Road Accident Fund Claims: What Injuries Count as “Serious”?

Criteria for regarding an injury as serious

The Road Accident Fund (RAF) considers an injury “serious” based on guidelines provided in the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Sixth Edition.

These guidelines, called the AMA Guides for short, provide criteria for determining an injured person’s so-called “Whole Person Impairment” (WPI). WPI is expressed as a percentage of the body.

The Minister of Transport set the threshold percentage for determining serious injury at 30%.

This means that a road accident victim must be assessed as being 30% WPI to qualify for an award of general damages.

Who’s responsible for making a serious injury assessment?

The assessment of serious injury can be made only by an appropriate medical specialist.

The specialist is required to base the assessment on the AMA Guides.

If an injury isn’t rated as 30% WPI in terms of the AMA Guides, the medical practitioner may apply a “narrative test” to determine whether the claimant may still be entitled to compensation for general damages.

In this case, an injury can be classified as serious if it has resulted in:

• long-term impairment or the loss of a body function
• permanent, severe disfigurement
• a serious long-term mental or behavioural disturbance or disorder
• the loss of an unborn child.

When the assessment can be made

The assessment can be made only after the victim has reached maximum medical recovery.

In other words, the person’s injuries must have stabilised. They shouldn’t have notably improved or deteriorated for a period of several months prior to the assessment.

Examples of road accident injuries that are and are not considered “serious”

Some examples of injuries that may meet the 30% threshold are amputations, permanent brain damage and paraplegia.

Certain common road accident injuries have, by regulation, been classified as not serious, unless there are complications. These include:

• whiplash
• strains, tears, crushes or other damage to soft tissue
• short-term sprains, strains, tears or other damage to ligaments that don’t result in long-term joint instability
• lacerations, abrasions, cuts, tears or damage to skin that doesn’t result in serious disfigurement
• partial or complete amputation of the little finger (pinky) of either or both hands
• partial or complete amputation of a single toe on either or both feet (big toe excluded)
• damage or loss of teeth
• superficial burns
• fracture of nasal bone or damage to the nasal cartilage
• scars caused by any of the above (except for serious disfigurement)
• mild or moderate depression, anxiety, chronic headaches or post-traumatic stress disorder.

Information needed to prove a serious injury

As part of a general damages claim, a medical professional must submit a Serious Injury Assessment Report. Without it, the claim won’t be approved.

The report must include the following details:

• details of the patient and medical practitioner
• any non-serious injuries
• serious injuries according to the American Medical Association guidelines
• how the injuries occurred (the nature of the road accident)
• how the injuries were treated
• final diagnosis and current symptoms
• medical history of the patient
• social and personal history of the patient
• educational and occupational history of the patient.

Educational, occupational and personal history must be included to assess how the injury has affected the victim’s life, ability to work and earn an income.

The form should also specify how any dependants may have been affected.

The medical professional will have to confirm that the patient has reached his or her maximum medical improvement (MMI) or maximum medical recovery (MMR).

This means that in the doctor’s opinion, the patient’s injury has reached the point at which it isn’t going to get any better with time or continued medical treatment.