ACC claims better win rate on appeals

ACC's success rate against elective-surgery patients in review is back up to 70 per cent. Photo / Thinkstock

The Accident Compensation Corporation's success rate against elective-surgery patients in review hearings is back up to 70 per cent.

ACC takes this as evidence that it is getting it right more often in its initial decision-making - but many claimants continue to report encountering a tough line at the corporation, especially on cases where there is any evidence of "degeneration".

"In January 2012, 70 per cent of decisions have been in ACC's favour," an ACC official said, releasing the latest statistics.

"This represents a positive trend since the implementation of the recommendations of the review into elective-surgery decision making."

ACC has been under fire all week from disgruntled claimants in a Herald series, which was launched after corporation chairman John Judge criticised the paper's 2010 series and the claimants it featured. He said the hard line on elective surgery was fair and was necessary to avoid a blow-out in levies. More than 150 people contacted the paper this week to complain about the corporation refusing to pay for their treatment, mostly elective surgery.

They were told they were not entitled to treatment financed by the state-owned no-fault accident insurer on grounds including ageing, or having a pre-existing medical condition or congenital disorder.

ACC is permitted to withhold cover if these things, sometimes referred to as degenerative, are "wholly or substantially" the cause of the injury. "Substantially" has been defined by the courts as at least 80 per cent.

ACC admitted last year, after its internal review, that it had been rejecting too many elective surgery claims since the introduction of a harder-nosed approach in 2008 designed to save money.

In 2008, ACC was winning 70 per cent of cases that elective surgery claimants took to a review hearing. But after the new approach, that dropped to 56 per cent in 2010/11.

In the seven months to the end of January, the win rate was back up to 67 per cent, and for the month of January it was 70 per cent.

Claimant advocate David Wadsworth said that since the internal review, ACC's elective surgery unit was more willing to concede before a claimant's review hearing, if the evidence was convincing that a claim was justified, "... whereas before, I had been told - unofficially by an ACC staff member - that they were under instruction by the branch manager not to concede regardless of the evidence.

"As from about four months ago, ACC has settled about one in four review applications I have lodged, before a hearing takes place."