1.1  For the purpose of this Part, any reference to motor vehicle is that defined in Part 1 section 4 of these Rules.

2.1 An application to become a participant in the Scheme is made by, or on behalf of the eligible person, or by the insurer or the nominal defendant. The application must demonstrate that:

2.1.1 the person sustained a bodily injury; and

2.1.2 the injury was caused by or arose out of the use of a motor vehicle; and

2.1.3 the relevant motor vehicle accident occurred in South Australia; and

2.1.4 the injury meets the criteria set out in these Rules.

3.1 Eligibility for interim and lifetime participation is limited to people injured in a motor vehicle accident who meet one or more of the following injury criteria at the time that the application is made.

3.2 An appropriately qualified medical specialist must certify that the eligible person meets the following injury criteria.

Criteria for spinal cord injury

3.3 The criteria for spinal cord injury (SCI) are:

3.3.1 Permanent neurological deficit as evidenced by an ASIA Impairment Scale score of A to D conducted as part of an assessment using ISNCSCI; and/or

3.3.2 Residual significant impact on the function of the autonomic nervous system (with particular reference to resultant bladder, bowel, infertility), as evidenced by a 0 score in any of the elements assessed by an appropriately qualified medical practitioner using the ISAFSCI.

3.3.3 The most recent assessment will be considered by the LSA, where there is more than one assessment.

Criteria for brain injury

3.4 The criteria for brain injury are:

3.4.1 For adults and children over eight, a traumatic brain injury with:

a.a recorded Post-Traumatic Amnesia (PTA) of seven days or more measured using the Westmead PTA Scale or a similar clinically accepted, validated scale for PTA as Gazetted by the LSA; and/or

b.a significant brain imaging abnormality;
and a score of five or less on any item in the FIM™ due to the brain injury.

3.4.2 For children aged three to eight years, a traumatic brain injury with:

a.a Glasgow Coma Scale (GCS) of less than nine (assessed post resuscitation or on admission to Accident and Emergency) and/or PTA of seven days or more, measured using the Westmead PTA Scale or a similar clinically accepted, validated scale for PTA; and/or

b.a significant brain imaging abnormality;
and a score two less than the age norm on any item on the WeeFIM® due to the brain injury.

3.4.3 For children under three years of age, a medical certificate from a paediatric rehabilitation physician or specialist that states the child will probably have permanent impairment due to the brain injury resulting in a significant adverse impact on their normal development.

Criteria for amputations

3.5 The criteria for amputations are:

3.5.1 The injury resulting in amputation or the equivalent impairment, is of the following types:

3.5.1.1 Limb amputation:

a. from the upper limb proximal to the first metacarpophalangeal joint of the thumb and the index finger; or

b. of the lower limb through or above the ankle.
or

3.5.1.2 A brachial plexus avulsion or rupture with an impairment equivalent to an eligible upper limb amputation.

Criteria for burns

3.6 The criteria for burns (as evidenced by a burn impact of 50 points or more on the Greenwood Scale or similar clinically accepted assessment) are:

3.6.1 full thickness burns to at least 40 per cent of the body or in the case of children aged 16 and under, 30 per cent of the body; or

3.6.2 permanent inhalation burns causing long term significant respiratory impairment; or

3.6.3 full thickness burns to the hands, face or genital area.

3.6.4 For Lifetime Participation the criteria in 3.6.1 must be fulfilled and

3.6.4.1 if over eight years of age at the time of assessment, a score of five or less on any item in the FIM™ or WeeFIM® due to burns; or

3.6.4.2 if aged from three to eight years at the time of assessment, a score two less than the age norm on any item on the WeeFIM® due to burns; or

3.6.4.3 for children under three years of age, a medical certificate from a paediatric rehabilitation physician or a specialist that states the child will probably have permanent impairment due to the burns resulting in a significant adverse impact on their normal development.

Criteria for permanent blindness

3.7 The criteria for blindness are:

3.7.1 Permanent legal blindness as demonstrated by:

a. Visual acuity on the Snellen Scale after correction by suitable lenses is less than 6/60 in both eyes; or

b. Field of vision is constricted to 10 degrees or less of arc around central fixation in the better eye irrespective of corrected visual acuity (equivalent to 1/100 white test object); or

c. A combination of visual defects resulting in the same degree of visual loss as that occurring in (a) or (b) above.

4.1 An application to become a participant will be considered as soon as it is clinically apparent that the person has an eligible injury. However, applications must be made within three years from the date of the relevant motor vehicle accident (section 25(7) of the Act) using the LSA’s form (as updated from time to time and published on its website).

4.2 In exceptional circumstances, the LSA may extend the time by two years.

4.3 When making an application the LSA requires the applicant to provide it with authorisation to obtain information and documents relevant to the injury, motor vehicle accident and/or motor vehicle.

4.4 The Application Form must be signed and all required information attached. If the form does not contain the information necessary for the LSA to make its decision about eligibility, the applicant may be requested to provide the required information.

4.5 Where the insurer/nominal defendant is the applicant, the insurer/nominal defendant shall pay for and/or provide the medical assessment reports required to determine eligibility.

4.6 An applicant must comply with any reasonable request by the LSA to supply specified additional information or provide authorisation for the LSA to obtain specified additional information. This could be in circumstances where the LSA cannot make a decision about eligibility without this information. This information could include, but is not limited to:

4.6.1 the South Australia Compulsory Third Party (CTP) Injury Claim Form (if it has been completed) or other personal injury claim forms;

4.6.2 ambulance or air ambulance/retrieval records;

4.6.3 hospital records;

4.6.4 treating doctor’s reports;

4.6.5 past medical, employment or school records;

4.6.6 records held by departments, agencies or instrumentalities of the Commonwealth, the State or another State, administering laws about health, police, transport, taxation or social welfare;

4.6.7 records held by insurance companies including RTWSA; or

4.6.8 police reports.

5.1 The FIM™ or WeeFIM® assessment must be conducted within two months (before or after) of the date of the initial completed application to the Scheme. If more than one FIM™ or WeeFIM® assessment has been conducted, then the most recent assessment must be used.

5.2 Prior to approving eligibility, the LSA may require that a FIM™ or WeeFIM® assessment is conducted by an appropriately qualified person.

6.1  The LSA may require that the consideration of an application for eligibility be deferred until such time as the injury is sufficiently stable. In such cases the LSA will inform the applicant in writing.

7.1 The LSA will acknowledge all applications in writing within 14 days of receipt.

7.2 The LSA will make its determination as soon as practicable, taking into account:

7.2.1 the information on the Application Form;

7.2.2 any information attached to the Application Form;

7.2.3 any additional information that the LSA may request in order to make its determination.

7.3 The applicant will receive the LSA’s determination in writing, including reasons for the decision.

7.4 If the LSA rejects an application for participation in the Scheme, the LSA will provide the applicant with information about the LSA’s process for resolving disputes.

8.1 Subject to the other provisions of this Rule, a participant should not remain an interim participant for more than two years, including any period of suspension. The LSA may extend the interim participation period if it considers necessary, for example on the advice of an appropriately qualified specialist or in exceptional circumstances.

8.2 With the exception provided at rule 8.5, the maximum period for interim participation, including any period of suspension, is three years from the date of acceptance into the Scheme.

8.3 Assessment of lifetime participation for eligibility may be initiated at the request of the interim participant and will occur once the LSA becomes satisfied that the injury has stabilised.

8.4 The LSA may make a decision regarding lifetime participation at any time where the lifetime impact of the impairment is apparent and meets the eligibility criteria.

8.5 A child with a brain injury will not be assessed for lifetime participation until they are six years or older, unless the lifetime impact of the impairment is apparent and meets the eligibility criteria.

9.1 At any time during the interim participation period, the LSA may require an eligibility assessment regarding whether the participant’s injury meets the eligibility criteria, but at no more than six monthly intervals. The LSA will notify the participant in writing that an eligibility assessment is required for the LSA to make an eligibility decision.

9.2 If, as a result of the eligibility assessment, the LSA decides that the participant is no longer eligible for the scheme, then participation ceases from the date specified in the written notification from the LSA to the participant. This notification will be accompanied by information regarding eligibility disputes.

9.3 Where the decision of the LSA, that the interim participant is now ineligible, is disputed in accordance with section 36 of the Act, the person will be deemed to be a participant until the dispute is resolved.

10.1 Any interim participant may request that the LSA make a determination on whether they are eligible, in accordance with the relevant criteria, to become a lifetime participant in the Scheme.

10.2 The LSA will notify the eligible person and any other interested party if any additional information is required.

11.1 An interim participant can be transitioned to lifetime participation, if the LSA is satisfied that the person is eligible for lifetime participation in the Scheme.

11.2 If a participant does not request to become a lifetime participant at least ninety days prior to the expiration of the maximum interim participation period, the LSA will consider their lifetime participation eligibility and may require the participant to undergo a medical assessment.

11.3 If a participant refuses to engage with any process set out in this Part, the LSA may conduct the assessment based on the available information, or suspend the participant.

12.1 The FIM™ or WeeFIM® assessment must be conducted within two months (before or after) of the date of a request from a participant or when the LSA requires it, in order to transition the participant to lifetime participation. The most recent assessment will be used.

Page last updated: 18 December 2020