The ACC files: Govt defends hardline over surgery cover

Minister cautions advisers against penny-pinching, but warns that more payouts would mean higher levies. Photo / Mark Mitchell

The Government has defended the doctors declining ACC cover for many claimants seeking cover for elective surgery.

The system in which the Accident Compensation Corporation's medical advisers reject claims, often without even meeting the patient, has been scrutinised in a Herald series.

Some lawyers and independent orthopaedic surgeons have criticised ACC over its crackdown since last year on access to surgery, alleging it relies on flimsy opinions from doctors, some of whom are retired and who are often not specialists in the areas they advise on.

Auckland lawyer Philip Schmidt yesterday wrote to MPs for a second time seeking an inquiry into the ACC medical-adviser system. He said many people gave up seeking their entitlements when turned down via an ACC medical adviser, because they could not afford to mount a challenge.

ACC was not designed to have so many disputes or the style of hearing now occurring, he said.

"New Zealanders [are now] funding a large litigation machine against themselves, where often the truth is playing second fiddle to convenience."

The Herald has had complaints from more than 400 people about their ACC cases. We found a big increase in the number of surgery cases going to legal review and a decline in ACC's success rate.

We have featured many cases in which claimants were refused surgery on grounds of pre-existing degeneration or gradual process injury.

And we have highlighted cases in which ACC's refusal has been overturned on review or in the District Court on appeal. Often degeneration has been found, but if it is not "wholly or substantially" the reason for surgery, ACC must cover the operation.

ACC said it was simply applying its legislation more strictly to control the cost of elective surgery, which had risen from $128 million in 2005 to $240 million last year.

More than 37,000 people a year had ACC-funded surgery, and only a small minority of surgery claimants were turned down.

ACC Minister Nick Smith said he was concerned by the number of complaints he was receiving and had spoken to the corporation and its specialist medical advisers.

He told the doctors ACC was "not in the business of penny-pinching" and they must apply the law fairly. But nor should ACC fund surgery to treat underlying conditions that were catered for by public hospitals.

He conceded there was a "grey area" between differing opinions over what injuries were caused by an accident or underlying conditions.

Dr Smith warned levies would rise if ACC treated more cases, and said people should not be naive about the financial interests of orthopaedic surgeons pushing for more work to be paid for by ACC. He said 10 orthopaedic surgeons were paid more than $2.4 million each by ACC last year, including one who got $3.6 million. Figures included hospital costs, but he estimated the surgeons would have received half of that money.

* 400 plus: People have complained to the Herald about their ACC case.

* 1528: The number of elective surgery cases going to review in the past financial year, up from 912 the year before.

* 65 per cent: ACC's success rate in review hearings, down from 70 per cent.

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