Bodily wear and tear is being used as a reason by ACC to turn down genuine claims, surgeons and legal advocates say.A 21-year-old Timaru woman is among an increasing number of people being told their injuries are not the result of accidents, but of pre-existing conditions, and therefore would not be covered.However, ACC said the number of people being turned down has increased only because ACC was assessing claims more carefully.Wellington orthopaedic surgeon Robert Kusel said he and his colleagues at Boulcott Hospital’s orthopaedic clinic had noticed an increase in the number of patients being denied ACC cover for surgery, many on the basis of “degeneration” in the injured joint.”They’re now using the age-degenerative reason to decline more people that really have a pretty bona fide case.” ….
…. An ACC spokesman said the corporation was turning down a slightly greater number of surgery claims but that was because it was looking more closely at claims.
“A lot of them aren’t wholly or substantially due to an accident.”
The number of disputed claims upheld in ACC’s favour had remained steady at 70 to 75 per cent.
“When you’re talking about a couple of hundred being wrong out of 57,000 [a year], that’s not a bad batting average.”
In all fairness, there will probably have been claims in the past that should probably have been denied. But at the same time, serious question marks can be placed before the stated statistics of the ACC spokesman. How many denied claimants end up “fighting” the decision of a denied claim? Experience is telling me that people very often rather walk away and find a way to get medical treatment funded themselves than to go against the big machine that that may need in the past. Involvement in mediation and tribunal cases tells me that more than once the evidence to support ACC’s decisions is thin if there is any evidence at all. General statistics to me do not count as such an that was recently confirmed again.
The first party to decide on whether ACC can deny a claim is ACC itself in the mediation. for many going through the process poses a hurdle they’d rather not go through, either all alone or with a representative or support person. You don’t like the decision ACC made and you are left with a tribunal (Dispute Resolution Services) that use to be a part of ACC. After that what is left is the court room.
The fact that a number of denied claims go unchallenged does not mean by any means that ACC was probably right. here are more and more people looking at private insurance as a safety net for ACC and many simply do not want to gp through the ordeal of mediation, tribunal and/or the court. There are other factors at play here that are of equal importance, conveniently left out by the ACC spokesman.
The situation appears to be pretty much like this:
- ACC denies certain claims as per default almost pointing to general a statistics;
- A substantial number of claimants take this for granted either because they do not understand the ACC decision or because they do not feel there is any merit fighting it;
- A smaller number of claimants are willing to fight it, and end up going through the Tribunal. They will see themselves confronted with a number of legal requirements, that will very likely require assistance that needs to be funded. At the same time the options of claiming these costs back when it turns out you are right are getting less and less favorable.
- SO: going against an ACC decision actually requires an investment that many, especially in the current economic climate can not afford, and it is not that the options of free or very low cost representation are widely advertised (myself included) and in general hiring a lawyer is a costly operation. So people are made to choose to “invest” money in their procedure with a risk of not being successful at all times. That money that could otherwise be used to fund their treatment. (The fact that ACC denies your claim does by no means mean that your pain is not genuine).
- You may well be required to spend hundreds if not thousands of dollars on specialist reports with again a limited option in claiming back these costs.
This is the situation up until the tribunal, and does not even cover a court procedure. This has nothing to do any longer with ACC being right or wrong in their decisions and all with an in my personal opinion unjust system in which your ACC levies are actually very likely funding nothing more or less than a litigation machine. Money that could have been used on treatment.
The almost habitual denial of certain claims is a symptom of an in my view derailed system. I do understand that there are financial troubles for ACC but that should not be a reason to trade in justice for convenience.