Bookmark

1. The Seafarers Safety, Rehabilitation and Compensation Authority (“the Authority”), under subsection 125(1) of the Seafarers Rehabilitation and Compensation Act 1992 (“the Act”), has delegated to the Chief Executive Officer of Comcare its functions and powers under section 42 of the Act by resolution dated 22 December 2005 with effect on and from that date.

2. I, Barbara Bennett, Chief Executive Officer of Comcare, under subsection 42 (1) of the Act, prepare the following Guide to the Assessment of the Degree of Permanent Impairment (“second edition of the Guide”).

3. The second edition of the Guide will come into operation in the manner specified in section 3 of the Introduction to the second edition of the Guide: Application of this Guide.

Dated: 30 January 2006

Barbara Bennett

Chief Executive Officer

Comcare

Delegate of the Seafarers Safety, Rehabilitation

and Compensation Authority

Guide to

the Assessment

of the Degree of Permanent Impairment

Second edition

Seafarers Safety, Rehabilitation

and Compensation Authority

Acknowledgement

Acknowledgment is made to Comcare for the assistance provided in developing this

Guide and in the use of the Tables contained in Comcare’s 2^nd edition of its Guide to the assessment of the degree of permanent impairment.

Introduction to second edition of the Guide

Page no

1. Authority ............................................................................................... iii

2. Structure of this Guide .................................................................... iii

3. Application of this Guide ................................................................ iv

4. Whole Person Impairment (WPI) ................................................ v

5. Entitlements under the Seafarers Act ........................................ v

6. Non-economic loss ............................................................................. v

7. Compensation Payable ..................................................................... v

8. Interim and Final Assessments ..................................................... v

9. Increase in Degree of Whole Person Impairment ................ vi

10. Claims for Permanent Impairment ........................................... 1

1. Authority

Division 4 of Part II (sections 39 to 42) of the Seafarers Rehabilitation and Compensation Act 1992 (the Seafarers Act) provides for payment of lump sum compensation for permanent impairment and non-economic loss resulting from a work related injury.

The amount of compensation payable (if any) is to be assessed by reference to the degree of permanent impairment or the degree of non-economic loss determined by employers under the provisions of the approved Guide:

“approved Guide” is defined by section 3 of the Seafarers Act as meaning:

(a) the document, prepared by the Authority in accordance with section 42 under the title “Guide to the Assessment of the Degree of Permanent Impairment”, that has been approved by the Minister and is for the time being in force; and

(b) if an instrument varying the document has been approved by the Minister—that document as so varied.

Authority for this document rests therefore in subsections 42(1), 42(2) and 42(3) of the Seafarers Act, which provide that:

(1) The Authority may, from time to time, prepare a written document, to be called the “Guide to the Assessment of the Degree of Permanent Impairment”, setting out:

(a) criteria by reference to which the degree of the permanent impairment of an

employee resulting from an injury must be determined;

(b) criteria by reference to which the degree of non-economic loss suffered by an

employee as a result of an injury or impairment must be determined; and

(c) methods by which the degree of permanent impairment and the degree of non economic loss, as determined under those criteria, must be expressed as a percentage.

(2) The Authority may, from time to time, by instrument in writing, vary or revoke the approved Guide.

(3) A document prepared by the Authority under subsection (1), and an instrument under subsection (2), have no force or effect unless and until approved by the Minister

This document is the new Guide to the Assessment of the Degree of Permanent Impairment. It may be referred to as ‘this Guide’ or ‘second edition of the Guide’. This Guide is binding on employers, and the Administrative Appeals Tribunal (subsection 29 (4)).

2. Structure of this Guide

This Guide has three divisions:

DIVISION 1 Division 1 (see page 17) is used to assess the degree of an employee’s permanent impairment resulting from an injury;

DIVISION 2 Division 2 (see page 151) is used to assess the degree of an employee’s non-economic loss resulting from impairment;

DIVISION 3 Division 3 (see page 159) is used to calculate the total entitlement based on the assessments completed in Divisions 1 and 2.

The Principles of Assessment (see page 11) and Glossary (see page 15) of this Guide contain information relevant to the interpretation and application of Divisions 1 & 2.

3. Application of this Guide

The Guide to the Assessment of the Degree of Permanent Impairment prepared by the Seafarers Safety, Rehabilitation and Compensation Authority under subsection 42 (1) of the Seafarers Rehabilitation and Compensation Act 1992 and approved by the Minister for Transport and Communications on 17 June 1993 is referred to as the “first edition of the Guide”.

Except as provided below, the first edition of the Guide is revoked in relation to determinations made under sections 39, 40 or 41 of the Seafarers Act in respect of claims under those sections received by employers after 28 February 2006. Claims under those sections received on or before 28 February 2006 will be determined under the provisions of the first edition of the Guide.

This Guide will apply on and from 1 March 2006 in relation to determinations made under sections 39, 40 or 41 of the Seafarers Act in respect of claims under those sections, received by employers after 28 February 2006.

Where a request by an employee (as defined in s4 of the Seafarers Act) pursuant to subsection 40 (1) of the Seafarers Act is received by an employer after the revocation date but relates to a claim under section 39 that was received by the employer on or before the revocation date, that request will be determined under the provisions of the first edition of the Guide.

Where a claim for compensation pursuant to subsections 40(4) of the Seafarers Act (in respect of a subsequent increase in the degree of permanent impairment) is received by the employer after the revocation date, that claim will be determined under the provisions of this Guide, notwithstanding that the initial claim for compensation for permanent impairment may have been determined under the provisions of the first edition of the Guide.

However, where the initial claim for compensation for permanent impairment was determined under the provisions of the first edition of the Guide, in determining whether or not there has been any subsequent increase in the degree of permanent impairment, the degree of permanent impairment or the degree of non-economic loss shall not be less than the degree of permanent impairment or degree of non-economic loss determined under the provisions of the first edition of the Guide unless that determination would not have been made but for a false statement or misrepresentation of a person.

In this Guide, “revocation date” means 28 February 2006.

4. Whole Person Impairment (WPI)

Prior to 1993, the Seamen’s Compensation Act 1911 (the 1911 Act) (repealed with the coming into effect of the Seafarers Act) provided for the payment of lump sum compensation where a seafarer (employee) suffered the loss of, or loss of efficient use of, a part of the body or faculty, as specified in a table of maims. The range of conditions compensated was exclusive and did not reflect the broad range of work-related injuries and diseases.

This Guide, like the first edition, is based on the concept of ‘whole person impairment’. Subsection 39(5) of the Seafarers Act provides for the determination of the degree of permanent impairment of the employee, that is, the employee as a whole person. The whole person impairment concept, therefore, provides for compensation for the permanent impairment of any body part, system or function to the extent to which it permanently impairs the employee as a whole person.

Whole person impairment is assessed under Division 1 of this Guide.

5. Entitlements under the Seafarers Act

Where the degree of permanent impairment of the employee determined under subsection 39(5) of the Seafarers Act is less than 10 per cent, paragraph 39(7) of the Act provides that compensation is not payable to the employee under section 39 of that Act.

Subsection 39(8) of the Act excludes the operation of subsection 39(7) in relation to impairment resulting from the loss, or the loss of the use, of a finger or toe, or the loss of the sense of taste or smell.

6. Non-economic loss

Subsection 41(1) of the Seafarers Act provides that where there is liability to pay compensation in respect of a permanent impairment, additional compensation for non-economic loss is payable in accordance with section 41.

Non-economic loss is assessed under Division 2 of this Guide.

7. Compensation Payable

The maximum level of payment is prescribed in the legislation and indexed annually on 1 July in accordance with the Consumer Price Index. Compensation is calculated at the rate applicable at the time of the assessment (see Division 3 for calculation of total entitlement).

8. Interim and Final Assessments

On the written request of the employee under subsection 40 (1) of the Seafarers Act, an interim determination must be made of the degree of permanent impairment suffered and an assessment made of an amount of compensation payable to the employee, where:

· a determination has been made that an employee has suffered a permanent impairment as a result of an injury;

· the degree of that impairment is equal to or more than 10%; and

· a final determination of the degree of permanent impairment has not been made.

When a final determination of the degree of permanent impairment is made, there is payable to the employee, under subsection 40 (3) of the Seafarers Act, an amount equal to the difference, if any, between the final determination and the interim assessment.

9. Increase in Degree of Whole Person Impairment

Where a final assessment of the degree of permanent impairment has been made and the level of whole person permanent impairment subsequently increases by 10% or more, the employee may request, pursuant to subsection 40 (4) of the Seafarers Act, another assessment for compensation for permanent impairment and non-economic loss. Additional compensation is payable for the increased level of impairment only.

See section 3 above (Application of this Guide) as to assessments of the degree of permanent impairment made under the first edition of the Guide.

CLAIMS FOR

PERMANENT IMPAIRMENT

List of Tables and Figures..................................................................................... 5

List of references..................................................................................................... 9

Principles of Assessment................................................................................. 11

Glossary................................................................................................................. 15

Division 1 Assessment of the Degree of an Employee’s

Permanent Impairment Resulting from an Injury......... 17

Chapter 1 – The Cardiovascular System............................... 19

Chapter 2 – The Respiratory System..................................... 29

Chapter 3 – The Endocrine System........................................ 35

Chapter 4 – Disfigurement and Skin Disorders................... 41

Chapter 5 – Psychiatric Conditions........................................ 45

Chapter 6 – The Visual System............................................... 47

Chapter 7 – Ear, Nose and Throat Disorders...................... 59

Chapter 8 – The Digestive System.......................................... 65

Chapter 9 – The Musculoskeletal System............................. 73

Chapter 10 – The Urinary System........................................... 119

Chapter 11 – The Reproductive System............................... 123

Chapter 12 – The Neurological System................................. 129

Chapter 13 – The Haematopoietic System............................ 147

Division 2 Guide to the Assessment of Non-Economic Loss........ 151

Division 3 Calculation of Total Entitlement....................................... 159

Index....................................................................................................................... 161

Appendix 1: Combined Values Chart........................................................... 169

List of Tables and Figures

Division 1 – Assessment of Degree and Employee’s Permanent Impairment Resulting from Injury

Chapter 1 – The Cardiovascular System

Figure 1-A: Activities of Daily Living............. 19

Figure 1-B: Symptomatic Level of Activity

in METS According to Age and

Gender ........................................... 21

Table 1.1: Coronary Artery Disease ............. 21

Table 1.2.1: Diastolic Hypertension ................ 23

Table 1.2.2: Systolic Hypertension ................. 24

Figure 1-C: Definitions of Functional Class .. 25

Table 1.3: Arrhythmias ................................... 25

Table 1.4 Peripheral Vascular Disease

of the Lower Extremities .............. 26

Table 1.5: Peripheral Vascular Disease

of the Upper Extremities 26

Figure 1-C: Definitions of Functional Class.. 27

Table 1.6: Raynaud’s Disease ....................... 27

Chapter 2 – The Respiratory System

Table 2.1: Conversion of Respiratory

............................... Function Values to

............................... Impairment ..................................... 31

Figure 2-A: ......... Calculating Asthma Impairment

............................... Score ............................................... 32

Table 2.2: ............ Whole Person Impairment

............................... Derived from Asthma

............................... Impairment Score .......................... 32

Figure 2-B: ......... Calculating Obstructive Sleep

............................... Apnoea Score ................................ 33

Table 2.4 ............. Whole Person Impairment

............................... Derived from Obstructive

............................... Sleep Apnoea Score ..................... 33

Chapter 3 – The Endocrine System

Table 3.1 Thyroid and Parathyroid

Glands ............................................. 36

Table 3.2 Adrenal Cortex and Medulla ....... 37

Table 3.3: Pancreas (Diabetes Mellitus)....... 38

Table 3.4: Gonads and Mammary Glands .... 39

Chapter 4 – Disfigurement and Skin Disorders

Table 4.1: Skin Disorders ............................... 42

Figure 4-A: Activities of Daily Living............. 42

Table 4.2: Facial Disfigurement ..................... 43

Table 4.3: Bodily Disfigurement.................... 43

Chapter 5 – Psychiatric conditions

Figure 5-A: Activities of Daily Living............. 45

Table 5.1: Psychiatric conditions ................. 45

Chapter 6 – The Visual System

Figure 6-A: Steps for Calculating

Impairment of the Visual

System ............................................ 49

Table 6.1: Conversion of the Visual

System to Whole Person

Impairment Rating ......................... 49

Figure 6-B: Revised LogMar Equivalent for Different Reading Cards 50

Figure 6-C: Percentage Loss of Central

Vision in One Eye ......................... 51

Figure 6-D: Normal Extent of the Visual

Field................................................. 52

Figure 6-E: Percentage Loss of Ocular

Motility of one Eye in

Diplopia Fields............................... 53

Figure 6-F: Calculation of Visual System Impairment for Both Eyes 55

Chapter 7 – Ear, Nose and Throat Disorders

Table 7.2: Tinnitus........................................... 60

Table 7.3: Olfaction and Taste....................... 60

Table 7.4: Speech............................................. 61

Table 7.5: Air Passage Defects...................... 62

Table 7.6: Nasal Passage Defects.................. 62

Table 7.7: Chewing and Swallowing............. 63

Chapter 8 – The Digestive System

Figure 8-A: Activities of Daily Living............. 65

Figure 8-B: Body Mass Index Criteria............. 66

Table 8.1: Upper Digestive Tract:

Oesophagus, Stomach,

Duodenum, Small Intestine

and Pancreas.................................. 67

Table 8.2: Lower Gastrointestinal Tract:

Colon and Rectum......................... 68

Table 8.3: Lower Gastrointestinal Tract:

Anus................................................ 70

Table 8.4: Surgically Created Stomas............ 70

Table 8.5: Liver (Chronic Hepatitis and Parenchymal Liver Disease) 71

Table 8.6: Biliary Tract.................................... 72

Table 8.7: Hernias of the Abdominal

Wall.................................................. 72

List of Tables and Figures continues over page

List of Tables and Figures

(continued)

Chapter 9 – The Musculoskeletal System

Figure 9-A Activities of Daily Living............. 74

Figure 9-B Tables of normal ranges of

motion of joints.............................. 75

Table 9.1: Feet and Toes................................. 77

Table 9.2: Ankles ............................................ 78

Table 9.3: Knees............................................... 79

Table 9.4: Hips.................................................. 80

Table 9.5: Lower Extremity Amputations..... 81

Figure 9-C: Grading System.............................. 82

Table 9.6.1: Spinal Nerve Root Impairment Affecting the Lower Extremity 83

Table 9.6.2a: Sensory Impairment due to

Peripheral Nerve Injuries

Affecting the Lower

Extremities....................................... 83

Table 9.6.2b: Motor Impairment due to

Peripheral Nerve Injuries

Affecting the Lower

Extremities....................................... 84

Table 9.7: Lower Extremity Function............. 85

Table 9.8.1a: Abnormal Motion/Ankylosis

of the Thumb –

IP and MP joints............................ 88

Table 9.8.1b: Radial Abduction/Adduction/ Opposition of the Thumb –

Abnormal Motion/Ankylosis...... 89

Table 9.8.1c: Abnormal Motion/Ankylosis

of the Fingers –

Index and Middle Fingers............. 90

Table 9.8.1d: Abnormal Motion/Ankylosis

of the Fingers –

Ring and Little Fingers.................. 90

Table 9.8.2a: Sensory Losses in the Thumb..... 92

Table 9.8.2b: Sensory Losses in the Index &

Index & Middle Fingers................ 92

Table 9.8.2c: Sensory Losses in the Little

Finger............................................... 92

Table 9.8.2d: Sensory Losses in the Ring

Finger............................................... 92

Table 9.9.1a: Wrist Flexion/Extension................ 94

Table 9.9.1b: Radial and Ulnar Deviation

of Wrist Joint.................................. 94

Table 9.10.1a: Elbow Flexion/Extension............... 96

Table 9.10.1b: Pronation and Supination of

Forearm............................................ 96

Table 9.11.1a: Shoulder Flexion/Extension.......... 98

Table 9.11.1b: Shoulder Flexion/Extension

Internal/External Rotation of Shoulder 98

Table 9.11.1c: Abduction/Adduction of

Shoulder.......................................... 99

Table 9.12.1: Upper Extremity

Amputations................................. 100

Table 9.12.2: Amputation of Digits.................. 100

Figure 9-D: Grading System............................ 101

Table 9.13.1: Cervical Nerve Root

Impairment.................................... 102

Table 9.13.2a: Specific Nerve Lesions Affecting

the Upper Extremities –

Sensory Impairment..................... 104

Table 9.13.2b: Specific Nerve Lesions

Affecting the Upper Extremities –

Motor Impairment........................ 104

Figure 9-E Diagnostic Criteria for CRPS...... 106

Figure 9-F Impairment Grading for CRPS.... 106

Table 9.14 Upper Extremity Function........... 109

Table 9.15: Cervical Spine –

Diagnosis-Related Estimates..... 114

Table 9.16: Thoracic Spine –

Diagnosis-Related Estimates..... 115

Table 9.17: Lumbar Spine –

Diagnosis-Related Estimates..... 116

Table 9.18: Fractures of the Pelvis................ 117

Chapter 10 – The Urinary System

Table 10.1: The Upper Urinary Tract............ 120

Table 10.2: Urinary Diversion........................ 120

Table 10.3: Lower Urinary Tract.................... 122

Chapter 11 – The Reproductive System

Table 11.1.1: Male Reproductive Organs –

Penis.............................................. 124

Table 11.1.2: Male Reproductive Organs – Scrotum 124

Table 11.1.3: Male Reproductive Organs –

Testes, Epididymes and

Spermatic Cords........................... 125

Table 11.1.4: Male Reproductive Organs – Prostate and Seminal

Vesicles......................................... 125

Table 11.2.1: Female Reproductive

Organs – Vulva and Vagina....... 126

Table 11.2.2: Female Reproductive

Organs – Cervix and Uterus....... 127

Table 11.2.3: Female Reproductive

Organs – Fallopian Tubes

and Ovaries................................... 128

Chapter 12 – The Neurological System

Figure 12-A: Activities of Daily Living........... 130

Table 12.1.1: Permanent Disturbances of

Levels of Consciousness

and Awareness............................ 131

List of Tables and Figures continues over page

List of Tables and Figures

(continued)

Table 12.1.2: Epilepsy, Seizures and

Convulsive Disorders................. 131

Table 12.1.3: Sleep and Arousal Disorders..... 132

Table 12.2: Impairment of Memory,

Learning, Abstract Reasoning

and Problem Solving Ability...... 133

Figure 12-B: Clinical Dementia Rating

(CDR)............................................. 134

Table 12.3.1: Comprehension of Speech

and Language Symbols.............. 136

Table 12.3.2: Production of Speech and

Language Symbols...................... 138

Table 12.4: Emotional or Behavioural Impairments 139

Table 12.5.1: The Olfactory Nerve (I)............... 140

Table 12.5.3: The Trigeminal Nerve (V)........... 141

Table 12.5.4: The Facial Nerve (VII)................. 142

Table 12.5.5: The Auditory Nerve (VIII).......... 143

Figure 12-C: % WPI Modifiers for

Episodic Conditions.................... 144

Table 12.5.6: The Glossopharyngeal,

Vagus, Spinal Accessory

and Hypoglossal Nerves

(IX, X, XI and XII)....................... 145

Table 12.6: Neurological Impairment of

the Respiratory System............... 145

Table 12.7: Neurological Impairment of

the Urinary System...................... 145

Table 12.8: Neurological Impairment of

the Anorectal System.................. 146

Table 12.9: Neurological Impairment

Affecting Sexual Function.......... 146

Chapter 13 – The Haematopoietic System

Table 13.1: Anaemia........................................ 147

Figure 13-A: Activities of Daily Living........... 148

Table 13.2: Leukocyte Abnormalities or

Disease.......................................... 149

Table 13.3: Haemorrhagic Disorders and

Platelet Disorders......................... 150

Table 13.4: Thrombotic Disorders................. 150

Division 2 – Guide to the Assessment of

Non-Economic Loss

Table B1: Pain................................................ 152

Table B2: Suffering........................................ 153

Table B3.1: Mobility......................................... 155

Table B3.2: Social Relationships.................... 155

Table B3.3: Recreation and Leisure

Activities....................................... 155

Table B4: Other Loss.................................... 156

Table B5: Loss of Expectation of Life......... 156

B6: Worksheet Calculation of

non-economic loss...................... 157

Division 3 – Final Calculation of Entitlements

Under Section 24 and Section 25

C1: Worksheet Final Calculation of

Entitlements.................................. 159

Appendices

Appendix 1 Combined Values Chart.............. 169

List of references

Abramson MJ et al, 1996, Aust NZ J Med, 26, 697-701.

American Academy of Sleep Medicine, 1999, ‘Sleep related breathing disorders in adults: Recommendations for syndrome definition and measurement techniques in clinical research’, 1999, Sleep, 22, 667-689.

American Medical Association, 1995, Guides to the Evaluation of Permanent Impairment, 4^th edition, Chicago: American Medical Association.

American Medical Association, 2001, Guides to the Evaluation of Permanent Impairment, 5^th edition, Chicago: American Medical Association.

American Thoracic Society Ad Hoc Committee on Impairment/Disability Criteria, 1986, ‘Evaluation of impairment/disability secondary to respiratory disorders’, Am Rev Respir Dis, 133, 1205-09

American Thoracic Society, 1993, ‘Guidelines for the evaluation of impairment/disability in patients with asthma’, Am Rev Respir Dis, 147, 1056-61.

Cummings J, Mega M, Gary K, Rosenberg-Thompson S, Carusi D, Gornbein J, ‘The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia’, Neurology, 1994, 44, 2308-2314.

Ensalada LH, ‘Complex regional pain syndrome’, in Brigham CR, ed, The Guides Casebook, Chicago, Ill: American Medical Association, 1999, 14.

Johns MW, 1991, ‘A new method for measuring daytime sleepiness: the Epworth sleepiness scale’, Sleep, 14, 540-5.

Morris JC, 1993, ‘The Clinical Dementia Rating (CDR): current version and scoring rules’, Neurology, 43(11), 2412-2414.

National Asthma Council, 2002, Asthma Management Handbook 2002, 5th edition, Melbourne: National Asthma Council of Australia.

Principles of Assessment

Page no.

1. Impairment and Non-Economic Loss ..................................... 11

2. Employability and Incapacity ..................................................... 12

3. Permanent Impairment ................................................................. 12

4. Pre-Existing Conditions and Aggravation ............................ 12

5. The Impairment Tables ................................................................ 12

6. Malignancies and conditions resulting in major

systemic failure................................................................................ 13

7. Percentages of Impairment ......................................................... 13

8. Comparing Assessments under Alternative Tables .......... 13

9. Combined Values ............................................................................ 13

10. Calculating the Assessment ........................................................ 14

11. Ordering of Additional Investigations .................................... 14

12. Exceptions to use of this Guide ................................................. 14

1. Impairment and Non-Economic Loss

Under section 3 of the Seafarers Act, impairment means ‘the loss, the loss of the use, or the damage or malfunction, of any part of the body or of the whole or part of any bodily system or function’. It relates to the health status of an individual and includes anatomical loss, anatomical abnormality, physiological abnormality, and psychological abnormality. The degree of impairment is assessed by reference to the impact of that loss on the normal efficient functioning of the whole person.

Non-economic loss is assessed in accordance with Division 2 (page 151) of this Guide, and deals with the effects of the impairment on the employee’s life. Under section 3 of the Seafarers Act, non economic loss, for an employee who has suffered an injury resulting in a permanent impairment, means:

‘loss or damage of a non-economic kind suffered by the employee (including pain and suffering, a loss of expectation of life or a loss of the amenities or enjoyment of life) as a result of that injury or impairment and of which the employee is aware’.

Non-economic loss may be characterised as the ‘lifestyle effects’ of an impairment. ‘Lifestyle effects’ are a measure of an individual’s mobility and enjoyment of, and participation in, social relationships, and recreation and leisure activities. The employee must be aware of the losses suffered. While employees may have equal ratings of whole person impairment it would not be unusual for them to receive different ratings for non-economic loss because of their different lifestyles.

2. Employability and Incapacity

The concepts of ‘employability’ and ‘incapacity’ are not the tests for the assessment of impairment and non-economic loss. Incapacity is influenced by factors other than the degree of impairment and is compensated by weekly payments which are separate and independent to permanent impairment entitlements.

3. Permanent Impairment

Compensation is only payable for impairments which are permanent. Under section 3 of the Seafarers Act ‘permanent’ means ‘likely to continue indefinitely’. Subsection 39(2) of the Seafarers Act provides that for the purposes of determining whether an impairment is permanent, the following matters shall be considered:

(a) the duration of the impairment;

(b) the likelihood of improvement in the employee’s condition;

(c) whether the employee has undertaken all reasonable rehabilitative treatment for the

impairment; and

(d) any other relevant matters.

Thus, a loss, loss of the use, damage, or malfunction, will be permanent if it is likely, in some degree, to continue indefinitely. For this purpose, regard shall be had to any medical opinion concerning the nature and effect (including possible effect) of the impairment, and the extent, if any, to which it may reasonably be capable of being reduced or removed.

4. Pre-Existing Conditions and Aggravation

Where a pre-existing or underlying condition is aggravated by a work-related injury, only the impairment resulting from the aggravation is to be assessed. However, an assessment should not be made unless the effects of the aggravation of the underlying or pre-existing condition are considered permanent. In these situations, the pre-existing or underlying condition would usually have been symptomatic prior to the work-related injury and the degree of permanent impairment resulting from that condition is able to be accurately assessed.

If the employee’s impairment is entirely attributable to the pre-existing or underlying condition, or to the natural progression of such a condition, the assessment for permanent impairment is nil.

Where the pre-existing or underlying condition was previously asymptomatic, all the permanent impairment arising from the work-related injury is compensable.

5. The Impairment Tables

Division 1 of this Guide is based on the concept of whole person impairment which is drawn from the American Medical Association’s Guides to the Evaluation of Permanent Impairment (see the 5^th edition, 2001).

Division 1 assembles into groups, according to body system, detailed descriptions of impairments. The extent of each impairment is expressed as a percentage value of the whole, normal, healthy person. Thus, a percentage value can be assigned to an employee’s impairment by reference to the relevant description in this Guide.

It may be necessary in some cases to have regard to a number of Chapters within this Guide when assessing the degree of whole person impairment which results from an injury.

Where a table specifies a degree of impairment because of a surgical procedure, the same degree of impairment applies if the same loss of function has occurred due to a different medical procedure or treatment.

6. Malignancies and conditions resulting in major systemic failure

Conditions such as cancer, HIV infection, diabetes, asbestosis, mesothelioma and others, often with terminal consequences, may result in failure or impairment of multiple body parts or systems.

Assessments should be made of the impairment suffered in each of the affected body parts and systems and combined using the Combined Values Chart in Appendix 1.

7. Percentages of Impairment

Each table in Division 1 contains impairment values expressed as percentages. Where a table is applicable in respect of a particular impairment, there is no discretion to choose an impairment value not specified in that table. For example, where 10% and 20% are the specified values, there is no discretion to determine the degree of impairment as 15%.

8. Comparing Assessments under Alternative Tables

Unless there are instructions to the contrary, where two or more tables (or combinations of tables) are equally applicable to an impairment, the decision-maker must assess the degree of permanent impairment under the table or tables which yields or yield the most favourable result to the employee.

9. Combined Values

Impairment is system or function based. A single injury may give rise to multiple losses of function and, therefore, multiple impairments. When more than one table applies in respect of that injury, separate scores should be allocated to each functional impairment. To obtain the whole person impairment in respect of that injury, those scores are then combined using the Combined Values Chart (see Appendix 1) unless the notes in the relevant section specifically stipulate that the scores are to be added (For instance, see 9.8.1 at page 87).

Where two or more injuries give rise to the same whole person impairment only a single rating should be given. For example, impairments resulting from separate injuries to the left and right knees are initially assessed separately under Tables 9.3 and then, in accordance with the notes – Introduction to Chapter 9 on page 74, the impairments are combined using the Combined Values Chart to obtain the overall impairment for the lower extremity function which is taken to be a single whole person impairment. Alternatively, a whole person impairment value can be obtained using the method set out in Table 9.7 (which treats the injuries to both knees as the same impairment*) and this value can then be compared to the combined value previously obtained to determine which is the most beneficial. [* The notes on page 84 to Table 9.7 provide: ‘A single assessment only may be made under Table 9.7, irrespective of whether one or two extremities are affected by the injury’]

However, where two or more injuries give rise to different whole person impairments, each injury is to be assessed separately and the final scores for each injury (including any combined score for a particular injury) added together.

It is important to note that whenever the notes in the relevant section refer to combined ratings, the Combined Values Chart must be used, even if no reference is made to the use of that Chart.

10. Calculating the Assessment

Where relevant, a statement is included in the Chapters of Division 1 which indicates:

· the manner in which tables within that Chapter may (or may not) be combined;

· whether an assessment made in that Chapter can be combined with an assessment made in another Chapter in assessing the degree of whole person impairment.

There are some special circumstances where addition of scores rather than combination is required. These circumstances are specified in the relevant sections and tables of this Guide.

11. Ordering of Additional Investigations

As a general principle, the assessing medical practitioner should not order additional radiographic or other investigations solely for impairment evaluation purposes, unless the investigations are specifically required in the relevant chapter of this Guide.

12. Exceptions to use of this Guide

In the event that an employee’s impairment is of a kind that cannot be assessed in accordance with the provisions of this Guide, the assessment is to be made under the edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment current at the time of assessment.

An assessment is not to be made using the American Medical Association’s Guides to the Evaluation of Permanent Impairment for:

· mental and behavioural impairments (psychiatric conditions);

· impairments of the visual system;

· hearing impairment; or

· chronic pain conditions, except in the case of migraine or tension headaches. (For complex regional pain syndromes affecting the upper extremities, see Chapter 9 – 9.13.3 Complex Regional Pain Syndrome, see page 105).

Any reference in this Guide to the American Medical Association’s Guides to the Evaluation of Permanent Impairment is a reference to the edition current at the time of assessment, unless there is reference to a specific edition.

Glossary

Definitions in italics are from section 3 of the Seafarers Act.

Activities of Daily Living are those activities that an employee needs to perform to function in a non-specific environment (that is, to live). Performance of Activities of Daily Living is measured by reference to primary biological and psychosocial function.

Ailment means any physical or mental ailment, disorder, defect or morbid condition (whether of sudden onset or gradual development).

Disease means

(a) any ailment suffered by an employee; or

(b) the aggravation of any such ailment;

being an ailment or an aggravation that was contributed to in a material degree by the employee’s employment.

Impairment means the loss, the loss of the use, or the damage or malfunction, of any part of the body or of the whole or part of any bodily system or function.

Injury means

(a) a disease suffered by an employee; or

(b) an injury (other than a disease) suffered by an employee,

being a physical or mental injury arising out of, or in the course of, the employee’s employment; or

(c) an aggravation of a physical or mental injury (other than a

disease) suffered by an employee (whether or not that injury arose out of, or in the course of, the employee’s employment), being an aggravation that arose out of, or in the course of, that employment;

but does not include anything suffered by an employee as a result of reasonable disciplinary action taken against the employee or failure by the employee to obtain a promotion, transfer or benefit in connection with his or her employment.

Loss of Amenities means the effects on mobility, social relationships and recreation and leisure activities.

Non-economic loss in relation to an employee who has suffered an injury resulting in a permanent impairment, means loss or damage of a non-economic kind suffered by the employee (including pain and suffering, a loss of expectation of life or a loss of the amenities or enjoyment of life) as a result of that injury or impairment and of which the employee is aware.

Glossary continues on following page

Glossary (continued)

Pain means physical pain.

Suffering means the mental distress resulting from the accepted conditions or impairment.

Whole person impairment (or WPI) means the medical effects of an injury or disease. WPI is based on the American Medical Association’s Guides to the Evaluation of Permanent Impairment. WPI is a medical quantification of the nature and extent of the effect of an injury or disease on a person’s functional capacity including Activities of Daily Living. This Guide presents descriptions of impairments in chapters and tables according to body system. The extent of each impairment is expressed as a percentage value of the functional capacity of a normal healthy person.

Division 1

Assessment of the Degree

of an Employee’s Permanent Impairment

Resulting from an Injury

Chapter 1 – The Cardiovascular System

Page no.

1.0 Introduction............................................................................................. 19

1.1... Coronary Artery Disease................................................................... 21

1.2.... Hypertension.......................................................................................... 23

1.2.1 Diastolic Hypertension...................................................................... 23

1.2.2 Systolic Hypertension........................................................................ 24

1.3 .. Arrhythmias............................................................................................ 25

1.4 .. Peripheral Vascular Disease of the Lower Extremities........ 26

1.5 ... Peripheral Vascular Disease of the Upper Extremities......... 26

1.6 .. Raynaud’s Disease............................................................................... 27

1.0 Introduction

In conducting an assessment, the assessor must have regard to the Principles of Assessment (see pages 11-14) and the definitions contained in the Glossary (see pages 15-16).

WPI ratings derived from tables in this Chapter may be combined with WPI ratings from other tables where there is co-existent disease (for example, cardiomyopathy, ischaemic heart disease, congenital heart disease, valvular heart disease).

‘Activities of Daily Living’ are activities which an employee needs to perform to function in a non-specific environment (that is, to live). Performance of Activities of Daily Living is measured by reference to primary biological and psychosocial function.

For the purposes of Chapter 1, Activities of Daily Living are those in Figure 1-A (see below).

Figure 1-A: Activities of Daily Living

Activity	Examples
Self care, personal hygiene.	Bathing, grooming, dressing, eating, eliminating.
Communication.	Hearing, speaking, reading, writing, using keyboard.
Physical activity.	Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising.
Sensory function.	Tactile feeling.
Hand functions.	Grasping, holding, pinching, percussive movements, sensory discrimination.
Travel.	Driving or travelling as a passenger.
Sexual function.	Participating in desired sexual activity.
Sleep.	Having a restful sleep pattern.
Social and recreational.	Participating in individual or group activities, sports activities, hobbies.

Chapter 1 does not cover impairments arising from cardiomyopathy, congenital heart disease, valvular heart disease, and pericardial heart disease. Where relevant, the degree of impairment arising from these conditions should be assessed in accordance with the appropriate table from the edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment current at the time of assessment.

For post-thrombotic syndrome, assessments under Tables 1.4 and 1.5 (peripheral vascular disease, see page 26) are an alternative to Table 13.4: Thrombotic Disorders (see page 150, Chapter 13 – The Haematopoietic System). WPI ratings from Tables 1.4 and 1.5 must not be combined with a WPI rating from Table 13.4. Tables 1.4 and 1.5 should be used as the primary guide for assessing peripheral complications of thrombosis.

Employees who have permanent cardiac limitation secondary to massive pulmonary embolism should be assessed under Chapter 1. A WPI rating assessed in these circumstances may not be combined with a rating from Table 13.4.

1.1 Coronary Artery Disease

Steps for assessment are as follows.

Step 1	Using Figure 1-B (see below), determine the symptomatic level of activity in METS according to age and gender. Figure 1-B may be used to assess conditions affecting left ventricular function (LVF) (including ischaemic heart disease, rheumatic heart disease, and hypertension).
Step 2	Using Table 1.1 (see below), refer to any one of pathology (column 3), drug therapy (column 4), or intervention (column 5), to identify the degree of impairment within the range of impairments for that symptomatic level of activity.

Figure 1-B (see below) may be used for the assessment of symptomatic impairment caused by ischaemic heart disease, hypertension, cardiomyopathy, or rheumatic heart disease.

Figure 1-B: Symptomatic Level of Activity in METS According to Age and Gender

Age and Gender	Symptomatic Level of Activity in METS
Age and Gender	1	1-2	2-3	3-4	4-5	5-6	6-7	7-8	8-9	10+
18-30 M	D	D	D	C	C	B	B	B	A	A
18-30 F	D	D	C	C	B	B	A	A	A
31-40 M	D	D	D	C	C	B	B	A	A
31-40 F	D	D	C	B	B	B	A
41-50 M	D	D	C	C	B	B	A	A
41-50 F	D	D	C	B	B	A	A
51-60 M	D	D	C	B	B	A	A	A
51-60 F	D	D	C	B	B	A	A
61-70 M	D	D	C	B	B	A	A
61-70 F	D	D	B	B	A	A
70+ M	D	C	B	B	A
70+ F	D	C	B	A	A

Table 1.1: Coronary Artery Disease

See notes to Table 1.1 on following page for further details regarding abbreviations and

symbols used in Columns 3, 4 and 5.

Column 1 % WPI	Column 2 Level of Activity in METS for Age and Gender	Column 3 Pathology	Column 4 Drug Therapy	Column 5 Intervention
5	A	not applicable	not applicable	not applicable
10	A	+	+	not applicable
15	A	++	++	PTCA
20	A	+++	+++	CABG/Tx
25	B	+	+	not applicable
30	B	++	++	PTCA
40	B	+++	+++	CABG/Tx
50	C	+	+	not applicable
60	C	++	++	PTCA
65	C	+++	+++	CABG/Tx
75	D	+	+	not applicable
85	D	++	++	PTCA
95	D	+++	+++	CABG/Tx

Notes to Table 1.1

1. In Table 1.1, not applicable means the criterion is not applicable to the specified level of impairment.

2. Pathology – Column 3.

(i) Coronary Artery Disease:

+ either <50% stenosis in one or more coronary arteries, or single vessel disease > 50% stenosis (except proximal left anterior descending [LAD] and left main coronary artery [LMCA]);

++ either >50% stenosis in two vessels, or >50% stenosis in proximal LAD, or <50% stenosis in LMCA;

+++ either >50% stenosis in 3 vessels, or LMCA >50% stenosis, or severe diffuse end organ disease.

(ii) Ischaemic Left Ventricular Dysfunction:

+ left ventricular ejection fraction (LVEF) 40-50%;

++ LVEF 30-40%;

+++ either LVEF < 30%, or LV aneurysm.

(iii) Myocardial Infarction (MI):

+ no previous MI;

++ previous possible MI (equivocal changes in ECG/cardiac enzymes);

+++ previous definite MI (unequivocal changes in ECG/cardiac enzymes: typical evolution of ST/T segments, or development of significant Q waves, or enzyme rise > 3 times upper limit of normal).

(iv) Arrhythmias

Assessed under Table 1.3 – Arrhythmias (see page 25).

3. Drug Therapy (continuous) – Column 4.

+ one or two drugs;

++ three or four drugs;

+++ five or more drugs.

4. Intervention – Column 5.

PTCA means percutaneous transluminal coronary angioplasty and/or stenting.

CABG means coronary artery bypass grafting.

Tx means heart transplant.

1.2 Hypertension

Either diastolic hypertension (section 1.2.1 below) or systolic hypertension (section 1.2.2, see following page) may be assessed, whichever provides the highest WPI rating.

1.2.1 Diastolic Hypertension

Hypertensive cardiomyopathy can be assessed using the edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment current at the time of assessment.

Functional class (determined in accordance with Figure 1-B, see page 21) is the primary criterion for assessment. Level of diastolic blood pressure (DBP) and therapy (see Table 1.2.1 below) are secondary criteria for assessment.

For assessment use either usual DBP, or therapy, for a given functional class, whichever provides the greater WPI rating. If DBP is consistently >120 on optimal therapy, one higher functional class may be assigned.

Table 1.2.1: Diastolic Hypertension

See note immediately following Table 1.2.1 for explanation of symbols

used in the final column (Drug Therapy).

% WPI	Level of Activity in METS for Age and Gender	Usual DBP	Drug Therapy
5	A	>90	+
10	A	>100	++
15	A	>110	+++
20	B	>90	+
25	B	>100	++
30	B	>110	+++
35	C	>90	+
40	C	>100	++
45	C	>110	+++
50	D	>90	+
55	D	>100	++
60	D	>110	+++

Note to Table 1.2.1

1. Drug Therapy (continuous) – final column of Table 1.2.1:

+ one drug;

++ two drugs;

+++ three or more drugs.

1.2.2 Systolic Hypertension

Hypertensive cardiomyopathy can be assessed using the edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment current at the time of assessment.

Functional class (determined in accordance with Figure 1-B, see page 21) is the primary criterion for assessment. Level of systolic blood pressure (SBP) and therapy (see Table 1.2.2 below) are secondary criteria for assessment.

Table 1.2.2: Systolic Hypertension

See note immediately following Table 1.2.2 for explanation of symbols

used in the final column (Drug Therapy).

% WPI	Symptomatic Level of Activity in METS for Age and Gender	Usual SBP	Drug Therapy
5	A	>160	+
10	A	>160	++
15	A	>160	+++
20	B	>170	+
25	B	>170	++
30	B	>170	+++
35	C	>180	+
40	C	>180	++
45	C	>180	+++
50	D	>190	+
55	D	>190	++
60	D	>190	+++

Note to Table 1.2.2

1. Drug Therapy (continuous):

+ one drug;

++ two drugs;

+++ three or more drugs.

1.3 Arrhythmias

Underlying cardiac disease can be assessed using other tables in Chapter 1.

Functional class (determined under Figure 1-C below), and therapy (see Table 1.3 below), are used to determine the WPI rating.

Figure 1-C: Definitions of Functional Class

Functional Class	Symptoms
I	No limitation of physical activity.
II	Slight limitation of physical activity. Comfortable at rest and with ordinary, light Activities of Daily Living. Greater activity causes symptoms.
III	Marked limitation of physical activity. Comfortable at rest. Ordinary activity causes symptoms.
IV	Inability to carry out any physical activity without discomfort.

Table 1.3: Arrhythmias

See note immediately following Table 1.3 for explanation of symbols

used in the final column (Therapy).

% WPI	Functional Class	Therapy
5	I	Nil
10	I	Drug(s)
15	I	Surgery/cath/PPM/Device
20	II	Nil
30	II	Drug(s)
40	II	Surgery/cath/PPM/Device
45	III	Nil
50	III	Drug(s)
55	III	Surgery/cath/PPM/Device
60	IV	not applicable

Note to Table 1.3

1. Therapy – column 3:

‘cath’ means either catheter ablation or catheter-associated therapy for arrhythmia;

‘PPM’ means permanent pacemaker;

‘Device’ means implanted defibrillator.

1.4 Peripheral Vascular Disease of the Lower Extremities

Amputations should not be assessed under Table 1.4. They should be assessed under Table 9.5: Lower Extremity Amputations (see page 81, Chapter 9 – The Musculoskeletal System).

A WPI rating from Table 1.4 must not be combined with a WPI rating from Table 13.4: Thrombotic Disorders (see page 150, Chapter 13 – The Haematopoietic System).

Table 1.4: Peripheral Vascular Disease of the Lower Extremities

% WPI	Signs and Symptoms
0	The employee experiences neither intermittent claudication nor pain at rest.
5	The employee has no difficulty with distances but experiences ischaemic pain on climbing either steps or gradients.
10	The employee experiences claudication on walking 200 metres or more at an average pace on level ground.
20	The employee experiences claudication on walking more than 100 but less than 200 metres at average pace on level ground.
30	The employee experiences claudication on walking more than 75 but less than 100 metres at average pace on level ground.
40	The employee experiences claudication on walking more than 50 but less than 75 metres at average pace on level ground.
50	The employee experiences claudication on walking more than 25 but less than 50 metres at average pace on level ground.
60	The employee experiences claudication on walking less than 25 metres at average pace on level ground.
70	The employee experiences ischaemic pain at rest.

1.5 Peripheral Vascular Disease of the Upper Extremities

Amputations should not be assessed under Table 1.5. They should be assessed under Table 9.12.1: Upper Extremity Amputations, or Table 9.12.2: Amputation of Digits (see page 100, Chapter 9 – The Musculoskeletal System).

A WPI rating from Table 1.5 must not be combined with a WPI rating from Table 13.4: Thrombotic Disorders (see page 150, Chapter 13 – The Haematopoietic System).

Table 1.5 Peripheral Vascular Disease of the Upper Extremities

% WPI	Symptoms	Signs
5	Either no claudication or transient oedema.	Calcification of arteries on X-ray.
10	Either no claudication or persistent oedema controlled by support.	Dilatation of either arteries or veins.
15	As above.	Either loss of pulse or healed ulcer or surgery.
20	Either claudication on strenuous exercise or persistent oedema uncontrolled by support.	Either calcification of arteries on X-ray or dilatation of either arteries or veins.
30	As above.	Superficial ulcer.
40	As above.	Either deep or widespread ulcer or surgery.
45	Claudication on mild-moderate exertion.	Either calcification of arteries on X-ray or dilatation of either arteries or veins.
50	As above.	Superficial ulcer.
55	As above.	Either deep or widespread ulcer or surgery.
60	Rest pain/unable to exercise.	not applicable

1.6 Raynaud’s Disease

Functional class (determined according to Figure 1-C below) is the primary criterion for assessment. Signs of vasospastic disease and therapy (see Table 1.6 below) are secondary criteria for assessment.

Figure 1-C: Definitions of Functional Class

See note to Figure 1-C immediately following Figure.

Functional Class	Symptoms
I	No limitation of physical activity.
II	Slight limitation of physical activity. Comfortable at rest and with ordinary, light Activities of Daily Living. Greater activity causes symptoms.
III	Marked limitation of physical activity. Comfortable at rest. Ordinary activity causes symptoms.
IV	Inability to carry out any physical activity without discomfort.

Note to Figure 1-C

1. Figure 1-C also appears in Section 1.3 – Arrhythmias, page 25. It is repeated here for ease of reference.

Table 1.6: Raynaud’s Disease

See note immediately following Table 1.6.

% WPI	Functional Class	Signs	Therapy
5	I	Nil.	Nil.
10	I	Nil.	Drug(s).
15	I	Nil.	Surgery.
20	II	Neither ulceration nor trophic changes.	Drug(s).
25	II	Either ulceration or trophic changes.	Drug(s).
30	II	not applicable	Surgery.
35	III	Neither ulceration nor trophic changes.	Drug(s).
40	III	Either ulceration or trophic changes.	Drug(s).
45	III	not applicable	Surgery.
50	IV	not applicable	not applicable

Note to Table 1.6

1. Therapy – final column of Table 1.6:

Surgery includes sympathectomy and local debridement;

Drug(s) means continuous therapy with one or more drugs.

Chapter 2 – The Respiratory System

Page no.

2.0 Introduction............................................................................................. 29

2.1 .. Assessing Impairment to Respiratory Function....................... 29

2.1.1 .. Measurements................................................................................. 29

2.1.2 .. Methods of Measurement.............................................................. 30

2.1.3... Impairment Rating........................................................................... 30

2.2... Asthma and other Hyper-reactive Airways Diseases............. 31

2.3... Lung Cancer and Mesothelioma.................................................... 32

2.4... Breathing Disorders Associated with Sleep............................... 33

2.0 Introduction

In conducting an assessment, the assessor must have regard to the Principles of Assessment (see pages 11-14) and the definitions contained in the Glossary (see pages 15-16).

The measure of impairment is the reduction in physiological function below that found in health.

Respiratory impairment is quantified by the degree to which measurements of respiratory function are changed by the compensable injury or injuries, relative to values obtained in a healthy reference population.

Conditions such as chronic obstructive airways disease and chronic bronchitis are to be assessed according to the methods used to measure loss of respiratory function.

Employees who have permanent respiratory limitation secondary to massive pulmonary embolism should be assessed under Chapter 2. Any WPI rating awarded in these circumstances must not be combined with a WPI rating from Table 13.4: Thrombotic Disorders (see page 150, Chapter 13 – The Haematopoietic System).

2.1 Assessing Impairment to Respiratory Function

2.1.1 Measurements

The most commonly recommended measurements for determining respiratory impairment are:

· spirometry with measurement of the forced expiratory volume at 1 second (FEV₁) and forced vital capacity (FVC); and

· the transfer factor, or diffusing capacity of the lung, for carbon monoxide (TlCO), measured by the single breath method.

However, the measurements used must be derived from either:

· the tests prescribed below where relevant (for example, in assessing asthma); or

· where a test is not prescribed, from tests appropriate to assessing the impairments caused by the particular compensable condition or conditions.

Other measurements commonly used to assess impairment include:

· the lung volumes;

· total lung capacity (TLC) and residual volume (RV); and

· the response to a maximum exercise test including measurement of the oxygen consumption at the maximum workload able to be achieved (vO₂max), and the degree of arterial oxygen desaturation during exercise.

On occasion, other measurements may be needed to define impairment accurately. For example:

· the elastic and flow resistive properties of the lungs;

· respiratory muscle strength;

· arterial blood gases;

· polysomnography (sleep studies);

· echocardiography with estimation of pulmonary artery pressure; and

· quantitative ventilation-perfusion scans of the lung.

Measurement of the partial pressures of oxygen and carbon dioxide in arterial blood (PaO₂ and PaCO₂ respectively) are not usually required to assign impairment accurately. However, individual variation may result in severe impairment in gas exchange when other measures of function indicate moderate impairment only. Arterial PaO₂of <55 mm Hg and/or PaCO₂ >50 mm Hg, despite optimal treatment, is evidence of severe impairment and attracts a WPI rating of 70%.

Measurements of arterial blood gases should be performed on two occasions with the employee seated.

2.1.2 Methods of Measurement

Measurements must be performed in a manner consistent with the methods used by a respiratory function laboratory accredited by one or more of the following bodies:

· the Thoracic Society of Australia and New Zealand;

· the Australian Sleep Society; or

· the Australian Council on Health Care Standards.

Methods of measurement should conform to internationally recognised standards in relation to the equipment used, the procedure, and analysis of the data. Reference values (‘predicted’ normal values) should be representative of the healthy population and be appropriate for ethnicity where possible. Laboratories providing measurements used to assess impairment should state the source of each method of measurement, and the source of the reference values used.

2.1.3 Impairment Rating

Several professional groups have published criteria for rating the severity of impairment based on spirometry, gas transfer and vO₂max. These professional groups include the Thoracic Society of Australia and New Zealand (Abramson, 1996), the American Thoracic Society (American Thoracic Society Ad Hoc Committee on Impairment/Disability Criteria, 1986), and the American Medical Association (2001). In general, measurements are expressed as a percentage of the predicted value (%P) and, where several measurements are performed, the most abnormal result is used to classify the degree of impairment.

Severity of impairment is rated as shown in Table 2.1 (see following page). This generic table can be used to assign WPI ratings using any valid measurement for which there is predicted normal data.

Table 2.1: Conversion of Respiratory Function Values to Impairment

See note immediately following Table 2.1

% WPI	Respiratory Function %P
0	>85
10	85 to 76
20	75 to 66
30	65 to 56
40	55 to 51
50	50 to 44
60	45 to 41
70	40 to 36
80	35

Note to Table 2.1

1. %P = percentage of mean value for healthy individuals of the same age, height and sex.

2.2 Asthma and other Hyper-reactive Airways Diseases

Impairment due to asthma can be confounded by the natural history of occupational asthma, by variably severe airflow obstruction, and therefore variable FEV₁, and by response to treatment.

For hyper-reactivity of airways due to occupational exposures, assessment of impairment is made after:

· the diagnosis and cause are established;

· exposure to the initiating factors eliminated; and

· appropriate treatment of asthma implemented.

Appropriate treatment follows the guidelines in the Asthma Management Handbook 2002 (National Asthma Council, 2002, 5th ed, Melbourne: National Asthma Council of Australia), a later edition of those guidelines, or later guidelines widely accepted as representing best practice by the medical profession.

Permanent impairment should not be assessed until 2 years after cessation of exposure as severity may improve during this period.

An impairment rating scale is set out in Figure 2-A and Table 2.2 (both on following page). The scale used in Figure 2-A and Table 2.2 is modified to account for frequency of increased impairment from asthma despite optimal treatment.

A score reflecting impairment from asthma is calculated by:

· adding the points scored for reduction in FEV₁ %P;

· and either

· change in FEV₁ with bronchodilator (reversibility);

· degree of bronchial hyperreactivity defined by the cumulative dose of metacholine, or histamine, required to decrease baseline FEV₁ by at least 20%;

· and

· measurement of FEV₁, or peak flow (PF) rate, measured by the employee morning and evening, before and after aerosol bronchodilator, for at least 30 days.

The number of days on which any valid measurement of FEV₁ or PF is less than 0.85 x the mean of the six highest values of FEV₁ or PF during the monitoring period is to be expressed as a percentage of total days in the monitoring period.

The maximum impairment score from Figure 2-A below is 11. One additional point is given, yielding a score of 12, if asthma cannot be controlled adequately with maximal treatment. The score from Figure

2-A is converted to a WPI rating using Table 2.2 (below).

Figure 2-A: Calculating Asthma Impairment Score

See notes immediately following Figure 2-A

Score	FEV₁, % P After Bronchodilator	DFEV₁, % Change in FEV₁with Bronchodilator	PD₂₀ OR mmol	*% of Days Lowest FEV₁ is 0.85 Highest FEV₁**
0	>85	<10	>4.0	<6
1	76 to 85	10 to 19	0.26 to 4.0	6 to 24
2	66 to 75	20 to 29	0.063 to 0.25	25 to 34
3	56 to 65	30	0.062	35 to 44
4	55			45

Notes to Figure 2-A

1. Figure 2-A is based on scales proposed by: the American Thoracic Society (1993), as adapted in Tables 5-9 and 5-10 of

American Medical Association’s Guides to the Evaluation of Permanent Impairment (5^th edition, 2001); and the Thoracic

Society of Australia and New Zealand (Abramson, 1996).

2. %P = percent predicted normal value.

3. PD₂₀= cumulative dose of inhaled metacholine aerosol causing a 20% decrease in FEV_1.

4. * monitored twice daily before and after aerosol bronchodilator for at least 30 days during adequate

treatment.

5. % of days = proportion of days any value of FEV₁ (or of peak flow rate) is less than highest repeatable FEV₁

(or peak flow rate) x 0.85.

Table 2.2: WPI Derived from

Asthma Impairment Score

% WPI	Asthma Impairment Score
0	0
10	1
20	2
30	3
40	4
45	5
50	6
55	7
60	8
65	9
70	10
75	11
80	12

2.3 Lung Cancer and Mesothelioma

Employees with lung cancers (other than mesothelioma) are considered severely impaired at the time of diagnosis and are given a WPI rating of 70%.

If there is evidence of tumour, or if tumour recurs one year after diagnosis is established, then the employee remains severely impaired and the WPI rating is increased to 80%.

Employees with mesothelioma are considered severely impaired and a WPI rating of 85 % is awarded upon diagnosis.

2.4 Breathing Disorders Associated with Sleep

Some disorders such as obstructive sleep apnoea, central sleep apnoea, and hypoventilation during sleep, can cause impairment which is not quantifiable by standard measurements of respiratory function such as spirometry, diffusing capacity, or response to exercise.

Obstructive sleep apnoea should be assessed using Table 2.4 below. Central sleep apnoea should be assessed using Table 12.1.3: Sleep and Arousal Disorders (see page 131, Chapter 12 – The Neurological System).

An overnight sleep study is used to define the severity of sleep-related disorders of breathing and can be used to define impairment after appropriate treatment has been implemented. During the overnight sleep study there is continuous monitoring of breathing pattern, respiratory effort, arterial oxygen saturation, electrocardiogram, and sleep state. Results of sleep studies cannot readily be expressed in terms of a percentage of predicted values. Consequently, impairment is rated by assigning scores to the degree of abnormality at sleep study (Figure 2-B, and Table 2.4, below). These ratings are based on frequency of disordered breathing, frequency of sleep disturbance, degree of hypoxaemia and, as appropriate, hypercapnoea during sleep. In addition, degree of daytime sleepiness is assessed using the Epworth sleepiness scale (Johns, 1991).

Where vascular morbidity is present (for example, high blood pressure, myocardial infarction, or stroke) and is attributable to sleep apnoea, impairment should be assessed against the relevant table in Chapter 1 – The Cardiovascular System (see page 19).

The total score derived from Figure 2-B below is the sum of the scores from each column: the maximum score is 12. This score is converted to a WPI rating using Table 2.4 below.

Figure 2-B: Calculating Obstructive Sleep Apnoea Score

See notes immediately following Figure 2-B.

Score	Epworth Sleepiness Score	Apnoeas + Hypopnoeas/hr of Sleep	*Respiratory Arousals/hr of Sleep**	Cumulative Sleep Time, mins, with SaO₂ <90% #
0	<5	<5	<5	0
1	5 to 10	5 to 15	5 to 15	<15
2	11 to 17	16 to 30	16 to 30	15 to 45
3	>17	>30	>30	>45

Notes to Figure 2-B

1. *An arousal within 3 seconds of a sequence of breaths which meet the criteria for an apnoea, an hypopnoea, or a respiratory effort related arousal, as defined by the American Academy of Sleep Medicine (1999).

2. SaO₂ = arterial oxygen saturation measured with a pulse oximeter.

Table 2.4: WPI Derived from Obstructive Sleep Apnoea Score

% WPI	Sleep Apnoea Score
0	0
10	1
20	2
30	3
40	4
45	5
50	6
55	7
60	8
65	9
70	10
75	11
80	12

Chapter 3 – The Endocrine System

Page no.

3.0 Introduction............................................................................................. 35

3.1 . Thyroid and Parathyroid Glands................................................... 36

3.2 .. Adrenal Cortex and Medulla............................................................ 37

3.3 .. Pancreas (Diabetes Mellitus)........................................................... 38

3.4 .. Gonads and Mammary Glands....................................................... 39

3.0 Introduction

In conducting an assessment, the assessor must have regard to the Principles of Assessment (see pages 11-15) and the definitions contained in the Glossary (see pages 15-16).

The degree of impairment caused by secondary conditions (such as peripheral neuropathy, or peripheral vascular disease) accompanying an endocrine system condition must also be assessed under the relevant tables in other Chapters, including tables in Chapter 10 – The Urinary System (see page 119).

In this circumstance, using the Combined Values Chart (Appendix 1), WPI ratings derived from the relevant tables in other Chapters are combined with WPI ratings from tables in Chapter 3.
3.1 Thyroid and Parathyroid Glands

Hyperthyroidism is not considered to cause permanent impairment because the condition is usually amenable to treatment. Where visual and/or cosmetic effects resulting from exophthalmos persist following correction of the hyperthyroidism, a WPI rating may be derived from:

· Chapter 4 – Disfigurement and Skin Disorders (see page 41); and/or

· Chapter 6 – The Visual System (see page 47, section 6.5 - Other Conditions Causing Permanent Deformities Causing up to 10% Impairment of the Whole Person).

Hyperparathyroidism is usually amenable to correction by surgery. If surgery fails, or the employee cannot undergo surgery for sound medical reasons, long-term therapy may be needed. If so, permanent impairment can be assessed after medication, in accordance with the criteria in Table 3.1 below.

Where an employee has more than one of the conditions in Table 3.1 below, combine the WPI ratings using the Combined Values Chart (see Appendix 1).

Permanent secondary impairment resulting from persistent hyperparathyroidism (such as renal calculi or renal failure) should be assessed under the relevant system (for example, Chapter 10 – The Urinary System, see page 119).

Table 3.1 Thyroid and Parathyroid Glands

% WPI	Criteria
0	Hyperparathyroidism – symptoms and signs readily controlled by medication or other treatment such as surgery. Hypoparathyroidism – symptoms and signs readily controlled by medication. Hypothyroidism adequately controlled by replacement therapy.
15	Hypothyroidism where the presence of a disease in another body system prevents adequate replacement therapy. Hyperparathyroidism – persisting mild hypercalcaemia, despite medication. Hypoparathyroidism – symptoms and signs such as intermittent hyper or hypocalcaemia not readily controlled by medication.
30	Hyperparathyroidism – persisting severe hypercalcaemia with serum calcium above 3.0mmol/l, despite medication.

3.2 Adrenal Cortex and Medulla

Where Cushing’s syndrome is present, Table 3.2 below should be used to evaluate impairment from the general effects of hypersecretion of adrenal steroids (for example, myopathy, easy bruising, and obesity).

Using the Combined Values Chart (see Appendix 1), WPI ratings derived from Table 3.2 may be combined with WPI ratings for specific associated secondary impairments (for example, fractures or diabetes mellitus).

Table 3.2 Adrenal Cortex and Medulla

% WPI	Criteria
0	Cushing’s syndrome – surgically corrected by removal of adrenal adenoma or removal of the source of ectopic ACTH secretion. Phaeochromocytoma – benign tumour, surgically removed or removable where the duration of hypertension has not led to the development of permanent cardiovascular disease.
5	Hypoadrenalism – symptoms and signs readily controlled with replacement therapy. Cushing’s syndrome due to moderate doses of glucocorticoids (for example, less than equivalent of 15 mg of prednisolone per day) where glucocorticoids will be required long-term.
10	Cushing’s syndrome – surgically corrected by removal of pituitary adenoma or adrenal carcinoma.
15	Cushing’s syndrome – due to: · bilateral adrenal hyperplasia treated by adrenalectomy; or · large doses of glucocorticoids (for example, equivalent of at least 15 mg of prednisolone per day) where glucocorticoids will be required long-term; or · inadequate removal of source of ectopic ACTH secretion. Phaeochromocytoma – malignant tumour where signs and symptoms of catecholamine excess can be controlled with blocking agents. Hypoadrenalism – recurrent episodes of adrenal crisis during acute illness or in response to significant stress.
70	Phaeochromocytoma – metastatic malignant tumour where signs and symptoms of catecholamine excess cannot be controlled with blocking agents or other treatment.

3.3 Pancreas (Diabetes Mellitus)

Where diabetic retinopathy has led to visual impairment, the visual impairment should be assessed using Chapter 6 – The Visual System (see page 47).

Where diabetes has led to secondary impairment of renal function, that impairment should be assessed using Chapter 10 – The Urinary System (see pages 119).

Using the Combined Values Chart (see Appendix 1), WPI ratings derived under Table 3.1 (see page 36) and Table 3.2 (see page 37) may be combined with WPI ratings from Table 3.3 below.

Microangiopathy may be manifest as retinopathy (background, proliferative, or maculopathy) and/or albuminuria measured with a timed specimen of urine. Where there is an overnight collection, the upper limit of normal is 20 mg/minute. Where a 24 hour specimen is taken, the upper limit of normal is 30mg/day. Albuminuria must be documented in at least 2 out of 3 consecutive urine specimens.

Table 3.3: Pancreas (Diabetes Mellitus)

See notes to Table 3.3 immediately following Table.

% WPI	Type	Therapy	Microvascular Complications
5	Type 2 (NIDDM)	Dietary restrictions with or without oral hypoglycaemic agents give satisfactory control.	Microangiopathy is not present.
10	Type 2 (NIDDM)	Dietary restrictions with or without oral hypoglycaemic agents give satisfactory control.	Microangiopathy and/or significant neuropathy are present.
15	Type 1 (IDDM)	Dietary restrictions and insulin give satisfactory control.	Microangiopathy is not present.
20	Type 1 (IDDM) Type 2 (NIDDM)	Dietary restrictions and insulin give satisfactory control Type 2 (NIDDM) where dietary restrictions & insulin &/or oral hypoglycaemic agents give satisfactory control.	Microangiopathy and/or significant neuropathy are present.
25	Type 1 (IDDM)	Dietary restrictions and insulin do not give satisfactory control and frequent episodes of severe hypoglycaemia requiring the assistance of another person have been documented.	Microangiopathy is not present.
30	Type 1 (IDDM)	Dietary restrictions and insulin do not give satisfactory control and frequent episodes of severe hypoglycaemia requiring the assistance of another person have been documented.	Microangiopathy is present.
40	Type 1 (IDDM)	Dietary restrictions and insulin do not give satisfactory control and frequent episodes of severe hypoglycaemia requiring the assistance of another person have been documented.	Microangiopathy is present as well as significant neuropathy.
50		Symptomatic hypoglycaemia due to metastatic tumour (usually insulinoma), uncontrolled by medication (such as diazoxide).

Notes to Table 3.3

1. For the purposes of Table 3.3, the degree of control is defined by reference to the glycated haemoglobin measurement (HbA1c) where:

· 4%-6% is the non-diabetic range;

· <8% is indicative of satisfactory control for the purposes of this table.

2. ‘Significant neuropathy’ means persistent symptoms of peripheral or autonomic neuropathy which interfere with

quality of life to a considerable degree.

3. ‘NIDDM’ means non-insulin dependent diabetes mellitus.

4. ‘IDDM’ means insulin dependent diabetes mellitus.

3.4 Gonads and Mammary Glands

Impairments resulting from inability to reproduce, and other impairments associated with gonadal dysfunction, are assessed under Chapter 11 – The Reproductive System (see page 123).

Loss of one or both breasts in females should also be assessed using Table 4.3: Bodily Disfigurement (see page 43, Chapter 4 – Disfigurement and Skin Disorders). Using the Combined Values Chart (see Appendix 1), a WPI rating derived from Table 4.3 may be combined with a WPI rating derived from Table 3.4 below.

Table 3.4: Gonads and Mammary Glands

% WPI	Criteria
0	Diminished or absent gonadal hormones in either sex. Abnormally high level of gonadal hormones in either sex.
5	Loss of one or both breasts in male. Loss of whole or part of one breast in female. Gynaecomastia in male where pain interferes with everyday activities – not controlled by medication.
10	Loss of whole or part of both breasts in female.

Chapter 4 –Disfigurement and Skin Disorders

Page no.

4.0 Introduction............................................................................................ 41

4.1 Skin Disorders...................................................................................... 42

4.2 Facial Disfigurement.......................................................................... 43

4.3 Bodily Disfigurement.......................................................................... 43

4.0 Introduction

In conducting an assessment, the assessor must have regard to the Principles of Assessment (see pages 11-14) and the definitions contained in the Glossary (see pages 15-16).

Impairments assessed under Chapter 4 include those caused by secondary conditions accompanying an endocrine system condition. A WPI rating from a table in Chapter 3 – The Endocrine System (see page 35) should be combined with WPI ratings resulting from the secondary conditions assessed under Chapter 4.

Loss of one or both breasts in females should be assessed under both:

· Table 3.4: Gonads and Mammary Glands (see page 39, Chapter 3 – The Endocrine System); and

· Table 4.3: Bodily Disfigurement (see page 43);

and the resulting WPI ratings combined.

In cases where two or three of Tables 4.1, 4.2 and 4.3 apply, WPI ratings from each table can be combined using the Combined Values Chart (see Appendix 1).

WPI ratings awarded under Table 4.2 cannot be combined with WPI ratings arising under section 6.4 –Other Ocular Abnormalities, or section 6.5 – Other Conditions Causing Permanent Deformities Causing up to 10% Impairment of the Whole Person (see page 47, Chapter 6 – The Visual System).

4.1 Skin Disorders

For the purposes of Table 4.1: Skin Disorders:

· ‘intermittent treatment’ means a course of treatment leading to a break, treatment alternately ceasing and beginning again;

· ‘constant treatment’ means treatment that continues on a regular basis without interruption;

· ‘complex treatment’ means treatment that requires regular and close supervision, usually by a dermatologist. Such supervision could involve regular blood tests and relevant regular physical examinations, such as blood pressure measurement. Complex treatments would be expected to have a potential for adverse side effects. Categories of drugs forming a part of, or the whole of, complex treatment would include high doses of systemic corticosteroids, or immunosuppressive medications such as azathioprine, methotrexate and cyclosporin. Phototherapy, photochemotherapy, or photophoresis, would also be considered a complex treatment.

Column 4 in Table 4.1 is referenced to Figure 4-A: Activities of Daily Living, immediately below the table.

Table 4.1: Skin Disorders

% WPI	Signs and Symptoms	Requirement for Treatment	Column 4 Activities of Daily Living Affected
0	Absent.	None, intermittent.	up to 2
5	Absent.	Constant.	up to 2
5	Intermittent.	Intermittent or constant.	up to 2
10	Present on a daily basis for periods aggregating 3 or more months per year, but less than 6 months per year.	Intermittent or constant.	1 to 3
15	Present on a daily basis for period aggregating 6 or more months per year, but less than 9 months per year.	Intermittent or constant.	1 to 3
20	Present on a daily basis for periods aggregating 9 months per year or more.	Intermittent or constant.	1 to 3
25	Present on a daily basis for periods aggregating 9 months per year or more.	Constant.	4 to 5
30	Present on a daily basis for period aggregating 9 months per year or more.	Constant and complex.	6 or more

Figure 4-A: Activities of Daily Living - See Column 4 in Table 4.1

No.	Activities	Examples
1	Self care, personal hygiene.	Bathing, grooming, dressing, eating, eliminating.
2	Communication.	Hearing, speaking, reading, writing, using keyboard.
3	Physical activity.	Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising.
4	Sensory function.	Tactile feeling.
5	Hand functions.	Grasping, holding, pinching, percussive movements, sensory discrimination.
6	Travel.	Driving or travelling as a passenger.
7	Sexual function.	Participating in desired sexual activity.
8	Sleep.	Having a restful sleep pattern.
9	Social and recreational.	Participating in individual or group activities, sports activities, hobbies.

4.2 Facial Disfigurement

Table 4.2: Facial Disfigurement

% WPI	Criteria
0	No structural changes. Normal facial appearance. Hyperpigmentation, depigmentation, redness or telangiectasis occupying less than 10% of facial area (excluding actinic damage). Scarring that does not significantly alter the appearance of the face.
5	Hyperpigmentation, depigmentation, redness or telangiectasis occupying 10% or more of the facial area (excluding actinic damage); or Scars and/or skin grafts occupying less than 5% of facial area that significantly alter the appearance of the face; or Depressed cheek, nasal or frontal bones. Total or partial loss of one pinna.
10	Scars and/or skin grafts occupying 5-15% of facial area that significantly alter the appearance of the face; or Total or partial loss of both pinnas; or Loss of less than 50% of the nose.
15	Scars and/or skin grafts occupying 15-25% of facial area that significantly alter the appearance of the face; or Loss of 50-75% of the nose.
20	Scars and/or skin grafts occupying more than 25% of facial area that significantly alter the appearance of the face; or Loss of more than 75% of the nose.

4.3 Bodily Disfigurement

Table 4.3: Bodily Disfigurement

% WPI	Criteria
0	Normal body appearance. Scars and/or skin grafts occupying less than 10% of body area.
5	Scars and/or skin grafts occupying 11% to 20% of body surface.
10	Scars and/or skin grafts occupying 21% to 40% of body area; or Tissue loss causing noticeable unilateral alteration of body line.
15	Scars and/or skin grafts occupying 41% to 60% of body area.

Federal Register of Legislation - Australian Government

Primary content

Seafarers Rehabilitation and Compensation Act 1992 - Guide to the Assessment of the Degree of Permanent Impairment (Second edition) (30/01/2006)

Second edition

Acknowledgement

Introduction to second edition of the Guide

1. Authority ............................................................................................... iii

4. Whole Person Impairment (WPI) ................................................ v

5. Entitlements under the Seafarers Act ........................................ v

6. Non-economic loss ............................................................................. v

7. Compensation Payable ..................................................................... v

8. Interim and Final Assessments ..................................................... v

9. Increase in Degree of Whole Person Impairment ................ vi

1. Authority

2. Structure of this Guide

4. Whole Person Impairment (WPI)

6. Non-economic loss

9. Increase in Degree of Whole Person Impairment

See section 3 above (Application of this Guide) as to assessments of the degree of permanent impairment made under the first edition of the Guide.

CLAIMS FOR

PERMANENT IMPAIRMENT

Table of Contents

Glossary................................................................................................................. 15

Division 1 Assessment of the Degree of an Employee’s

Permanent Impairment Resulting from an Injury......... 17

Chapter 2 – The Respiratory System..................................... 29

Chapter 3 – The Endocrine System........................................ 35

Chapter 4 – Disfigurement and Skin Disorders................... 41

Chapter 5 – Psychiatric Conditions........................................ 45

Chapter 6 – The Visual System............................................... 47

Chapter 7 – Ear, Nose and Throat Disorders...................... 59

Chapter 8 – The Digestive System.......................................... 65

Chapter 9 – The Musculoskeletal System............................. 73

Chapter 10 – The Urinary System........................................... 119

Chapter 11 – The Reproductive System............................... 123

Chapter 12 – The Neurological System................................. 129

Division 2 Guide to the Assessment of Non-Economic Loss........ 151

Division 3 Calculation of Total Entitlement....................................... 159

Index....................................................................................................................... 161

Appendix 1: Combined Values Chart........................................................... 169

List of Tables and Figures

Chapter 2 – The Respiratory System

Chapter 3 – The Endocrine System

Table 4.3: Bodily Disfigurement.................... 43

Chapter 5 – Psychiatric conditions

Chapter 7 – Ear, Nose and Throat Disorders

Table 7.7: Chewing and Swallowing............. 63

Chapter 8 – The Digestive System

Table 8.1: Upper Digestive Tract:

Chapter 9 – The Musculoskeletal System

Table 9.18: Fractures of the Pelvis................ 117

Chapter 10 – The Urinary System

Table 10.2: Urinary Diversion........................ 120

Table 10.3: Lower Urinary Tract.................... 122

Chapter 11 – The Reproductive System

Table 11.1.1: Male Reproductive Organs –

Penis.............................................. 124

Table 11.1.3: Male Reproductive Organs –

Testes, Epididymes and

Spermatic Cords........................... 125

Table 11.1.4: Male Reproductive Organs – Prostate and Seminal

Vesicles......................................... 125

Chapter 12 – The Neurological System

Table 12.2: Impairment of Memory,

Learning, Abstract Reasoning

and Problem Solving Ability...... 133

Table 12.5.5: The Auditory Nerve (VIII).......... 143

Division 2 – Guide to the Assessment of

Non-Economic Loss

List of references

Principles of Assessment

1. Impairment and Non-Economic Loss ..................................... 11

2. Employability and Incapacity ..................................................... 12

3. Permanent Impairment ................................................................. 12

4. Pre-Existing Conditions and Aggravation ............................ 12

5. The Impairment Tables ................................................................ 12

6. Malignancies and conditions resulting in major

systemic failure................................................................................ 13

7. Percentages of Impairment ......................................................... 13

8. Comparing Assessments under Alternative Tables .......... 13