are then mixed with an appropriate substitute fluid and returned to
the person.
Radiotherapy
Radiotherapy is the use of X-rays to kill cancer cells. It is given as a series of
administrations, with varying intervals between doses. Persons undergoing
radiotherapy often feel very unwell for a few days after each dose.
Renal dialysis
Renal dialysis is used in the treatment of kidney (renal) failure. It is the process
whereby waste products, which would usually be excreted in the main by the
kidneys, are artificially removed from the body. There are two forms of dialysis:
haemodialysis and peritoneal dialysis.
In haemodialysis, blood is circulated from the person's arm into a machine which
removes the waste substances; the cleansed blood is then returned to the person.
Haemodialysis is usually carried out two or three times a week.
In peritoneal dialysis the process involves introducing fluid into the abdomen through
a permanently-positioned tube (an indwelling catheter). Harmful waste products are
removed from the blood into this fluid through the inner lining of the abdomen (the
peritoneum). After some hours, the fluid is drained from the abdomen and replaced
with a fresh volume, and the cycle is repeated on a continuous basis.
Total parenteral nutrition
Total parenteral nutrition is a recent development in the treatment of serious
intestinal conditions such as Crohn's disease. It is a way of ensuring adequate
nutrition when normal absorption of food and fluid from the gut is impossible as a
result of severe disease.
A fine tube (catheter) is inserted into a major vein in the neck, and is held in
permanent position; its end is capped when not in use. A special feeding solution,
three to five litres in all, is pumped through the catheter using a special pump
mounted on a stand. The process takes eight to fourteen hours, and is usually
carried out overnight.
For most people, the need for total parenteral nutrition will be life-long.