The Special Rules Check/Terminal Illness Check
When a claimant contacts JCP indicating that they wish to apply for ESA/UC they may state that they are terminally ill.
Existing benefit claimants may also inform JCP that they have become terminally ill.
The definition of terminal illness in the Welfare Reform Act legislation is: “That he is suffering from a progressive disease and his death in consequence of that disease can reasonably be expected within 6 months.” When a claimant is considered to be potentially terminally ill, a referral will be sent to the Health Advisory Assessment Centre for advice.
The Health Care Professional will access the case using the Medical Services Referral System (MSRS) and follow a process which has been agreed by the customer (DWP). The advice provided to the Decision Maker will be generated using the LiMA application. In summary, a check takes place to find out whether a DS1500 has been submitted by the claimant.
If the DS1500 confirms the claimant is terminally ill (TI), this advice is submitted to the Decision Maker ((DWP) on form ESA85A or UC85A . If no DS1500 has been submitted with the ESA/UC claim, a check takes place to see if there has been a recent application for DLA, AA or PIP under the special rules.
If terminal illness was confirmed at that stage, the claimant can be considered as terminally ill for the purposes of ESA. If no DS1500 is available and there is no confirmation of TI through a previous DLA/AA or PIP application, the HCP will seek further medical evidence from a practitioner involved in the medical care of the claimant.
It should be noted that a claimant who is TI will be entitled to the higher rate of benefit while still in the 13 week assessment phase and from day 1 of the health related UC claim. The HCP will review the evidence obtained and provide advice on the body of evidence, indicating whether or not it is likely that the claimant is suffering a terminal illness as defined in the legislation.
If the claimant is considered to be TI, the HCP will submit this advice to the Decision Maker. If the advice is accepted, the claimant will be considered to meet the criteria of being considered to have Limited Capability for both Work and Work Related Activity (LCW/LCWRA). N.B meeting criteria for having LCW and LCWRA is also known as Support Group in ESA) and there will be no requirement for them to be further assessed or participate in any form of work-related activity.
If the claimant is not considered to be suffering from a terminal illness, there may be sufficient evidence that they satisfy one of the other LCW/LCWRA (Support Group) criteria or one of the criteria for ‘Treat as LCW’. If not, the claim will continue to be processed in the normal manner.
This LCWRA criterion should be applied where claimants are:
likely to receive treatment for cancer within the next 6 months
receiving treatment for cancer
recovering from treatment for cancer Treatment in this specific situation is defined as chemotherapy (irrespective of route) and / or radiotherapy.
It does not include surgical treatment in isolation i.e. without chemotherapy and / or radiotherapy. It is DWP policy intent that it is the debilitating effects of such treatment that will determine entitlement, but the presumption would be that an individual undergoing the above treatments for cancer should be treated as having LCW/LCWRA. Consideration should include the overall effects arising from the interactions of the cancer, cancer treatment and any co-morbid conditions.
It is likely for the vast majority of individuals undergoing the above treatments for cancer, it would not be reasonable that they should undertake work or work-related activity. The term chemotherapy traditionally has been used to describe cytotoxic drugs. However, with modern developments in treatment it can also be used to describe biological therapies (such as monoclonal antibodies and cancer growth inhibitors) and hormonal therapies.
For radiotherapy, both external and internal types are eligible treatments. The test for inclusion is whether the treatment is likely to have debilitating effects. Entitlement for LCW/LCWRA then depends on both the likely debilitating effects and treatment conditions being met.
©A1 ESA/DLA/PIP Benefits Help and Support (UK only)