LETTER TO EDITOR
|Year : 2006 | Volume
| Issue : 3 | Page : 184-186
Neurological legal disability
T Murali, AB Taly, Abhishek Srivastava
National Institute of Mental Health and Neurosciences,Bangalore, India
National Institute of Mental Health and Neurosciences,Bangalore
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Murali T, Taly A B, Srivastava A. Neurological legal disability. Ann Indian Acad Neurol 2006;9:184-6
India is a vast country with variable social, cultural, geographical and economic background. The changing demographic pattern has brought in its wake a number of disability problems in all age groups that requires measures for legislation and guidelines for disability evaluation and benefits.
According to WHO, disability is defined as 'In the context of health experience, a disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being'. Disability can be divided into three periods- (i) Temporary partial disability - is that period in which the affected person is totally unable to work, (ii) Temporary partial disability - is that period when recovery has reached the stage of improvement so that the person may begin some kind of gainful occupation and (iii) Permanent disability - applies to permanent damage or loss of use of some part/parts of the body after the stage of maximum improvement has been reached and the condition is stationary from any medical treatment. Recently WHO has proposed revision of the earlier definitions and gave new terminologies like activity limitation and participation restriction. Activity is the nature and extent of functioning at the level of the person and may be limited in nature, duration and quality. Participation is the nature and extent of a person's involvement in life situation in relationship to impairment of activities, health conditions and contextual factors and may be limited in nature, duration and quality.
National Sample Survey Organization (NSSO) in 1991 reported that 1.9% of the total population of our country is suffering from some form of disability and 0.75 million new cases of disability will be added every year. Global burden of disease study published by WHO reported that the share of neuro-psychiatric disorders would rise to 14.7% by 2020 and although neurological and psychiatric disorders comprise only 1.4% of all deaths, they account for a remarkable 28% of all years of life lived with disability.
Medically, disability is physical impairment and inability to perform physical functions normally. Disability in a neurological illness is not interpretation of the diagnosis/disease per se but the measurement of the clinical manifestations/impairments. Similarly, we have to differentiate between scientific versus legal aspects of disability. Legally, disability is a permanent injury to the body for which the person should or should not be compensated. According to the guidelines of the PWD Act, 1995 a person with more than 40% disability is entitled to avail disability benefits. Ministry of Social Justice and Empowerment had amended section 47 of the PWD Act regarding noninvalidation of the government servant who has been permanently incapacitated on account of mental or physical disability vide order 6/17/2002-SCS/1925 and states that 'No establishment shall dispense with or reduce in rank an employee who acquires a disability during his service and the employee who has acquired disability if is not suitable for the post he was holding, could be shifted to some other post with the same pay scale and service benefits. In case it is not possible to adjust him against any post, he may be kept on supernumerary post until a suitable post is available or he attains the age of superannuation, whichever is earlier. No promotion shall be denied to a person merely on the ground of his disability'.
The Government of India had organized 'Expert group meeting on disability evaluation' in Sept' 1981 with the objective to develop simple norms for evaluation of permanent physical impairment and the guidelines formed were enacted through an order from Government of India, Ministry of Welfare O.M No.4-2/83-HW-III, dated August 6, 1986. In order to review the guidelines for evaluation of various disabilities and the process of certification and to recommend modifications/alterations in view of Persons with Disabilities Act, 1995, government of India, Ministry of Social Justice and Empowerment, vide order no. 16-18/97-NI. I, dated August 28, 1998, set up four committees under the chairmanship of Director General of Health Services- one each in the area of mental retardation, locomotor/orthopaedic, visual and speech and hearing disability. Subsequently, in July 1999 another committee was set up for assessment of multiple disabilities.
In accordance to the recommendations of these expert committees and according to the Persons with Disabilities Act rules, Ministry of Social Justice and Empowerment issued a gazette notification on June1, 2001. According to the notification, guidelines for evaluation of following disabilities and process of certification were outlined (i) visual disability, (ii) locomotor/orthopaedic disability, (iii) speech and hearing disability, (iv) mental retardation and (v) multiple disabilities. Medical Board duly constituted by the central and state governments can only issue disability certificate. The state government can constitute a medical board consisting of at least three members out of which at least one shall be a speacialist in the particular field, as the case may be. The Director General of Health Services, Ministry of Health and Family Welfare will be the final authority, should there arise any controversy/doubt regarding the interpretation of the definitions/classifications/evaluation tests, etc.
Neurological disability was not taken as a separate entity and is grouped under locomotor/orthopaedic disability defined as 'Persons inability to execute distinctive activities associated with moving both himself and the objects, from place to place and such inability resulting from affliction of musculoskeletal and or nervous system'. Locomotor/orthopaedic disability section includes evaluation of permanent physical impairment of the diseases of upper limb, lower limb, trunk/spine, short stature/dwarfism, amputation, congenital deficiencies of the limbs, neurological conditions and cardio-pulmonary diseases.
According to the gazette notification, June 2001 following basic guidelines were outlined for the evaluation of permanent physical impairment in neurological illness:
- Assessment in neurological conditions is not the assessment of disease but the evaluation of its effects, i.e., clinical manifestations.
- These guidelines should only be used for central and upper motor neuron lesions.
- For lower motor neuron lesions, assessment should be done as those done for the evaluation of permanent physical impairment of upper/lower limbs.
- Assessment should be done six months after the onset of the disease. However the exact time period is to be decided by the physician evaluating the case and has to recommend the review of certificate as required.
- Total impairment should not exceed 100%.
- In mixed cases the highest score will be taken into consideration. The lower score should be added telescopically to it using the combining formula- a+b (90-a)/90.
- Additional 4% rating to be given for dominant upper extremity.
- Additional weightage of 10% can be given for loss of sensation in each extremity.
Fallacies of the current system
- Evaluation of the disability in lower motor neuron lesions is lengthy and takes a lot of time.
- Other important parameters in upper motor lesions like cognitive deficits, swallowing dysfunction, spasticity, dystonia, rigidity, tremors, bowel incontinence and so on are not addressed.
Disadvantages with proposed system
- Maximum disability for both lower limbs weakness will be 40% only, which is considerably less than the existing system.
- Similarly, maximum disability for both upper limb weakness will be 45% only which is less than the existing system.
- Guidelines are not given for involvement of spinal pathology, which are otherwise available in the existing system.
- Evaluation of dis ability in involvement of other cranial nerve is not outlined.
- Maximum disability in speech deficits and ataxia is restricted to 40% only.
- Sphincter involvement is given maximum 25% disability only.
- Although, the issue of cognitive deficits is addressed but Folstein mini mental status examination in not enough for certifying disability and a complete neuropsychological testing is required with particular lobe involvements and deficits.
- For epilepsy, guidelines are available in the existing system depending upon the frequency of the convulsions while on adequate medications.
- 25% disability to be given for each grade of spasticity as per Ashworth grading, is remarkably high as compared to weakness of both upper/lower limbs getting only 40-45% disability.
- Separate guidelines are given for evaluation of disability in Parkinson's disease as per modified Hoen and Yahr staging. Similarly, staging is available for other neurological illnesses and they should also have been considered.