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EPN 507 - Scheme Medical Adviser (SMA) Services – changes to the appeal procedures

Audience

  • Civil Service and New Fair Deal employers – particularly individuals responsible for making referrals to the Scheme Medical Adviser (SMA)

Actions

  • To note the procedure changes for appeal cases where the original decision was made by Health Assured

Timing

  • Immediate

Detail

1. In EPN487 (25 January 2017) we announced that the Scheme Medical Adviser was changing from Health Assured (HA) to Health Management Limited (HML) with effect from 1 July 2017.

2. During the transition project, Cabinet Office identified a number of technical issues with HA’s systems which in addition to data protection requirements, has prevented the transfer of historic data from HA to HML. This has affected all cases closed by HA prior to the transfer to HML on 30 June 2017. 

This EPN contains important actions and information for employers that are required as a result.

Ill-Health Retirement - appeal against a decision by HA

3. If an employee wishes to appeal a decision made by HA, they should complete the appeal form and submit it to HML with copies of the following documents:

  • All previous outcome reports from the Scheme Medical Adviser. (Please note that all the reports must be provided not simply the report that has led to the appeal request);
  • Any previous GP and/or specialist reports listed in the outcome reports from the Scheme Medical Adviser;
  • Any Occupational Health reports you as the employer have received (usually included in the Medical In Confidence pack);
  • Any Independent Medical Assessment reports (if held by the employee).

4. As an Employer, you would not normally have copies of all the medical reports listed above.

If the employee has copies of reports which they do not wish you to see, they can send these directly to HML with a covering letter.

You  should note on the appeal form that your employee is sending a copy of a report to HML directly and you should provide your employee with a covering letter using the attached template. 

Alternatively, your employee can provide the report to you in a sealed envelope, which you can forward to HML.

5. HML will arrange for a clinician to review the evidence and will provide an outcome report where possible. If the clinician requires additional information before they can issue a report, then HML will request it from you, your employee or the medical specialist as appropriate.

6. Details of the appeal process can be found using this link:

Medical Reviews and Appeals Guide

Injury Benefit Scheme – appeal against HA decision

7. If an employee wishes to appeal against an Injury Benefit assessment, they should send an appeal to the scheme administrator in the usual way. The administrator  will forward the relevant items to HML but may not hold all the medical reports that are needed by HML. Therefore, the employee should send copies of the following reports to HML with a covering letter using the attached template:

  • Any previous GP and/or specialist reports
  • Independent Medical Assessment reports

If your employee advises you that they are sending a copy of a report directly to HML, you should note this on the appeal form accordingly.

8. HML will arrange for a clinician to review the evidence and will provide an outcome report where possible. If the clinician requires additional information before they can issue a report, then HML will request it from the scheme administrator, you, the employee or the medical specialist as appropriate.

9. Details of the appeal process can be found using this link:

Medical Reviews and Appeals Guide

Complaints about HA’s service

HML is unable to comment on the service an employee received from HA. If your employee feels that HA’s service has affected the decision made on their application, they can use the appeal process. There is guidance available on the process and the information you will need to provide using this link:

Medical Reviews and Appeals Guide

10. If an appeal had already been made to HA, then the case will have been transferred to HML and confirmation of the outcome will be provided in due course, but please read the above guidance for completeness.

11. If the employee has exhausted the appeals process, or their concern isn’t about the decision that was made, then they can make a complaint under the pension scheme’s internal dispute resolution procedure. Information on how to make a complaint can be found using this link:

IDR FAQs

Other issues subject to a further EPN

  • Report on the completion of the National Cyber Security Council (NCSC) data assurance process

Other Information

If you require further assistance on the content of this EPN please contact SMAProject@cabinetoffice.gov.uk

If you have a question about the distribution of EPNs contact employerpensionnotice@cabinetoffice.gov.uk

You can find electronic copies of the Employer Pension Guide, all current EPNs and forms on our Website: www.civilservicepensionscheme.org.uk

This notice is for employers and should not be issued to scheme members.

If members have a question about their pension they can find information on this Website or by contacting MyCSP.