Case Studies » Sickness » Illness Benefit - Case from 2016 Annual Report (ref: 2016/10)

2016/10 Illness Benefit

Oral hearing

Question at issue: Eligibility (medical)

Background: The appellant, in his 40s, had a certified incapacity of chronic back pain (lumbar spine) and had been in receipt of Illness Benefit for some months. Prior to the onset of incapacity, he had been working in construction. Following two medical examinations, his claim was disallowed on grounds that he was no longer deemed to be incapable of work and not entitled to Illness Benefit under the provisions of the governing legislation (Section 40 (3)(a) of the Social Welfare Consolidation Act 2005). In support of his appeal, the appellant submitted further medical evidence, including a letter from his G.P., stating that his life had changed completely after back surgery and that he experienced acute exacerbation episodes, which could last for up to a week.

Oral hearing: The appellant was accompanied by his wife. He reported that he had undergone discectomy surgery in 2014 but that it had been unsuccessful and he was experiencing continuous back pain. He said that while there had been a reduction from the extreme level of pain which he had prior to surgery, he continued to experience an ongoing high level of discomfort.

The appellant reported that the pain tends to be more extreme in the mornings, and that he struggles to get out of bed on occasion and requires his wife’s assistance. He said that he also needs help to put on his shoes and socks, he cannot do any housework or lift anything heavy, he experiences discomfort in standing or sitting for any length of time, and his sleep is disturbed. He confirmed that he had attended physiotherapy and was currently following a recommended exercise programme at home and that he has been referred to a consultant in anesthetics and pain management and hopes to be given pain relief injections. He advised that the constant feeling of pain and discomfort, and the restrictions imposed on his lifestyle, have caused him to become depressed and that he has been prescribed anti-depressant medication. He went on to say that the dose had been increased recently and that his G.P. had suggested that he see a counsellor.

The Appeals Officer outlined details of the reports completed by the Medical Assessors for the Department of Social Protection and invited the appellant to comment. He noted that the first Medical Assessor reported that there were no signs of nerve root impingement or substantial restriction and that, in his opinion, the appellant was capable of light duties with appropriate back care. The second Medical Assessor had observed that a clinical examination had not revealed acute nerve root irritation and he had opined that the appellant was capable of light/semi-sedentary work.

In response, the appellant said that both assessments had been held in the afternoon when he was not experiencing the same degree of stiffness and restriction as he feels in the morning. In addition, he asserted that neither assessment had been conducted during periods when he was experiencing pain most acutely and he advised that he has frequent acute episodes.

Consideration: The Appeals Officer considered that the opinions of the Medical Assessors had been qualified; both had deemed the appellant capable (at best) of light, sedentary type work. He noted that there was no indication that the appellant’s mental health had been assessed. He noted also that his G.P. had provided a comprehensive letter of support and additional medical evidence which served to establish that her opinion that the appellant was not capable of work for the foreseeable future was a strongly reasoned one. He concluded that this had been reinforced by the appellant’s testimony at oral hearing.

Outcome: Appeal allowed.