Part 4Financial benefits

Part 4—Financial benefits Division 1—Claims 30—Claims (1) Subject to this section, a claim under this Part— (b) must be made within the prescribed period; and (c) must be supported by a certificate in the designated form by a designated person certifying— (i) the nature of the injury; (ii) the probable cause of the injury so far as that is ascertainable by the designated person; (iii) if the claimant claims to be incapacitated for work—the claimant's current and likely future capacity; (iv) any other matter specified by the Corporation with the approval of the Minister. (2) If a notice of an injury is required under this Act, a claim may not be made in respect of that injury unless notice of the injury has been given as required. (3) Despite subsections (1) and (2)— (a) the absence of, or a defect in, a notice of injury is not a bar to the making of a claim if— (i) the proper determination of the claim has not been substantially prejudiced; or (ii) the failure to give the notice, or the defect in the notice, was occasioned by ignorance of the claimant, mistake or absence from the State, or other reasonable cause; and (b) a failure to make a claim within the prescribed period is not a bar to the making of a claim if— (i) the proper determination of the claim has not been substantially prejudiced; or (ii) the failure to make the claim within the prescribed period was occasioned by ignorance of the claimant, mistake or absence from the State, or other reasonable cause. (4) A claim must be given at first instance as follows: (a) where the worker is at the commencement of the incapacity in employment—the claim must be given to the employer; (b) in any other case—the claim must be given to the Corporation. (5) Within 5 business days after receipt of a claim under this section, an employer (not being a self-insured employer) must forward to the Corporation— (a) a copy of the claim; (b) a statement in the designated form. (6) An employer (not being a self‑insured employer) must furnish to the Corporation, in such manner and form as the Corporation may determine, such other information as the Corporation may reasonably require in order to assess or determine a claim. (7) If it appears from a claim that the worker was not, at the time of making the claim, in the employment of the employer from whose employment the injury arose, the Corporation must (where it is practicable to do so) notify that employer of the claim. (8) The Corporation may dispense with a requirement under this section. (9) A self-insured employer may dispense with the requirement for a certificate under subsection (1)(c) if a claim only relates to Division 2. (10) In this section— designated person means— (a) a recognised health practitioner; or (b) another person of a prescribed class acting in prescribed circumstances and subject to any limitations or conditions prescribed by the regulations; prescribed period, in relation to the making of a claim under this section, means the period of 6 months commencing on the day on which the entitlement to make the claim arises. 31—Determination of claim (1) On receipt of a claim, the Corporation may undertake such investigations and inquiries as are necessary in order to achieve an evidence based decision with respect to the determination of the claim. (2) Without limiting any other provision, for the purpose of satisfying itself of the nature, extent or probable duration of an injury, the Corporation may require a worker to submit to an examination by a recognised health practitioner nominated by the Corporation. (3) If a claimant— (a) fails or refuses to furnish information reasonably required by the Corporation to assess or determine the claim; or (b) fails or refuses to submit to an examination as required under subsection (2), the claim may be rejected. (4) The Corporation must determine claims for compensation as expeditiously as reasonably practicable and where the claim is for compensation by way of income support must, wherever practicable, endeavour to determine the claim within 10 business days after the date of receipt of the claim. (a) the injury results from a road accident; and (b) no member of the police force attends at the scene of the accident; and (c) the claimant is required to report the accident to a member of the police force or at a police station under the Road Traffic Act 1961, the Corporation may refrain from determining the claim until the accident is so reported. (6) If an employer notifies the Corporation, before the Corporation determines a claim, that the employer disputes that the injury is compensable under this Act, the Corporation must, before determining the claim, make a reasonable investigation into the grounds on which the employer disputes the compensability of the injury. (7) As soon as practicable after determining a claim the Corporation must give notice in writing of the determination— (a) to the claimant; and (b) to any employer who may be directly affected. (8) If any part of a claim is rejected, a notice under subsection (7) must include— (a) such information as the regulations may require as to the grounds on which the claim is rejected; and (b) a statement of the claimant's rights to have the determination reviewed. (9) The Corporation may, in an appropriate case, by notice in writing to the worker, redetermine a claim. (10) For the purposes of subsection (9), an appropriate case is one where— (a) the redetermination is necessary to give effect to an agreement reached between the parties to an application for review or to reflect progress (short of an agreement) made by the parties to such an application in an attempt to resolve questions by agreement; or (b) the claimant deliberately withheld information that should have been supplied to the Corporation and the original determination was, in consequence, based on inadequate information; or (c) the redetermination is appropriate by reason of new information that was not available and could not reasonably have been discovered by due enquiry at the time that the original determination was made; or (d) the redetermination is for the purposes of section 5(11) and is appropriate by reason of the stabilising of a work injury; or (e) the original determination was made as the result of an administrative error and the redetermination is made within 2 weeks of the making of the original determination. (11) The redetermination of a claim does not give rise to any right on the part of the Corporation to recover from the worker money paid under a previous determination unless the previous determination was made in consequence of the worker's fraud. 32—Payment of interim benefits (1) The Corporation may, pending the final determination of a claim, make interim payments under this Part to a claimant. (2) The Corporation must offer to make interim payments under this section if it fails to determine the relevant claim within 10 business days after the date of receipt of the claim. (3) If on the final determination of a claim it appears that an amount to which the claimant was not entitled has been paid under this section, the Corporation may recover that amount as a debt in a court of competent jurisdiction. Division 2—Medical expenses etc 33—Medical expenses (1) Subject to this section, a worker is entitled to be compensated for costs of services described in subsection (2) that are reasonably incurred by the worker in consequence of having suffered a work injury— (a) in accordance with a scale published by the Minister under this section; or (b) if the relevant service is not covered by a scale under this section—to the extent of a reasonable amount for the provision of the service. (2) The costs referred to in subsection (1) are the necessary costs of: (a) medical services; (b) hospitalisation and all associated medical, surgical and nursing services; (c) approved recovery/return to work services; (d) travelling, or being transported, to and from any place for the purpose of receiving medical services, hospitalisation or approved recovery/return to work services (but not where the worker travels in a private vehicle); (e) where it is necessary for the worker to be accommodated away from home for the purpose of receiving medical services or approved recovery/return to work services—such accommodation (but not exceeding limits prescribed by regulation); (f) attendance by a registered or enrolled nurse, or by some other person approved by the Corporation or of a class approved by the Corporation, where the injury is such that the worker must have nursing or personal attendance; (g) the provision, maintenance, replacement or repair of therapeutic appliances; (h) medicines and other material purchased on the prescription or recommendation of a health practitioner; (i) other services (or classes of services) authorised by the Corporation. (3) Compensation in respect of costs to which this section applies may be paid— (a) to the worker; or (b) directly to the person to whom the worker is liable for those costs. (4) If a worker has been charged more than the amount that the worker is entitled to claim for the provision of a service in respect of which compensation is payable under this section, the Corporation may reduce the charge by the amount of the excess. (5) A decision of the Corporation under subsection (4) does not constitute a reviewable decision under Part 6. (a) services of a kind to which this section applies were provided to a worker in relation to a work injury; and (b) the Corporation considers that the services were, in the circumstances of the case, unnecessary or unreasonably incurred, the Corporation may disallow charges for the services. (7) If the Corporation disallows or reduces a charge under this section— (a) it must give to the provider of the service a notice setting out— (i) the basis of the Corporation's decision to disallow or reduce the charge; and (ii) where the charge has been disallowed under subsection (6) the provider's right to have the decision reviewed under this section; and (b) the worker is not liable to the provider for the disallowed charge, or for more than the reduced charge, (as the case requires) and, if the worker has in fact paid an amount for which he or she is not liable, the Corporation will reimburse the worker for that amount and may recover it from the provider as a debt. (8) If a worker travels in a private vehicle to or from any place for the purpose of receiving medical services, hospitalisation or approved recovery/return to work services, and the travel is reasonably necessary in the circumstances of the case, the worker is entitled to a travel allowance at rates fixed by a scale published by the Minister under this section. (9) A reference in this section to approved recovery/return to work services is a reference to recovery/return to work services provided by a person who has an agreement with the Corporation for the provision of those services. (10) If a treatment protocol or framework for the provision of services has been published by the Minister under this section, costs for the provision of those services are only compensable where— (a) the services are provided in accordance with the protocol or framework; or (b) the provider of the services establishes, to the Corporation's satisfaction, that services outside the terms of the protocol or framework are justified in the circumstances of the particular case. (11) The amount of compensation for a service covered by a scale of charges published by the Minister under this section must be in accordance with the scale. (12) The Minister may, by notice in the Gazette, on the recommendation of the Corporation, publish— (a) scales of charges for the purposes of this section (ensuring as far as practicable that the scales comprehensively cover the various kinds of services to which this section applies); (b) treatment protocols or frameworks as contemplated by this section. (13) Subject to subsection (14), a scale of charges published under this section must be based on the average charge to private patients for the relevant service unless the Minister determines that it is not reasonably practicable or feasible to determine such an average charge for a relevant service (but in any event the amount fixed for the service must not exceed the amount recommended by the relevant professional association). (14) A scale of charges for services provided by a public hospital may be based on government charges for the relevant service. (15) Before the Corporation makes a recommendation to the Minister about the publishing of a scale of charges, or a treatment protocol or framework, the Corporation must consult with— (a) professional associations representing the providers of medical services of the relevant kind; and (b) associations representing self‑insured employers (including Self-Insurers of South Australia Incorporated); and (c) associations representing employers other than self‑insured employers (including the South Australian Employers Chamber of Commerce and Industry); and (d) associations representing employees (including the United Trades and Labor Council). (16) A person who provides a service for an injured worker, knowing the worker to be entitled to compensation for the service under this section, must not charge for the service an amount exceeding the amount allowed under a scale of charges published under this section. Maximum penalty: $2 500. (17) A worker is entitled, in relation to prescribed classes of services, appliances, medicines or materials referred to in subsection (2), to apply to the Corporation for approval to obtain the provision of those services or otherwise to incur costs on the basis that the Corporation will agree in advance to be liable for the relevant costs rather than the worker being required to claim compensation under this section once the costs have been incurred. (18) An application under subsection (17) must be made in accordance with the regulations and the Corporation must make a decision in relation to the application within the period prescribed by the regulations. (19) The Corporation must give the same consideration to an application under subsection (17) that would be given to an application if the worker were to incur the relevant costs and then claim compensation under subsection (1). (20) Subject to subsection (21), an entitlement to compensation under this section (including an entitlement to make an application under subsection (17)) comes to an end if the worker has not had an entitlement to receive weekly payments in relation to the work injury under Division 4 for a continuous period of 12 months (or has not had an entitlement to receive weekly payments under Division 4 and a period of 12 months has expired) (insofar as costs are incurred after the end of that period). (21) Subsection (20)— (a) does not apply in relation to a seriously injured worker; and (b) does not apply— (i) in relation to any therapeutic appliance required to maintain the worker's capacity; or (ii) in relation to surgery, any associated medical, nursing or medical rehabilitation services (including the cost of hospitalisation), where the Corporation has determined or accepted, on application made before the end of the period referred to in subsection (20), that it is reasonable and appropriate for such surgery to be undertaken at a later time due to the impact (or likely impact) of the work injury on the worker's health and capacity (or future health and capacity); or (iii) in relation to prescribed classes of injury, where the Corporation has determined or accepted, on application made before the end of the period referred to in subsection (20), that it is reasonable and appropriate for the services to be provided after the end of that period (and then, in such a case, the services will be compensable to the extent determined by the Corporation); or (iv) in any other circumstances prescribed by the regulations. (22) The right of review referred to in subsection (7)(a)(ii) is a right to have the decision of the Corporation to disallow or reduce a charge reviewed by the Tribunal by application to the Tribunal under the South Australian Employment Tribunal Act 2014. 34—Transportation for initial treatment (1) If— (a) a worker is injured at the worker's place of employment during the course of employment; and (b) the injury is such as to require immediate medical treatment, the employer must, at the employer's own expense, provide the worker with immediate transportation to a hospital or health practitioner for initial treatment. (2) If an employer fails to provide transportation in accordance with subsection (1), the cost may be recovered by the Corporation from the employer as a debt due to the Corporation. (3) An amount recovered by the Corporation under subsection (2) must, if the worker incurred costs in consequence of the employer's failure to provide transportation, be paid to the worker. (4) If the cost of transportation provided by an employer (other than a self‑insured employer) to a worker in accordance with subsection (1) exceeds an amount prescribed by the regulations, the employer is, on application to the Corporation in a manner and form approved by the Corporation, entitled to recover the excess from the Corporation. (5) An amount prescribed by regulation under subsection (4) may, if the regulations so provide, be indexed so as to provide annual adjustments according to changes in the CPI. Division 3—Property damage 35—Property damage (1) If a worker suffers a work injury and, in consequence of the trauma out of which the injury arose, damage occurs to any therapeutic appliances, clothes, personal effects or tools of trade of the worker, the worker is, subject to limitations prescribed by regulation, entitled to be compensated for the full amount of the damage. (2) An entitlement under subsection (1) does not extend to compensation for damage to a motor vehicle. (3) An amount prescribed by regulation under subsection (1) may, if the regulations so provide, be indexed so as to provide annual adjustments according to changes in the CPI. Division 4—Income support 36—Capacity to perform work (1) For the purposes of this Act, the current work capacity of a worker is constituted by a present inability arising from a work injury such that the worker is not able to return to his or her employment at the time of the occurrence of the injury but is able to return to work in suitable employment. (2) For the purposes of this Act, a worker has no current work capacity if the worker has a present inability arising from a work injury such that the worker is not able to return to work, either in his or her employment at the time of the occurrence of the injury or in suitable employment. 37—Prescribed benefits The following are prescribed benefits for the purposes of this Division: (a) any amount paid to the worker by the Corporation or a self‑insured employer in respect of an employment program provided or arranged by the Corporation or self‑insured employer for the purposes of this Act; (b) any of the following received by the worker from an employer: (i) any payment, allowance or benefit related to annual or other leave; (ii) any payment, allowance or benefit paid or conferred by the employer on the worker's retirement; (iii) any payment, allowance or benefit paid or conferred under a superannuation or pension scheme; (iv) any payment, allowance or benefit paid or conferred on the retrenchment, or in relation to the redundancy, of the worker; (ba) any prescribed amount ordered by the Tribunal to be paid to the worker by the employer under section 18(5e); (c) any other payment, allowance or benefit of a prescribed kind. 38—Prescribed allowances In this Division, a reference to weekly earnings, or current weekly earnings, is a reference to weekly earnings exclusive of prescribed allowances.