Wrongs (Part VBA Claims) Regulations 2015

Authorised Version Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 TABLE OF PROVISIONS Regulation Page 1 Objective 1 2 Authorising provision 1 3 Commencement 1 4 Revocation 1 5 Certificate of assessment 2 6 Certificate of assessment where injury has not stabilised 2 7 Agreement to waive assessment of impairment 2 8 Copy of certificate of assessment to be served on respondent 3 9 Respondent must provide information to Medical Panel 5 Schedule 1—Forms 6 ═══════════════ Endnotes 18 Authorised by the Chief Parliamentary Counsel i -- 1 of 19 -- Authorised Version STATUTORY RULES 2015 S.R. No. 31/2015 Wrongs Act 1958 Wrongs (Part VBA Claims) Regulations 2015 The Governor in Council makes the following Regulations: Dated: 5 May 2015 Responsible Minister: MARTIN PAKULA Attorney-General YVETTE CARISBROOKE Clerk of the Executive Council 1 Objective The objective of these Regulations is to prescribe forms and other matters for the purposes of Part VBA of the Wrongs Act 1958. 2 Authorising provision These Regulations are made under section 28LZP of the Wrongs Act 1958. 3 Commencement These Regulations come into operation on 9 May 2015. 4 Revocation The Wrongs (Part VBA Claims) Regulations 20051 are revoked. Authorised by the Chief Parliamentary Counsel 1 -- 2 of 19 -- Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 5 Certificate of assessment The prescribed form of a certificate of assessment under section 28LN of the Wrongs Act 1958 is Form 1 in Schedule 1. 6 Certificate of assessment where injury has not stabilised The prescribed form of a certificate of assessment where the injury has not stabilised under section 28LNA of the Wrongs Act 1958 is Form 2 in Schedule 1. 7 Agreement to waive assessment of impairment (1) For the purposes of section 28LO(1A) of the Wrongs Act 1958, the following information is prescribed— (a) the name of the claimant; (b) the name of the claimant's legal representative (if applicable); (c) the address of the claimant or the claimant's legal representative; (d) the telephone number of the claimant or the claimant's legal representative; (e) the email address of the claimant or the claimant's legal representative; (f) the date of birth of the claimant; (g) the name of the respondent; (h) the address of the respondent; (i) the telephone number of the respondent (if known); (j) a statement of reasons explaining why the claimant asserts that the respondent is the proper respondent to the claim; 2 Authorised by the Chief Parliamentary Counsel -- 3 of 19 -- Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 (k) the name, address and telephone number (if the number is known) of any party (other than the respondent) who the claimant considers to be a proper respondent to the claim and reasons why the other party is also considered to be a proper respondent; (l) the date, time and location of the incident; (m) a description of the incident; (n) details of the injury suffered as a result of the incident; (o) details of any of the following categories of loss suffered by the claimant as a result of the injury— (i) pain and suffering; (ii) loss of amenity of life; (iii) loss of enjoyment of life; (p) details of any report of the incident on which the claimant intends to rely, including the date of the report and the person to whom the report was made; (q) the name, professional qualifications, address, telephone number and email address of any medical practitioner who has treated the injury of the claimant. (2) For the purposes of section 28LO(1A) of the Wrongs Act 1958, the prescribed form is Form 3 in Schedule 1. 8 Copy of certificate of assessment to be served on respondent (1) For the purposes of section 28LT(2) of the Wrongs Act 1958, the following information is prescribed— (a) the name of the claimant; 3 Authorised by the Chief Parliamentary Counsel -- 4 of 19 -- Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 (b) the name of the claimant's legal representative (if applicable); (c) the address of the claimant or the claimant's legal representative; (d) the telephone number of the claimant or the claimant's legal representative; (e) the email address of the claimant or the claimant's legal representative; (f) the date of birth of the claimant; (g) the name of the respondent; (h) the address of the respondent; (i) the telephone number of the respondent (if known); (j) a statement of reasons explaining why the claimant asserts that the respondent is the proper respondent to the claim; (k) the name, address and telephone number (if the number is known) of any party (other than the respondent) who the claimant considers to be a proper respondent to the claim and reasons why the other party is also considered to be a proper respondent; (l) the date, time and location of the incident; (m) a description of the incident; (n) details of the injury suffered as a result of the incident; (o) details of any one or more of the following categories of loss suffered by the claimant as a result of the injury— (i) pain and suffering; (ii) loss of amenity of life; (iii) loss of enjoyment of life; 4 Authorised by the Chief Parliamentary Counsel -- 5 of 19 -- Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 (p) details of any report of the incident on which the claimant intends to rely, including the date of the report and the person to whom the report was made; (q) the name, professional qualifications, address, telephone number and email address of any medical practitioner who has treated the injury of the claimant. (2) For the purposes of section 28LT(2) of the Wrongs Act 1958, the prescribed form is Form 4 in Schedule 1. 9 Respondent must provide information to Medical Panel (1) For the purposes of section 28LZA(1)(a)(ii) of the Wrongs Act 1958, the following other information is prescribed— (a) the name of the respondent; (b) the address of the respondent; (c) the telephone number of the respondent; (d) the email address of the respondent; (e) the date on which the respondent received the claimant's certificate of assessment; (f) the name, address, telephone number and email address of the respondent's legal or other representative (if any); (g) the claimant's statement of claim (if this has been provided to the respondent); (h) a copy of Form 4 received from the claimant. (2) For the purposes of section 28LZA(1)(a) of the Wrongs Act 1958, the prescribed form is Form 5 in Schedule 1. 5 Authorised by the Chief Parliamentary Counsel -- 6 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 Schedule 1—Forms FORM 1 Regulation 5 CERTIFICATE OF ASSESSMENT OF DEGREE OF IMPAIRMENT ARISING FROM STABILISED INJURY Wrongs Act 1958 Section 28LN DETAILS OF MEDICAL PRACTITIONER Name: Qualification: Address: Telephone: Email: CERTIFICATION I certify that on: [date] I examined: [insert name of person seeking the assessment] of: [address of person seeking the assessment] and *I am satisfied/*I am not satisfied [delete whichever inapplicable] that: [*tick appropriate box/boxes]  the degree of impairment resulting from this person's injury is more than 5%. Brief description of injury assessed:  the degree of impairment resulting from this person's psychiatric injury and symptoms (which has not arisen as a consequence of, or secondary to, a physical injury) is more than 10%. Brief description of psychiatric injury assessed: SIGNED: DATED: 6 Authorised by the Chief Parliamentary Counsel -- 7 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 Please note: This certificate must be provided by a medical practitioner who is an approved medical practitioner within the meaning of section 28LB of the Wrongs Act 1958. This certificate must not state the specific degree of impairment. Impairment is defined in section 28LB of the Wrongs Act 1958 to mean permanent impairment. The degree of psychiatric impairment must not have regard to any psychiatric or psychological injury, impairment or symptoms which has arisen as a consequence of, or secondary to, a physical injury—see section 28LJ of the Wrongs Act 1958. 7 Authorised by the Chief Parliamentary Counsel -- 8 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 FORM 2 Regulation 6 CERTIFICATE OF ASSESSMENT OF DEGREE OF IMPAIRMENT WHERE INJURY HAS NOT STABILISED Wrongs Act 1958 Section 28LNA DETAILS OF MEDICAL PRACTITIONER Name: Qualification: Address: Telephone: Email: CERTIFICATION I certify that on: [date] I first examined: [insert name of person seeking the assessment] of [address of person seeking the assessment]: in relation to [*tick appropriate box/boxes]  an injury. Brief description of injury assessed: I certify that I have conducted a subsequent examination today in relation to the same injury and I am unable to determine the degree of impairment. However, I am satisfied that the degree of impairment resulting from this injury will be more than 5% once the injury has stabilised.  the degree of impairment resulting from this person's psychiatric injury and symptoms (which has not arisen as a consequence of, or secondary to, a physical injury) is more than 10%. Brief description of psychiatric injury assessed: 8 Authorised by the Chief Parliamentary Counsel -- 9 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 I certify that I have conducted a subsequent examination today in relation to the same psychiatric injury and I am unable to determine the degree of impairment. However, I am satisfied that the degree of impairment resulting from this psychiatric injury will be more than 10% once the injury has stabilised. SIGNED: DATED: Please note: This certificate must be provided by a medical practitioner who is an approved medical practitioner within the meaning of section 28LB of the Wrongs Act 1958. This certificate must not state the specific degree of impairment. Impairment is defined in section 28LB of the Wrongs Act 1958 to mean permanent impairment. The date of the first examination of the person seeking an assessment must be at least six months before the date of this assessment. The degree of psychiatric impairment must not have regard to any psychiatric or psychological injury, impairment or symptoms which has arisen as a consequence of, or secondary to, a physical injury—see section 28LJ of the Wrongs Act 1958. 9 Authorised by the Chief Parliamentary Counsel -- 10 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 FORM 3 Regulation 7 AGREEMENT TO WAIVE ASSESSMENT OF IMPAIRMENT Wrongs Act 1958 Section 28LO(1A) 1. CLAIMANT'S NAME Claimant's full name: 2. CLAIMANT'S DETAILS Go to Part 3 if the claimant has a legal representative. Claimant's address: Claimant's telephone number: Claimant's email: Claimant's date of birth: 3. CLAIMANT'S LEGAL REPRESENTATIVE'S DETAILS Go to Part 4 if the claimant does not have a legal representative. Legal representative's name: Legal representative's address: Legal representative's telephone number: Legal representative's email: 4. RESPONDENT'S DETAILS Name of respondent: Address of respondent: Telephone number of respondent: [leave blank if not known] Reason why claimant asserts the respondent is the proper respondent to the claim: 10 Authorised by the Chief Parliamentary Counsel -- 11 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 5. ADDITIONAL RESPONDENTS For each other party the claimant considers to be a proper respondent: Name: Address: Telephone number: [leave blank if not known] Reason why claimant asserts this party is the proper respondent to the claim: 6. DESCRIPTION OF THE INCIDENT Date of incident: Time of incident: Location of incident: Description of incident: 7. THE INJURY TO THE CLAIMANT Set out all the injuries that you claim you suffered as a result of the incident: Details of any one or more of the following categories of loss suffered by the claimant as a result of the injury: (i) Pain and suffering (ii) Loss of amenity of life (iii) Loss of enjoyment of life 8. DOCUMENTATION OF THE INCIDENT AND INJURY If the claimant intends to reply on a report of the incident to make the claim: Date of report: Name of person to whom the report was made: 11 Authorised by the Chief Parliamentary Counsel -- 12 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 If the claimant has been treated by a medical practitioner in relation to the injury: Name of medical practitioner: Professional qualifications of medical practitioner: Address of medical practitioner: Telephone number of medical practitioner: Email of medical practitioner: 9. CERTIFICATION BY CLAIMANT (or claimant's legal representative) Signature of claimant: Date: Please note: Under subsection 28LO(2) of the Wrongs Act 1958, a respondent who has received this Form must respond in writing to the request within 60 days of receiving it. 12 Authorised by the Chief Parliamentary Counsel -- 13 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 FORM 4 Regulation 8 CLAIMANT PRESCRIBED INFORMATION FORM Wrongs Act 1958 Section 28LT(2) 1. CLAIMANT'S NAME Claimant's full name: 2. CLAIMANT'S DETAILS Go to Part 3 if the claimant has a legal representative. Claimant's address: Claimant's telephone number: Claimant's email: Claimant's date of birth: 3. CLAIMANT'S LEGAL REPRESENTATIVE'S DETAILS Go to Part 4 if the claimant does not have a legal representative. Legal representative's name: Legal representative's address: Legal representative's telephone number: Legal representative's email: 4. RESPONDENT'S DETAILS Name of respondent: Address of respondent: Telephone number of respondent: [leave blank if not known] Reason why claimant asserts the respondent is the proper respondent to the claim: 13 Authorised by the Chief Parliamentary Counsel -- 14 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 5. ADDITIONAL RESPONDENTS For each other party the claimant considers to be a proper respondent: Name: Address: Telephone number: [leave blank if not known] Reason why claimant asserts this party is the proper respondent to the claim: 6. DESCRIPTION OF THE INCIDENT Date of incident: Time of incident: Location of incident: Description of incident: 7. THE INJURY TO THE CLAIMANT Set out all the injuries that you claim you suffered as a result of the incident: Details of any one or more of the following categories of loss suffered by the claimant as a result of the injury: (i) Pain and suffering (ii) Loss of amenity of life (iii) Loss of enjoyment of life 8. DOCUMENTATION OF THE INCIDENT AND INJURY If the claimant intends to reply on a report of the incident to make the claim: Date of report: Name of person to whom the report was made: 14 Authorised by the Chief Parliamentary Counsel -- 15 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 If the claimant has been treated by a medical practitioner in relation to the injury: Name of medical practitioner: Professional qualifications of medical practitioner: Address of medical practitioner: Telephone number of medical practitioner: Email of medical practitioner: 9. CERTIFICATION BY CLAIMANT (or claimant's legal representative) Signature of claimant: Date: Please note: Under subsection 28W(1) of the Wrongs Act 1958, a respondent on whom a copy of a certificate of assessment is served must respond in writing to the claimant within 60 days after receiving the certificate and the required information under section 28LT. 15 Authorised by the Chief Parliamentary Counsel -- 16 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 FORM 5 Regulation 9 NOTICE OF REFERRAL OF MEDICAL QUESTION TO MEDICAL PANELS Wrongs Act 1958 Section 28LZA(1)(a) 1. MEDICAL QUESTION * Does the degree of impairment resulting from the physical injury to the claimant alleged in the claim satisfy the threshold level? * Does the degree of impairment resulting from the psychiatric or psychological injury to the claimant alleged in the claim satisfy the threshold level? [*tick appropriate box/boxes] 2. RESPONDENT'S DETAILS Respondent's full name: Respondent's address: Respondent's telephone number: Respondent's email: 3. RESPONDENT'S LEGAL REPRESENTATIVE'S DETAILS (if applicable) Legal representative's name: Legal representative's address: Legal representative's telephone number: Legal representative's email: 4. RECEIPT OF INFORMATION FROM CLAIMANT Date on which the respondent received the certificate of assessment: 16 Authorised by the Chief Parliamentary Counsel -- 17 of 19 -- Schedule 1—Forms Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 Date on which the respondent received Form 4 from the claimant: 5. ATTACHED DOCUMENTS The following documents must be included as attachments to this form:  Certificate of assessment received from the claimant  A copy of Form 4 received from the claimant  Statement of claim (if received from the claimant) 6. CERTIFICATION BY RESPONDENT (or respondent's legal representative)  I have advised the claimant that I have referred a medical question in relation to the assessment to a Medical Panel for determination. Signature of respondent: Date: ═══════════════ 17 Authorised by the Chief Parliamentary Counsel -- 18 of 19 -- Endnotes Wrongs (Part VBA Claims) Regulations 2015 S.R. No. 31/2015 Endnotes 1 Reg. 4: S.R. No. 27/2005. 18 Authorised by the Chief Parliamentary Counsel -- 19 of 19 --