News » Open Letter to ACC re: Surgery Funding Decisions

18 May 2011

Denise Cosgrove
General Manager Claims Management
ACC Corporate Head Office
PO Box 242
Wellington

(Open Letter) Elective Surgery Funding Decisions

I am writing to you regarding the outcome of ACC’s recent internal review into elective surgery funding decisions and the potential unfairness brought about as a result of the way ACC has been making these decisions since 2009.

Part of the internal review found that, of those decisions declining to fund surgery challenged through the independent review process, in the nine months to March 2011 an average of 44% were overturned in the claimant’s favour and in the previous 2009/10 financial year 36% of were overturned; compared to the average of 25% (1 in 4) for all reviews.

Access Support Services’ position is that the review statistics demonstrate ACC has been overzealous in declining surgery funding since 2009. Access Support Services is not alone. The NZ Herald recently reported the president of The Orthopaedic Association, Associate Professor Gary Hooper, saying surgeons were increasingly frustrated at having to appeal for funding of patients’ surgery, “even when they apparently met the criteria and were clearly in urgent need”.
We find most surgery funding decisions are essentially an issue of causation i.e. whether ACC accept surgery is to treat a personal injury as defined by legislation. A decline to fund surgery means the claimant may not be eligible for other entitlements; such as weekly compensation, vocational and social rehabilitation, and lump sum compensation.

By my calculations, in the last two years there have been about 18,000 decisions declining surgery funding were not challenged through the review process. While I accept not all of ACC’s decisions will be incorrect, it is safe to assume a significant proportion of the 18,000 odd claimants affected may have been unfairly disadvantaged. Unfortunately, a vast majority of these claimants will not be able to review their decisions due to the statutory three month time-limit for lodging a review application.

Access Support Services considers that, in light of findings of ACC’s internal review, ACC has an obligation to revisit those decisions declining surgery funding issued since 2009 that were not challenged through the independent review process. We suggest this can be done by writing to the affected claimants offering to issue a fresh decision and clearly explaining the review process, including the claimant’s right to representation and that review costs can be awarded for representation, medical reports etc.

Please advise if ACC is prepared to address the potential unfairness of its decision-making process since 2009 for those claimants who did not review the decisions declining to fund surgery and, if so, what steps ACC will be taking.

I look forward to your response.

Yours sincerely,
Access Support Services

David Wadsworth
Principal

 

03 548 6962 or 09 281 4558

enquiries@accesssupport.co.nz

PO Box 9058, Nelson