• 1.1This Part applies for the purposes of Part 4 of the Act.
  • 1.2The LSA will only pay for necessary and reasonable TCS needs that relate to the Motor Vehicle Injury.

  • 2.1The LSA will pay for the Participant’s necessary and reasonable TCS needs related to the Motor Vehicle Injury, where the LSA is satisfied that:
    • 2.1.1there is clinical justification for services;
    • 2.1.2there is evidence that the service is necessary and reasonable in relation to the Motor Vehicle Injury;
    • 2.1.3the service is likely to be effective and achieve or maintain a measurable functional improvement; and
    • 2.1.4the service promotes progress towards functional autonomy, participation in community life and the economy.
  • 2.2TCS services included in the bed day fee when the Participant is an inpatient will not be paid for separately.
  • 2.3TCS needs are defined in section 4 of the Act to include:
  • a.medical treatment, including pharmaceuticals;
  • b.dental treatment;
  • c.rehabilitation;
  • d.ambulance transportation;
  • e.respite care;
  • f.attendant care and support services;
  • g.aids and appliances;
  • h.prostheses;
  • i.education and vocational training;
  • j.home and transport modification;
  • k.workplace modification;
  • l.such other kinds of TCS or services as may be prescribed by the regulations; and
  • m.such other kinds of TCS or services as may be determined by the LSA (either generally, for specified classes of cases, or for a particular person).
  • 2.4The LSA may, in limited circumstances, determine funeral services to be within the ambit of Rule 2.3 (m) above.
  • 2.5There may be items that are related to the Motor Vehicle Injury that are necessary and reasonable in the circumstances, but are not regarded as TCS or services under the scope of the Act, regulations or these Rules. In this case, the LSA will not pay for any such services or supports, but may work with the Participant or Decision Maker or both, as the case may require, Service Providers and other authorities to facilitate access to such services where there may need to be congruence with TCS or services funded by the LSA.

  • 3.1TCS will be dealt with on an individual basis and decided taking into account the ‘necessary and reasonable’ criteria outlined below.
  • 3.2If a specific service (incorporating TCS or items of Assistive Technology) is not the subject of a specific Rule in these Rules, the LSA may pay the costs of that service, if it is determined by the LSA to be necessary and reasonable in the circumstances.
  • 3.3In determining whether TCS is ‘necessary and reasonable’ the LSA will consider a number of factors, including the following:
  • a.benefit to the Participant;
  • b.appropriateness of the service;
  • c.appropriateness of the provider;
  • d.cost effectiveness; and
  • e.relationship of the services to the injuries sustained in the accident.
  • 3.4Each of these factors involves several considerations, detailed below. No one consideration is determinative or required.

Benefit to the Participant

  • 3.5The proposed service will be considered by the LSA to be of benefit to the Participant if:
    • 3.5.1it can be demonstrated that the proposed service is expected to assist the Participant in achieving their goals;
    • 3.5.2the outcome of the service is expected to progress or maintain the Participant’s functional capability or participation;
    • 3.5.3it is a service or related service which has been provided in the past with positive results or outcomes;
    • 3.5.4the service has a specific goal or goals, and expected duration and expected outcome/s; and
    • 3.5.5any potential risk is sufficiently offset by the expected benefits from providing the service.

Appropriateness of service

  • 3.6The proposed service will be considered by the LSA to be appropriate for the Participant if:
    • 3.6.1it is consistent with the Participant’s current medical or Rehabilitation management that is required as a result of the Motor Vehicle Injury;
    • 3.6.2it relates to the Participant’s goals in the MyPlan (if relevant);
    • 3.6.3it is consistent with current clinical practice, evidence-based practice or clinical rules;
    • 3.6.4a similar service is not already being provided to the Participant;
    • 3.6.5there is evidence acceptable to the LSA that the requested service is effective;
    • 3.6.6it is consistent with other services currently being offered or proposed;
    • 3.6.7the cost is reasonable in the context of the person’s injury and severity assessment;
    • 3.6.8the service is not, in the course of ordinary circumstances, paid for by Local, State and Commonwealth Governments (or other jurisdictions/ schemes) as benefits available to the community (wholly or in part) and the Participant remains eligible for; and

For example:

  • a child Participant would receive education supports available to all children with disability and the LSA would fund additional TCS services that were needed.
  • a Participant who is an NDIS Participant due to other injuries or disabilities would continue to receive support from the NDIS for that injury or disability and the LSA would fund the TCS services related to the Motor Vehicle Injuries.
  • A Participant who is eligible for aged care supports would receive services and supports required due to their ageing, whilst the LSA would continue to fund supports related to the Motor Vehicle Injuries.
  • 3.6.9it is new or innovative, there is sufficient rationale for offering it and measures exist to quantify its outcomes.
  • 3.7Where a Participant or Decision Maker or both, as the case may require, prefers a service that, whilst it is related to the Motor Vehicle Injury, exceeds what the LSA considers to be necessary and reasonable, the Participant or Decision Maker or both, as the case may require, may be offered the opportunity to receive the desired service by contributing the additional costs.

Appropriateness of provider

  • 3.8The proposed Service Provider will be considered by the LSA to be appropriate if they are:
    • 3.8.1qualified and appropriately experienced to provide the service;
    • 3.8.2registered with the LSA (if applicable);
    • 3.8.3appropriate considering the Participant’s age, ethnicity and any cultural and linguistic factors;
    • 3.8.4it is consistent with Participant or Decision Maker or both, as the case may require, choice;
    • 3.8.5expected to be found acceptable by the Participant or Decision Maker or both, as the case may require; and
    • 3.8.6readily accessible by the Participant.

Cost effectiveness

  • 3.9The proposed service will be considered by the LSA to be cost effective if:
    • 3.9.1consideration has been given to the long-term compared to the short-term benefits, taking into account evidence-based practice, clinical experience and costs;
    • 3.9.2the cost of the proposed service is comparable to those charged by providers in the same geographical area or clinical area;
    • 3.9.3the service is required because other services or Assistive Technology are not available or not appropriate;
    • 3.9.4lease or rental costs of Assistive Technology or modifications have been considered in comparison to purchase costs; and
    • 3.9.5any realistic alternatives to purchasing Assistive Technology/ modifications have been considered, including the impacts of technology advances and changes to Participant’s needs over time.

Relationship to Motor Vehicle Injuries

  • 3.10The proposed service will be considered by the LSA to be directly related to the Motor Vehicle Injuries if:
    • 3.10.1there is sufficient evidence to demonstrate that the service relates to the Motor Vehicle Injuries including exacerbation of pre-existing injuries or conditions; and
    • 3.10.2the impact of time since injury, previous and subsequent injuries, ageing, other disabilities and co-morbidities have been taken into account.

  • 4.1The LSA or these Rules may place limits, terms or conditions on the provision of particular TCS services. The LSA may determine such limits, terms and/or conditions from time to time and publish any such determination in the Gazette or on its website.
  • 4.2The LSA may determine not to pay for TCS services that are not provided in a manner consistent with the LSA’s limits, terms or conditions.
  • 4.3The LSA will not pay for TCS costing more than the maximum amount for which the LSA is liable in respect of:
    • 4.3.1any claim for fees for services not provided at public hospitals, as published by the Minister in the Gazette under subsection 41(3) of the Act;
    • 4.3.2services or expenses that are not TCS under the scope of the Act, in particular under subsection 28(1), such as gratuitous services, ordinary costs of raising a child, services not provided by an approved provider or provided in contravention of these Rules.
  • 4.4The LSA will not pay for economic loss, capital items, rent or bond for rental properties, lost wages, maintenance and income support, assistance to keep a business open (such as paying for temporary staff to do a Participant’s job), additional expenses incurred during inpatient or outpatient treatment or Rehabilitation (such as food, laundry, newspapers and magazines).
  • 4.5The LSA will not pay for experimental or non-established treatment where the LSA is not satisfied that:
    • 4.5.1peer reviewed journal articles demonstrate efficacy;
    • 4.5.2interventions are widely supported by practitioners in the field;
    • 4.5.3interventions have progressed past the early stages of clinical trial; or
    • 4.5.4there is an MBS item number (for medical treatment, procedures and surgery).
  • 4.6The LSA will not provide TCS for any complications arising out of any experimental or non-established treatment that is undertaken without the LSA’s approval.
Page last updated: 16 September 2022