Nearly 200 people contacted the Herald over the last few days to claim ACC had unfairly rejected their claims. We will be running some of their stories.
ACC's medical advisers are not being held properly accountable when they make bad decisions that lead to claimants wrongly being denied cover, a lawyer says.
Accident compensation law specialist Peter Sara said yesterday that the methods for controlling the quality of medical advice to the Accident Compensation Corporation were inadequate.
Hundreds of ACC claimants have told the Herald they have been unfairly denied cover. Typically this is because ACC has hired a doctor who has diagnosed the person's problems as largely due to underlying physical degeneration, rather than the accidental injury for which they had sought help.
Some of the seven medical specialists who advise ACC are retired from clinical practice, although they still hold an annual practising certificate from the Medical Council, an indicator they are keeping up with continuing medical education requirements. Some completed medical school more than 40 years ago and in one case nearly 50 years ago.
The corporation said last night that the advisers were ACC employees. It would not say how much they were paid, but said they received market rates.
"The majority of them see patients in their private capacity."
Mr Sara, of Dunedin, said ACC medical advisers were not subject to the Health and Disability Commissioner system when they were advising about a claim - and this needed to be changed.
It was considered that because they were advising ACC "there's no doctor-patient relationship. It's a third-party situation.
"If there were a doctor-patient relationship they could be put on the carpet, and they jolly well should be ... Because if they are following the party line, in other words someone in head office is saying 'this is our view now on shoulder injuries and we are not going to approve any', they are just following that through, they are not even providing independent clinical advice, [they are] rubber-stamping a process. It's appalling that they are immune, really, from this."
They were named in District Court decisions, but that was insufficient.
Mr Sara said another problem was that ACC permitted its advisers to work outside their specialist areas. Shoulder injuries, for instance, should be considered only by orthopaedic surgeons who specialised in shoulder surgery.
Auckland lawyer Philip Schmidt has asked Parliament for an independent inquiry into ACC's medical adviser system.
The corporation's executive leadership, according to an internal report last year, signed up to a harder-nosed approach - a switch from improving claimant access to cost containment; and from "social insurer" to "insurer".
ACC general manager Denise Cosgrove said last night the corporation was bound by legislation.
"We cannot pay for conditions that are degenerative or pre-existing."
One of the many claimants to be declined cover is 65-year-old Ian Boag, of Palmerston North, but this week he had that decision overturned by an ACC reviewer.
The computer business owner had surgery on his left shoulder after a rotator cuff tendon was badly torn in a fall last December. He paid around $10,000 for the operation, which was reimbursed by health insurer Southern Cross, a cost ACC must now pay.
An ACC adviser, in a three-line diagnosis, said that Mr Boag had underlying degeneration. Mr Boag said the adviser was not given complete information, then failed in his duty to seek it out.
"He didn't ask anything. The first thing you do when you are a medic is you ask for a history and he didn't."
THREE CASE STUDIES
(1) ELAINE WOLSTENHOLME, 45
INJURIES: Slipped disc, twisted spine
REJECTED: Degeneration
A 45-year-old Aucklander says she is using her 80-year-old mother's walking stick after rejected insurance claims delayed her treatment and left her with permanent nerve damage.
Elaine Wolstenholme slipped her disc in 2007 while bending over to pick up a towel. She suffered a further spinal injury in February this year when falling awkwardly in the primary classroom she taught in.
The second incident exacerbated the first, and she became increasingly uncomfortable. By April, the spinal injury prevented her from walking, and she was admitted to North Shore Hospital. Unable to work, ACC paid for her lost income.
Her private specialist recommended urgent surgical work to repair her back problem.
"But at this point I found out ACC were querying my claim of an accident," said Ms Wolstenholme.
She was turned down for an operation on the grounds that the injury was degenerative. This was despite reports from her specialist and ACC's own appraiser that stated her condition was the direct result of an injury and was not degenerative.
She appealed twice, but was turned down by an ACC panel of experts. "What I cannot understand, is if they accepted this injury, and paid my income claim, why did they refuse to pay for the surgery, or anything else?"
Between appeals, the severity of the injury saw her return for spells in hospital.
She missed two terms of teaching. Increasing pain meant she occasionally had to be prescribed morphine, as well as daily painkillers.
Ms Wolstenholme became so fed up with seeking an ACC-funded operation that she paid for her own private surgery, at a cost of $10,000. She has ongoing costs of painkillers, which set her back $50 a week. She has returned to teaching at Laingholm Primary, but says the delay in getting an operation left her with permanent damage to her sciatic nerve.
"My left leg is still dull and my left foot is partially numb. I use a walking stick.
"The funny bit is it's my 80 year-old mother's walking stick, given to her 45 year-old daughter."
She said she could not afford a lawyer, so could not take her case any further.
- Isaac Davison
(2) IAN STRAKA, 30
INJURY: Back
REJECTED: Degenerative
When Ian Straka's back surgery went wrong, ACC agreed to pay for an operation to fix it - but only for the cost of another incision, not for any of the lasting effects.
Mr Straka is having to pay out of his own pocket for ongoing scans and physiotherapy.
"I'm in nowhere land and the bills are piling up," he said.
ACC declined to pay for his original surgery, saying his back injury after slipping on stairs was degenerative - "even though I was an otherwise healthy, active man in my 20s".
A radiographer mislabelled his scans and Mr Straka ended up with screws in the wrong parts of his spine. Now, he has to take 33 tablets a day, plus morphine on bad days, and struggles to lift his 1-year-old daughter from the floor.
Because he was not covered by ACC initially, he paid for all his subsequent treatments - except for the second operation to replace the screws. He has tried to deal with ACC but found it very difficult.
"I've absolutely had a gutsful of it, the bureaucracy and the sheer amount of paperwork."
(3) PAT DILLON, 64
INJURY: Hernia
REJECTED: Injury not caused by accident
Pat Dillon says he had to force an answer out of ACC as it delayed making a decision for three months and his hernia worsened.
Mr Dillon felt a sharp pain in late August while lifting furniture at work. Doctors told him that he had developed a double hernia and needed surgery.
Mr Dillon said he had been fit and never had trouble before.
He rang ACC but got stuck talking to call centre workers who could only tell him to wait.
He reached the end of his tether when he received a letter that it could be three more months before a decision.
He rang ACC and refused to hang up until he got an answer. His claim was declined on the spot, with ACC saying documentation didn't show his hernia resulted from the accident - even though his doctors said it had.
Mr Dillon cancelled his life insurance to pay for his surgery.
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