Secretary of State for Work and Pensions v Whalley

The Court of Appeal considered whether a previous adverse finding by an Adjudicating Medical Authority (AMA) that a claimant did not suffer from a prescribed disease is final and therefore binding on a later decision-maker determining entitlement to reduced earnings allowance (REA) for the same disease. The court interpreted section 60 of the Social Security Administration Act 1992 as giving finality to determinations on whether a person is suffering from a prescribed disease (the diagnosis question), whether that determination arises in a disablement benefit (DB) claim or an REA claim. The court held that a tribunal cannot later fix a date of onset of the disease earlier than a date in respect of which it has already been finally determined that the claimant did not suffer from the disease. Regulations 5 and 6 of the Social Security (Industrial Injuries) (Prescribed Diseases) Regulations 1985 were relied on to show how date of onset is determined for the purposes of DB and how that date may be treated for subsequent claims. The court also rejected the Social Security Commissioner’s conclusion that REA could be obtained without a claim for DB, holding that entitlement to REA is dependent on the DB assessment framework.

Background and procedural history:

• The appellant Secretary of State appealed from a decision of a Social Security Commissioner. Earlier, an AMA in 1991 had decided that the respondent, Mr Whalley, was not suffering from the prescribed disease Vibration White Finger (PD A11) and had not suffered from it since 1985. That AMA decision was not appealed. In 1998 a Medical Appeal Tribunal reached an inconsistent conclusion on a subsequent DB claim. The Social Security Commissioner concluded that the earlier AMA diagnosis was not binding for a later REA claim on the basis of section 60(2) of the Social Security Administration Act 1992 and that REA could be pursued without a DB claim.
• The appeal to this court raised whether the diagnosis in the first DB decision was final and binding on a later decision-maker considering REA and whether REA could be obtained without a DB claim.

Nature of the applications and issues:

1. The Secretary of State sought a declaration that the AMA’s 1991 finding was final and that a later tribunal could not specify an earlier date of onset for the same disease for REA purposes.
2. The primary legal issue was the proper construction and effect of section 60 of the Social Security Administration Act 1992 read with the regulations determining date of onset (Regulations 5 and 6 of the 1985 Regulations) and the relationship between disablement benefit and reduced earnings allowance under the Social Security Contributions and Benefits Act 1992 and its schedules.

Court’s reasoning:

• The court analysed the statutory scheme distinguishing diagnosis questions (whether the claimant suffers from a prescribed disease) from disablement questions (extent and period of loss of faculty) and how date of onset is determined for a DB claim under reg.6 of the 1985 Regulations.
• The court concluded that Parliament intended finality for determinations on whether a person is suffering from the prescribed disease: such a diagnosis, once finally determined, is binding for subsequent determinations, whether they arise in the context of DB or REA. Section 60(1) gives finality and section 60(2) does not operate to make a prior diagnosis non-conclusive for a later REA decision in the way the Commissioner had held.
• The court found no logical or policy basis for distinguishing repeated claims for the same benefit from consecutive claims for different benefits where both depend on the same diagnosis question.

Outcome: The Court allowed the appeal, declared the AMA’s earlier finding final and binding for both claims, and concluded that the date of onset could not be fixed earlier than the date of the AMA decision; given the identified dates, the respondent could not recover REA.

This is an appeal allowed. The Court of Appeal held that under section 60 of the Social Security Administration Act 1992 a prior final determination that a claimant did not suffer from a prescribed disease is final and binding on later decision‑makers considering entitlement to reduced earnings allowance for the same disease. The court rejected the Social Security Commissioner’s distinction between different benefits, held that date of onset determined for a DB claim binds subsequent claims, and accepted that entitlement to REA is dependent on the DB assessment framework. On the facts the AMA’s 1991 finding is final and the respondent cannot establish an earlier date of onset for REA purposes; consequently REA is not payable.

Appeal from a decision of a Social Security Commissioner (Mr David Williams) concerning determinations on industrial injuries benefit and reduced earnings allowance; matter brought to the Court of Appeal as A1/2002/0987 & 0987(A), reported as [2003] EWCA Civ 166. Earlier administrative decisions included an Adjudicating Medical Authority decision (6 September 1991) and a Medical Appeal Tribunal decision (1998).