• 1.1For the purpose of this Part, any reference to motor vehicle is that defined in Part 1 Rule 3 of these Rules.

  • 2.1An 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. In addition to the requirements outlined in Part 1, Rule 3 of these Rules, the application must demonstrate that:
    • 2.1.1the person sustained a bodily injury; and
    • 2.1.2the injury was caused by or arose out of the use of a motor vehicle; and
    • 2.1.3the relevant Motor Vehicle Accident occurred in South Australia; and
    • 2.1.4the injury meets the criteria set out in these Rules.

  • 3.1Eligibility 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.
  • 3.2An Appropriately Qualified Medical Specialist must certify that the eligible person meets the following injury criteria, unless otherwise provided for in these Rules.

Injury criteria for spinal cord injury

  • 3.3The injury criteria for spinal cord injury (SCI) are:
    • 3.3.1Permanent neurological deficit as evidenced by an ASIA Impairment Scale Score of A to D conducted as part of an assessment using ISNCSCI; and/or
    • 3.3.2Residual 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.
    • 3.3.3The most recent assessment will be considered by the LSA, where there is more than one assessment.

Injury criteria for traumatic brain injury

  • 3.4The injury criteria for traumatic brain injury are:
    • 3.4.1For adults and children over eight years of age, a traumatic brain injury with:
  • a.a recorded Post-Traumatic Amnesia (PTA) of seven Calendar 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 traumatic brain injury.

    • 3.4.2For children aged three to eight years of age, 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 Calendar 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 of two less than the age norm on any item on the WeeFIM® due to the brain injury.

    • 3.4.3For 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.

Injury criteria for amputations

  • 3.5The injury criteria for amputations are:
    • 3.5.1The injury resulting in amputation or the equivalent impairment, is of the following types:
      • 3.5.1.1Limb amputation:
  • a.of the upper limb Proximal to the first Metacarpophalangeal Joint of the thumb and the index finger; or
  • b.of the lower limb Proximal to the ankle.

or

  • 3.5.1.2A Brachial Plexus Avulsion or rupture with an impairment equivalent to an eligible upper limb amputation.

Injury criteria for burns

  • 3.6The injury criteria for burns (as evidenced by a burn impact of 50 points or more on the Greenwood Burns Scale or similar clinically accepted assessment) are:
    • 3.6.1full 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
    • 3.6.2permanent inhalation burns causing long term significant respiratory impairment; or
    • 3.6.3full thickness burns to the hands, face or genital area.
    • 3.6.4For lifetime participation, the criteria in Rules 3.6.1, 3.6.2 or 3.6.3 of this Part must be fulfilled and
      • 3.6.4.1if 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 the burns; or
      • 3.6.4.2if 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 the burns; or
      • 3.6.4.3for 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.

Injury criteria for permanent blindness

  • 3.7The injury criteria for blindness are:
    • 3.7.1Permanent 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.

  • 4.1An application to become a Participant:
    • 4.1.1must be made no later than three years from the date of the relevant Motor Vehicle Accident;
    • 4.1.2should be made as soon as practicable once it is clinically apparent that the person has an Eligible Injury;
    • 4.1.3must be made on the form published on the LSA’s website (as updated from time to time);
    • 4.1.4must be made by a person authorised by the Act to make an application;
    • 4.1.5must give the LSA authorisation to obtain and disclose information and documents relevant to the injury, Motor Vehicle Accident and motor vehicle;
    • 4.1.6must be signed by a person authorised by the Act to make an application;
    • 4.1.7must attach all required information reasonably able to be obtained.
  • 4.2If the application 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.
  • 4.3Where the insurer or nominal defendant is the Applicant, the insurer or nominal defendant must pay for and provide the medical assessment reports required to determine eligibility.
  • 4.4In exceptional circumstances, the LSA may extend the time limit to make an application by up to two years, but the total time limit must not exceed an aggregate of five years from the date of the relevant motor vehicle accident (section 25(7) of the Act).

Editorial Notes –

Subsections 25(7) and 56(3)(d) of the Act authorise Part 2 Rule 4.1.1 and Part 2 Rule 4.4.

  • 4.5For the purposes of Part 2, Rule 4.4, exceptional circumstances include, but are not limited to consideration of the following factors:
    • 4.5.1The LSA’s assessment of the certainty of causation and extent of severity of the injury to the relevant Motor Vehicle Injury; and
    • 4.5.2The LSA’s assessment that a full and satisfactory explanation has been provided regarding the factors that have prevented an application being submitted within time or the person engaging in required assessments; and
    • 4.5.3The LSA’s assessment of prejudice to other relevant parties.
  • 4.6An Applicant must comply with any reasonable request by the LSA (including requests for information to support decision-making about eligibility) to supply specified additional information or provide authorisation for the LSA to obtain specified additional information.

Editorial Notes –

Subsection 56(3)(d) of the Act authorise Part 2 Rule 4.6.

  • 4.7Such information includes, but is not limited to:
    • 4.7.1the South Australia Compulsory Third Party (CTP) Injury Claim Form (if it has been completed) or other personal injury claim forms;
    • 4.7.2ambulance or air ambulance/ retrieval records;
    • 4.7.3hospital records;
    • 4.7.4treating doctor’s reports;
    • 4.7.5past medical, employment or school records;
    • 4.7.6records held by departments, agencies or instrumentalities of the Commonwealth, the State or another State, administering laws about health, police, transport, taxation or social welfare;
    • 4.7.7records held by insurance companies including RTWSA; or
    • 4.7.8police reports.
  • 4.8The LSA will acknowledge all applications In Writing within 14 Calendar Days of receipt.

  • 5.1The FIM™ or WeeFIM® assessment must be conducted within two months (before or after) of the date of the completed application to the Scheme. If more than one FIM™ or WeeFIM® assessment has been conducted, then the most recent assessment must be used.
  • 5.2Prior to approving eligibility, the LSA may require that a FIM™ or WeeFIM® assessment is conducted by an Appropriately Qualified person.

  • 6.1The LSA shall determine whether to:
    • 6.1.1accept a person as a Participant and if so, whether they will be accepted as an Interim Participant, or as a Lifetime Participant (regardless of whether the Applicant stated that they sought acceptance as either type of Participant);
    • 6.1.2not accept a person as a Participant, either as an Interim or Lifetime Participant;
    • 6.1.3extend interim participation;
    • 6.1.4suspend a Participant; or
    • 6.1.5when making a lifetime participation decision for an Interim Participant, defer making a decision until the injury has stabilised sufficiently.
  • 6.2The LSA will make its determination as soon as practicable, taking into account:
    • 6.2.1the information on the Application Form;
    • 6.2.2any information attached to the Application Form;
    • 6.2.3any additional information that the LSA may request in order to make its determination.
  • 6.3The Applicant will receive the LSA’s determination In Writing, including reasons for the decision and, if applicable, information about the LSA’s process for resolving Disputes.

  • 7.1Rule 7 applies to an Applicant accepted as an Interim Participant.
  • 7.2In accordance with subsection 26(4) of the Act, the LSA shall accept as a Lifetime Participant, an Applicant initially accepted as an Interim Participant, if the LSA becomes satisfied that the person is eligible to be a Lifetime Participant.
  • 7.3Subject to the other provisions of Part 2 Rule 7, a Participant should not remain an Interim Participant for more than two years from the date they were first accepted as an Interim Participant, including any period of suspension.
  • 7.4Subject to Part 2, Rule 7.5 and in accordance with subsection 26(7) of the Act, the maximum period for interim participation, including any period of suspension, is three years from the date they were first accepted as an Interim Participant.

Editorial Notes –

Subsection 26(7) of the Act authorises the LSS Rules to include Rules relating to the period for interim participation.

  • 7.5The LSA may extend the interim participation period outlined in Part 2, Rules 7.3 and 7.4 if:
    • 7.5.1the person is engaged in legal proceedings relating to their status under the Return to Work Act 2014 (SA); or
    • 7.5.2it considers it necessary to do so, on the advice of an Appropriately Qualified Medical Specialist; or
    • 7.5.3the LSA is satisfied, at its sole discretion, that exceptional circumstances exist, which include but are not limited to:
      • 7.5.3.1A child Participant with a traumatic brain injury who is less than six years of age;
      • 7.5.3.2A child Participant with a traumatic brain injury who is between the ages of six and 18 years of age, and the lifetime impact of the impairment is not apparent;
      • 7.5.3.3The Interim Participant is suspended;
      • 7.5.3.4There is insufficient contemporaneous evidence to make a lifetime participation decision, and the Participant has not cooperated in undertaking the assessments required by the Lifetime Support Authority to make the lifetime participation decision.
  • 7.6Interim participation may be extended on more than one occasion.
  • 7.7The LSA may make a decision regarding lifetime participation at any time where the LSA determined the lifetime impact of the impairment is apparent.

  • 8.1At 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 no more frequently than six monthly intervals. The LSA will notify the Participant or Decision Maker or both, as the case may require, In Writing that an eligibility assessment is required for the LSA to make an eligibility decision.
  • 8.2If, 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 or Decision Maker or both, as the case may require. This notification must be In Writing and accompanied by information regarding the eligibility Disputes process.
  • 8.3Where the decision of the LSA, that the Interim Participant is no longer eligible, is disputed in accordance with sections 33 to 37 of the Act, the person will be deemed to be an Interim Participant until the Dispute is resolved.

  • 9.1An Interim Participant or Decision Maker or both, as the case may require, 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.
  • 9.2The LSA will notify the eligible person and any other interested party if any additional information is required, including the requirement for the Participant to undergo relevant medical assessments.

  • 10.1An Interim Participant can be transitioned to lifetime participation if the LSA is satisfied that the person is eligible for lifetime participation in the Scheme.
  • 10.2If a Participant or Decision Maker or both, as the case may require, does not request the LSA to make the Participant a Lifetime Participant at least 90 Calendar Days prior to the expiration of the 2 years that a person should be an Interim Participant, the LSA may consider their lifetime participation eligibility, unless
    • 10.2.1the person has been granted an extension to 3 years under Part 2, Rule 7.4, or
    • 10.2.2the person has been granted an extension under Part 2 Rule 7.5.
  • 10.3If the person has been granted an extension under either Part 2, Rule 7.4 or Part 2 Rule 7.5, then If the Participant or Decision Maker or both, as the case may require, does not request the LSA to make the Participant a Lifetime Participant at least 90 Calendar Days prior to the expiration of the extended period, the LSA may consider their lifetime participation eligibility.
  • 10.4If relevant medical assessments are required to determine eligibility, the Participant is required to undergo relevant medical assessments identified by the LSA.
  • 10.5If a Participant or Decision Maker or both, as the case may require, refuses to engage with the process set out in this Part, the LSA may suspend the Participant.

  • 11.1The FIM™ or WeeFIM® assessment must be conducted:
    • 11.1.1within two months (before or after) of the date of a request from a Participant or Decision Maker; or
    • 11.1.2when the LSA requires it,

in order to make an eligibility determination. The most recent assessment will be used.

Page last updated: 16 September 2022