ACC Declining Injury
Declining Claims
An employee in a heavy manual labour role had an injury at work. There was clearly a cause of injury which was initially diagnosed as a sprain. The sprain flew through the ACC auto acceptance process (as most do) and treatment commenced. After three treatments, there was no improvement in symptoms and the employee was sent for imaging. The imaging showed muscular tears, and the employee was sent for a surgical consultation.
The surgeon recommended a non-surgical option and send a request to ACC to have the non-surgical option approved. Here’s where the wheels fell off.
The surgeon didn’t link the tears to the mechanism of injury (ACC need this to approve the surgery). With this, the surgeon must be very specific about how the incident caused the injury.
The imaging showed fresh tears as well as older tears (that had never been an issue)
The surgeon mentioned in their request to ACC that there was nerve impingement
The imaging showed an unusual shape to the bone structure which makes the claimant more vulnerable to nerve impingement (according to my unofficial research approx. 40% of people have this shoulder shape, so not that unusual?)
What does all this mean?
ACC have confirmed (in this case) that they will not cover nerve impingement due to the shape of the bone structure (even when caused by an incident).
Sprains and strains are the most common way to get an injury accepted by ACC yet it causes issues when the injury needs to be updated.
Imaging can be the claimants best friend and worst enemy (frenemy?) - if there is any sign of degeneration, ACC are likely to decline treatment under the scheme. The claimant must either use personal insurance or go on the public system
Side note - ACC will not pay weekly compensation where the surgical treatment has been carried out by a secondary provider (ie - Southern Cross).