The Date of Clinical Onset Is Not the Date of the Scan

What clinical onset means

Clinical onset is the point at which the disease or injury was first present or first manifested. It is the time when relevant symptoms, signs or other evidence of the condition were first present, such that an appropriate medical practitioner can say the condition had manifested at that time.

CLIK 3.4.4 states the position plainly: clinical onset is not necessarily the date the condition was diagnosed. Clinical onset and diagnosis are two distinct concepts. They may coincide in some cases — an acute fracture, a myocardial infarction, or a condition whose SOP requires a defined diagnostic threshold — but coincidence is the exception rather than the rule.

CLIK 3.4.4.1 describes onset as a point along a spectrum, occurring somewhere between the injury or exposure and the making of the claim. It directs that the evidence be examined to identify the earliest point at which it can be said the disease was present, and that the earliest date of onset supported by the evidence be adopted.

The relevant authorities

Re Robertson and Repatriation Commission [1998] AATA 127 — cited directly in CLIK 3.4.4 — identifies clinical onset as occurring when either:

the person becomes aware of some feature or symptom that enables a doctor to say the disease was present at that time; or
a finding is made on investigation that indicates to a doctor that the disease was present at that time.

The two limbs are alternatives. The second limb does not displace the first. Where symptoms preceded the investigation, the first limb fixes the earlier date.

Repatriation Commission v Cornelius [2002] FCA 750 established that what is required is material pointing to signs and symptoms of the injury or disease sufficient to enable a medical practitioner to say the condition was present at a particular time. This principle was endorsed by the Full Federal Court in Lees v Repatriation Commission [2002] FCAFC 398. See also Repatriation Commission v Gosewinckel [1999] FCA 313.

The consistent thread through these decisions is that onset is fixed by the presence of the pathology, evidenced by symptoms and signs, and not by the date on which the pathology was first captured on a film or confirmed by a report.

Why the imaging date is the wrong date

An imaging study records a state of affairs that already exists. Degenerative change visible on a film in 2019 did not come into existence on the day of the scan. In most cases it will have been developing, and producing symptoms, for years beforehand. Treating the scan date as the onset date confuses the date of proof with the date of presence.

This is not merely a logical point; the Department’s own medical guidance says so. The CLIK Medical Research Library commentary on Cervical Spondylosis (N003) states that clinical onset is likely to predate the first imaging evidence of degenerative change, and that fixing onset is a matter of medical judgement based on the associated symptoms.

The practical consequence of getting this wrong is significant. SOP factors are almost always framed by reference to a period before clinical onset — for example, an injury within a specified number of years before clinical onset, or a period of cumulative exposure before clinical onset. Pushing onset forward to the imaging date artificially lengthens the gap between service and onset, and can defeat a factor that is in fact satisfied on the evidence.

A note on Boys

Boys v Repatriation Commission (Federal Court, March 2022) is sometimes advanced for the proposition that onset for cervical spondylosis is the date of the X-ray demonstrating degenerative change. That decision turned on the particular two-limbed definition of cervical spondylosis in the applicable SOP (clinical manifestations and imaging evidence of degenerative change) and on the way the argument was put in that case. It is a single-judge decision and it sits uneasily with Cornelius, Lees and Robertson, and with the Department’s published policy.

It should not be read as a general rule that imaging dates fix onset. Where a SOP defines the condition by reference to a diagnostic threshold, the delegate must consider when that threshold was first met on the evidence — which may well be earlier than the date on which it was first documented. Where a SOP contains no such threshold, Boys has no application at all.

The approach a delegate should take

Identify whether the applicable SOP contains a condition-specific definition of clinical onset or a diagnostic threshold. Most do not.
Where there is no threshold, ask when the symptoms and signs of the condition were first present, not when they were first investigated or labelled.
Read the service and civilian medical records for the earliest complaint consistent with the diagnosed pathology — bearing in mind that non-specific symptoms (for example, isolated neck pain) require a pattern consistent with the condition rather than a single entry.
Give weight to a treating doctor’s or specialist’s opinion that onset predated diagnosis. CLIK 3.4.4.1 provides that a treating doctor defining an earlier onset prior to diagnosis can generally be accepted.
Where the diagnosis falls comfortably within the SOP timeframe, the simplified approach in CLIK 3.4.4.1 permits reliance on the diagnosis date provided the decision records that onset occurred prior to that date. That approach is not available where the diagnosis date falls outside the SOP timeframe, where the evidence is unclear or conflicting, where a diagnostic threshold applies, or where a treating doctor has nominated a specific onset date.
Where the evidence is genuinely uncertain, obtain clarification from the treating practitioner or a Medical Adviser before fixing a date. Do not default to the imaging date because it is the most easily documented.
Record the reasoning for the onset date adopted, and the evidence relied on, in the decision.

In summary

The date of an X-ray, CT or MRI is the date the condition was demonstrated. It is not, without more, the date the condition began. Adopting the imaging date as the date of clinical onset, absent a SOP requirement to do so, misapplies CLIK 3.4.4 and the principles in Cornelius, Lees and Robertson — and risks the rejection of a claim that is in fact made out.

What this means if you are the veteran

If your claim has been refused on the basis that the condition only “began” on the date of a scan, that is a reviewable error, and it is one that turns on the medical record rather than on argument. The earliest consistent complaint in your service and civilian records is usually the answer — and it is usually already written down, years before anyone ordered the imaging.

Finding it is what a chart review does: it reads every page of the record and identifies the earliest entry consistent with the diagnosed pathology, so that onset is argued from the evidence rather than from the most convenient date. See also why there is no time limit on making a DVA claim — the periods in a SOP measure backwards from clinical onset, not forwards from the date you lodged.

Talk to us

Call 0429 146 039 or email reception@vhc.org.au — Veterans Health Centre, Ipswich, Queensland.

Sources

CLIK, MRCA Policy Manual 3.4.4 — Establishing the clinical onset and/or worsening
CLIK, MRCA Policy Manual 3.4.4.1 — Onset Considerations
CLIK, Medical Research Library — Cervical Spondylosis N003
Re Robertson and Repatriation Commission [1998] AATA 127
Repatriation Commission v Cornelius [2002] FCA 750
Lees v Repatriation Commission [2002] FCAFC 398
Repatriation Commission v Gosewinckel [1999] FCA 313
Boys v Repatriation Commission (FCA, March 2022)