ACC (Accident Compensation Corporation)

This advice is based on my experience of treating ACC-covered patients for 25 years.

Key points

• ACC want an EVENT that involves FORCE that causes ACTUAL BODILY DAMAGE that can be seen in the flesh or measured on an xray or scan. The event must have happened at a certain time on a certain day. • Actual bodily damage can not always be seen on xrays and scans, especially for some spinal injuries and other conditions. • Spinal pain often comes on with no obvious event that caused it - it is not uncommon to wake up with pain in the morning, or for the pain to come on with a minor activity. • Even if your claim is initially accepted, ACC does not promise to cover everything relating to your injury, for ever. • ACC know how long the average injury will take to heal.  If you go outside those timeframes they may ask for more information or further medical assessments. • Even people with wear and tear (degeneration) on their xrays and scans can still suffer a genuine injury. • Where there is a mixture of wear and tear (degeneration) and you have an ACC-coverable injury, ACC may agree to only contribute a part of the proposed treatment costs. • Symptoms initially covered by an ACC claim but later found not to be accident related, can hinder efficient access to medical treatment using personal health insurance or individual funding. • You, have the right to appeal and challenge any decision ACC makes to deny cover or treatment, BUT make sure you get good medical or legal advice as to the wisdom of proceeding with such a claim, and the likely costs. • Challenging ACC and appealing their decisions will take time - sometimes many months. • If I don’t think that your problem is accident related I will make it very clear to you and help you to understand why. ACC requires this of me.

Accidental injury

When you accidentally injure yourself, your doctor, physiotherapist or another treatment provider will help you register an ACC claim.  If the claim is accepted, you will receive a letter from ACC indicating that “you’re covered.”  Although this letter looks very formal and authoritative, it doesn’t mean that ACC have promised to cover everything relating to your injury, for ever! In general, an accident needs to be sudden and unexpected and needs to lead to measurable actual damage to body tissues. Examples of an accident that ACC would likely cover include: • stumbling and rolling your ankle (ankle sprain) which leads to pain, swelling, bruising, inability to walk, and tearing of ligaments on the outside of the ankle. • Colliding with another player in a game of soccer and fracturing your shinbone. Examples of accidents which ACC are unlikely to cover include: • going for a run and, a few hours later, you develop back pain without any obvious event bringing it on. • gardening all day then that evening or the next morning you develop knee pain. ACC do not collect much initial information about your injury so it is important to be very detailed and specific when you write the description on the ACC45 form.  The doctor or health provider who fills out the first ACC45 form will document (on their own record system) how you injured yourself so make sure you get that doctor or other health provider to clearly record the events surrounding your injury IN DETAIL as ACC will be able to access this clinical information in the future. ACC have a huge database of historical and international data showing the average amount of time a person would take to recover from any injury. Of course, no two injuries and no two patients are the same so these are only averages.

Cover

ACC’s cover for your injury may include: • including earnings related compensation (”compo”), • visits to a doctor or rehabilitation therapist, • partial contribution toward x-rays and usually full contribution toward complex scans if requested by a specialist, • They will also pay for you to be assessed by a specialist if your doctor or physiotherapist thinks it is necessary. There has to be genuine “personal injury by accident” that meets ACC’s criteria for cover.  Sometimes cover is accepted initially, and then as more information becomes available, it is clear that the condition being treated is not “wholly or substantially” due to the injury.  This can come as a disappointment to some patients so it’s good to know about it in advance. Once you exceed the normal timeframes for recovery, ACC looks more closely at any other factors which may be delaying your return to normal. ACC may ask for you to be assessed by another specialist (of their choice), physiotherapist, or occupational therapist in order for them to get more information about what is delaying your recovery. ACC's responsibility is to cover you for genuine injuries and to maximise treatment and rehabilitation in order to get you back to normal as soon as possible. Your responsibility is to ensure that you have strong determination and motivation to get back to normal.   You should comply with all requests from the health professionals who are treating you.  You should also comply with all requests from ACC.

Surgery

ACC take a number of things into consideration when they make a decision regarding their responsibility to contribute towards the treatment costs for surgery.  Lots of people have accidents and injuries, some of which involve significant forces such as spraining your ankle, falling from a height, being involved in a motor vehicle accident. In these situations, soft tissues get injured, bones get broken, and it is easy to define the injury with clinical examination, x-rays and more complex scans when required. Unfortunately, with neck and back injuries, things are often not so clear. Many people injure their backs or necks during normal daily activities such as getting out of bed, bending over to pick something up, twisting, swinging a golf club etc. Other people injure their backs or necks doing things that are beyond the forces involved in normal daily activities such as heavy lifting and more serious accidents involving significant forces. Most neck and back injuries are initially registered with ACC as a “strain or sprain.” If surgery is needed, this diagnosis needs to be updated (a separate process) BEFORE we can apply for surgical approval.

Degeneration

As people get older, wear and tear changes appear on x-rays and scans. It is my opinion that most of the time, these changes do not cause pain and are part of the normal ageing process.  Back pain decreases as you get older because you get stiffer and the demands on your body are less.  This is supported by scientific studies but there are also other scientific studies which suggest that wear and tear changes can sometimes cause pain. Other than fractures and dislocations, there are only a couple of specific conditions affecting the back and the neck which clearly indicate that an injury has occurred. Most people who have a neck or back “strain” (causing a short period of painful incapacity followed by a rapid return to normal) will have x-rays which are normal for their age. You can’t see pain on an x-ray or a scan – only patterns of injury and disease which, based on experience, may be associated with painful conditions. More often than not, complex scans such as MRI usually won’t pick up the cause of the pain caused by a back "strain." In other words, if you "strain" your back, it is unlikely to show new damage on an x-ray or a scan. The common conditions which do indicate that an injury has occurred are disc prolapses (slipped discs) and annular tears (tearing of the annular ligament of the disc).  Older people can sustain compression, or crush, fractures predisposed by soft bones (osteoporosis).  It is important for your doctor or treatment provider to think about rare and more serious causes of back and neck pain and to exclude these. Factors which can influence ACC’s decision to cover your surgical costs include (but are obviously not limited to): • the genuineness of the injury; • whether the symptoms were of gradual onset or sudden onset; • the amount of force involved in the injury; • the presence or absence of pre-existing episodes of similar pain or other injuries • the presence of so-called degenerative changes (which I frequently dispute); • specific evidence proving injury from the clinical examination, x-rays and scans where indicated; • whether you were completely normal before the injury. With your permission, ACC can gain access to medical information from your family doctor, physiotherapist or other manipulative therapists, specialists and other involved parties. This will enable them to understand the timeline of your problem and other problems from the past which may be related.

Challenging ACC’s decision

If you feel that ACC have made the wrong decision in declining your cover, rehabilitation or therapy, your access to specialist assessment, investigations (tests and scans) or surgery, these are some of the options that you can consider: • you can apply to ACC for an appeal or review of their decision. There are certain timeframes within which you must apply; • you can complain to ACC formally if you feel you have not been treated fairly; • you can take your case to a lawyer who specialises in representing people in your situation.  This may involve you paying some money to the lawyer up front, plus ongoing legal fees, which may or may not be reimbursed if you win the case. You will need to take responsibility for initiating the above options.  If further clinical information is required from me then ACC or your legal representative will contact me. Ultimately, if you do not have the finances or health insurance, you may choose to be referred to the public hospital system for assessment.  More information about this here.