Appendix 2: How people qualify for a sickness benefit or invalid's benefit

Sickness benefit

The sickness benefit is a weekly payment that helps people who are temporarily off work or working at a reduced level because of sickness, an injury, pregnancy, or a disability.

To qualify for a sickness benefit, the person must:

• be 18 years of age or older, or 16 to 17 years of age and living with a partner and children whom they support;
• be in a job and have had to stop working or reduce their hours and income because of sickness, injury, pregnancy, or disability; or unemployed or working part-time and find it hard to look for work or do full-time work because of sickness, injury, pregnancy, or disability;
• be a New Zealand citizen or permanent resident who normally lives here;
• have lived in New Zealand for at least two years at any one time since becoming a New Zealand citizen or permanent resident (unless they are a refugee); and
• have an income under a certain level (this includes any partner's income).

To support their application for a sickness benefit, the person is required to provide a medical certificate. The certificate must include:

• a diagnosis;
• the effect of the condition on the person's ability to work;
• the likely duration of the effect of the condition; and
• any other information that the Chief Executive of the Ministry of Social Development requires.

The medical certificate must be signed by a registered:

• medical practitioner;
• dentist (where appropriate); or
• midwife (for pregnancy, childbirth, or any related conditions).

Before granting a sickness benefit, Work and Income staff need to be satisfied that the person is:

• limited in their capacity to seek, undertake, or be available for full-time employment because of sickness, an injury, pregnancy, or a disability; or
• losing earnings through sickness, an injury, pregnancy, or a disability because they are not working or they are working at a reduced level.

This assessment is usually based on the information provided in the medical certificate. However, in some circumstances a person may be referred to a designated doctor for further assessment – for example, when the medical practitioner indicates on the certificate that a second opinion is appropriate.

It is expected that most sickness beneficiaries' ability to work will improve, allowing them to progress towards employment. When completing the medical certificate, the medical practitioner will advise when the person's medical entitlement to a benefit should be reassessed.

Generally, the medical practitioner's recommendation is accepted. However, if there is inconsistent information on the medical certificate, or the "recommended incapacity duration" held in SWIFTT suggests that a further check on the duration recommended by the medical practitioner is needed, the application is referred to the regional health advisor or the regional disability advisor for advice. The regional health advisor or the regional disability advisor may recommend that the applicant be referred to a designated doctor for further assessment.

Work and Income requires beneficiaries to have their medical eligibility to the sickness benefit reviewed regularly. The first medical certificate is accepted for only up to four weeks (even if the certificate states that the medical condition will last longer). The beneficiary has to go back to their medical practitioner, dentist, or midwife to get another medical certificate if they are unable to work and need the sickness benefit for more than four weeks.

The second or subsequent medical certificates can cover a period of up to 13 weeks.

Invalid's benefit

To qualify for the invalid's benefit, the person must:

• be 16 years of age or over;
• be a New Zealand citizen or permanent resident;
• have lived continuously in New Zealand for two years or more at any one time since becoming a New Zealand citizen or permanent resident;
• be ordinarily resident in New Zealand when they first apply for the benefit; and
• be both permanently and severely restricted in their capacity for work because of sickness, injury, or disability, or be totally blind.

"Permanent" means the sickness, injury, or disability is expected to continue for at least two years or that a person has been diagnosed with a terminal illness and is not expected to live more than two years.

"Severely" means that the person cannot work 15 hours or more each week in open employment (that is, employment other than sheltered⁸ employment).

When applying for an invalid's benefit, a person can provide either a medical certificate from their medical practitioner or suitable existing medical or disability assessments.

Work and Income staff can consider granting an invalid's benefit solely from a medical certificate completed by the applicant's own medical practitioner if they are satisfied that the information confirms that the person meets the medical criteria for an invalid's benefit. However, Work and Income staff are encouraged to use all information available because one form of medical or disability information may not be enough to decide entitlement to an invalid's benefit. This additional information includes:

• the existing assessment(s);
• information contained in Work and Income records (for example, information on disability allowance, Child Disability Allowance); and
• previous Work and Income certificates.

Before granting an invalid's benefit, Work and Income staff have to be satisfied from the information available that the applicant is:

• both permanently and severely restricted in their capacity for work because of sickness, or injury or disability from an accident, or a congenital condition; or
• totally blind.

Work and Income staff can refer the applicant to a designated doctor if the applicant is unable to, or chooses not to provide existing reports, assessments or a medical certificate, and Work and Income records do not hold sufficient information to decide entitlement to an invalid's benefit. An applicant may also be referred to a designated doctor for further assessment when the medical practitioner indicates on the medical certificate that a second opinion is appropriate.

Also, if the benefit eligibility is unclear from the information provided, Work and Income staff can refer the application to the regional health advisor or the regional disability advisor for advice. Some regions require their staff to refer all new applications for, and reassessments of, invalids' benefits to the regional health advisor or regional disability advisor for a recommendation before the benefit is granted.

An applicant may also be referred for a specialist assessment. This usually occurs when the applicant's medical practitioner advises on the medical certificate that they are not best placed to provide medical information. This could be because the applicant:

• is under the care of a specialist;
• has a complex condition; or
• has an unclear outcome from treatment.

The medical practitioner can recommend that a specialised assessment is required to clarify the diagnosis and help determine the severity and permanency of the applicant's condition.

In these circumstances, the regional health advisor or the regional disability advisor determines whether a specialised assessment, and the type of assessment, is required.

Work and Income staff need to decide, when they grant an invalid's benefit, whether the person's eligibility should be reassessed.

For those beneficiaries where the impact of their ill health or disability on their ability to work, is unlikely to improve, their eligibility for a benefit will never require reassessment.

For other beneficiaries, the impact of their permanent medical conditions or disabilities may change over time and their ability to work may improve. Reassessment for these beneficiaries is done after two or five years.

The medical practitioner or clinical psychologist will indicate on the medical certificate whether reassessment is required. This is generally accepted by Work and Income staff unless there is inconsistent information on the medical certificate – for example, where the diagnosis and impact on the beneficiary's ability to work is described as severe and permanent with no likelihood of any form of employment for the foreseeable future, yet the medical practitioner has indicated medical reassessment is required in two years. In these circumstances, Work and Income staff will refer the application to the regional health advisor or regional disability advisor for advice.

1: Before September 2007, the Programme was supporting people receiving other types of benefits, such as the unemployment benefit.

2: The READ codes replaced much broader diagnostic categories and are designed to provide case managers with a more detailed and accurate description of the beneficiary's ability to work.

3: Sickness Benefit, Invalid's Benefit and Independent Youth Benefit (Sickness): Guide for Health Practitioners (2007), Ministry of Social Development, Wellington.

4: Health Practitioner Handbook: Work and Income (2008), Ministry of Social Development, Wellington.

5: A designated doctor is a health professional to whom a Work and Income case manager or regional health or disability advisor may refer a person for a second medical opinion to establish or review whether they meet the medical requirements for a sickness or invalid's benefit. Designated doctors are usually vocationally registered medical practitioners with a minimum of five years' experience in New Zealand and a demonstrated ability to work constructively with Work and Income staff.

6: These initiatives include comprehensive case management, better processes, support and services for people with ill health and disabilities, and better processes for establishing benefit eligibility.

7: The Joint Ministers were the Minister of Finance, the Minister of Health, the Minister for Disability Issues, and the Minister for Social Development and Employment.

8: A person is considered to be in sheltered employment if the employment conditions need to be specifically designed to cater for their needs. This applies to full-time employment, self-employment, supported employment, or contract work.