ACC review case studies
These case studies look at some of the common types of ACC cases that come up for review and explain how the final decisions were reached. The case studies are not about specific people, but they have been based on a number of real cases.
- Is my injury covered by ACC?
- Do I have to pay for my employee's accident?
- Why won't ACC pay for my surgery?
- How long can I expect ACC to pay weekly compensation?
- Why has ACC stopped paying for my medication?
- What if I'm not dealing with ACC?
- How is my level of impairment measured and does that entitle me to compensation?
What is and isn’t an accident is tightly defined by the Injury Prevention, Rehabilitation, and Compensation Act 2001.
Case study 1
An injury needs to be the result of an ‘external force’. ACC decided not to pay for treatment of a person who, while making a bed, sneezed, and felt a sharp pain in their back. The person then came to FairWay Resolution to have the decision reviewed. When all of the information had been considered, the reviewer agreed that ACC did not have to cover the cost of the treatment because the injury was not caused by an external force. The person’s claim to have their treatment paid for by ACC was declined. ACC also have to consider if a person’s injuries are as a result of an accident, or if there is an underlying reason for an injury.
Case study 2
A woman experienced sharp pain in her shoulder and back while exercising at the gym. After seeing her doctor, a specialist, and being x-rayed, she was told she had an underlying problem that had been aggravated by the exercises she had been doing at the gym. Because her injury was a result of an underlying problem ACC did not pay for her treatment. The woman applied to have the decision reviewed.
The reviewer looked at all the information, including similar cases that had gone to court. In those cases the court confirmed that even if there had been no symptoms of an underlying problem in the past, any injury caused by the underlying problem was not covered by ACC. The reviewer decided ACC had acted correctly, although they also noted that if future medical evidence showed injury had been caused by the accident at the gym, she should contact ACC again.
If an employee has accident at work, their employer must pay for the first week of compensation (80% of the earnings the employee would have lost in that week).
Case study 1
In this case study it was the employer who applied for a review of ACC’s decision to provide cover to their employee. A supermarket worker claimed they had badly hurt their hand on the job. On doctor’s advice the worker took a week off work.
The employer applied for a review of ACC’s decision that the accident happened at work after doing their own investigation, including interviews and looking at their security film footage. The reviewer agreed it was unlikely the accident had happened at work as claimed and ACC’s decision to cover the costs of the accident was overturned.
ACC may cover all or part of the surgery costs when someone needs surgery after an accident. However, it can be difficult to determine whether the need for surgery is a direct result of an accident. Sometimes there are underlying medical issues that have caused the problem in the first place. ACC might not pay for surgery if the problem is, for example, a gradual process injury that isn't accident related, or a medical condition that isn't related to the accident.
Case study 1
A woman hurt her arm when she was lifting a heavy object out of the boot of her car. She was referred to an orthopaedic surgeon, who recommended surgery. ACC decided there was no evidence the woman’s condition was caused by an accident and said there was no link between the need for surgery and the accident. Rather, it said the woman had a gradual process condition that had been discovered during the treatment for her accident, and that it would not pay for the surgery. The woman then applied for a review of that decision.
The reviewer said ACC didn’t provide any explanation or support for its decision and the information from the medical specialists was significant. The specialist said it was difficult to be certain of the cause of the woman’s condition, but that based on the woman’s history and symptoms, the surgery was probably required for an injury caused by the accident. The reviewer overturned ACC’s original decision and ordered that it cover the surgery and pay the woman $550 in costs.
ACC covers not only the treatment required after an injury, it can also pay weekly compensation if a person is injured and not able to work for a period of time because of their injury.
Case study 1
In October 2006 a woman injured her back while lifting a heavy object. Three months later, she went to her doctor, who diagnosed a muscle strain, and recommended light duties for the woman from then on.
ACC covered the cost of the treatment, but reviewed whether or not the woman was entitled to weekly payments to compensate for any drop in income as a result of the accident.
It found that effects of her injury were ‘spent’ (meaning they had now settled) and that any other existing pain or discomfort was the result of a degenerative problem that was present before the accident. It decided not to pay the woman weekly compensation.
The woman applied for a review of that decision. The reviewer said the medical evidence was clear – the woman’s muscle strain from the accident had settled, and that any ongoing problem was due to a degenerative disease in her thoracic and lumbar spine, not a result of an accident. Therefore she was not entitled to weekly compensation.
ACC may put on hold or cancel existing treatment if it believes a person is no longer suffering as a result of an accident.
Case study 1
A man injured his back when he was lifting a heavy object. He was in a lot of pain and eventually had a MRI scan. He was prescribed anti-inflammatory medication, which ACC funded for the following eight years. When ACC reviewed the man’s case it decided that while the drug was the most appropriate medication for the man, it would no longer fund the medication because the symptoms were related to a degenerative problem in the man’s back, not as a result of an accident. The man applied to have this decision reviewed. The reviewer also noted that the medication was the most appropriate for the man’s condition, but said the cause of the pain was the main issue. All of the medical opinions about the man’s condition said there were two problems – a muscular tear, and a degenerative disease that was not related to the accident. The reviewer said that, while the man continued to have ongoing back pain, it was largely due to a degenerative disease, not an accident. The reviewer also noted that even if the original accident had aggravated a pre-existing condition, this does not mean ACC must cover the costs of treatment. The reviewer agreed with the ACC decision to stop funding the medication.
Many of the country’s large employers manage their own employee’s accident claims in partnership with the ACC. Any employees that are injured on the job are covered by their employer’s scheme, but they still have the right to apply for a review of the company’s decision. These employers are called ‘accredited employers’. They must still meet the same legal requirements as ACC would regarding cover and entitlements.
Case study 1
A woman lodged a claim for a neck sprain that was the result of wearing an earpiece, which she had to do as part of her job. Her doctor diagnosed a neck sprain, which was caused by having to wear the earpiece.
The employer initially declined to cover the costs of the treatment because it did not accept that there had been an accident as defined by law. Once the employer did accept there had been an accident it again declined to pay for treatment on the basis that it was not a personal injury (meaning a physical injury). The employee then applied for a review.
After looking at the case the reviewer said the claim met the definitions that were required by law; that there had been an accident, and there had been a personal injury as a result of that accident. Because both of these criteria were met the reviewer decided the employee was entitled to have her treatment costs covered by her employer.
To qualify for an ACC independence allowance or lump sum payment, a person needs to be assessed as having more than 10% impairment. An appropriate medical specialist usually assesses the level of impairment.
Case study 1
A man was receiving ACC compensation because of his work-related hearing loss. An ear, nose and throat specialist assessed the man’s hearing loss, at over 60%, and that 15% of that was work-related. Another assessment was carried out to determine the man’s total impairment, which was rated at less than 8% and therefore he was not entitled to an independence allowance. The man applied for a review of his assessment.
The reviewer looked at all of the information and referred to the law relating to independence allowances and lump sum compensation. The law says that impairment is defined as any loss or loss of use of any body part, organ system, or organ function. That differs from disability, which is the effects an injury has on a person’s ability to carry our normal activities.
He found that many of the issues raised by the man were related to disability rather than impairment, and so the total impairment assessment was correct.