ACC is accused of increasingly and unjustifiably rejecting surgery claims. Bevan Hurley reports.
A 17-year-old girl who badly hurt her knee during a soccer match was refused surgery by ACC after being told her injury was degenerative.
The Accident Compensation Corporation has been rejecting 60 per cent more applications for elective surgery, and surgeons say the reason given is often the same: the
injury is degenerative.
The decision against operating on the Tauranga girl was overturned when her surgeon appealed directly to ACC director of clinical services Kevin Morris. An apology was issued.
But the initial refusal last September meant the teen had to undergo two separate operations after injuring an ankle at the same time as the knee.
Surgeon John Calder said it "beggars belief" ACC had turned down surgery for his young patient on the grounds of prolonged wear and tear.
"It's hard to justify telling people as young as 17 that their problem is due to a gradual process injury or degenerative change," added Calder, president of the New Zealand Orthopaedic Association. "Some of their decisions defy logic."
Calder said performing both operations at the same time would have saved around $2000 and shortened the girl's rehabilitation period.
"I think [ACC] have taken a broad brush approach and it's unfair for a lot of people."
The teenager is one of hundreds of patients who have appealed against ACC decisions after being denied assistance for accidents in the past year.
The number of people being refused elective surgery was up by 60 per cent in the six months to December compared to the same period the previous year, according to figures given to the Herald on Sunday.
The most common type of injury involved shoulders, spines and knees.
Health professionals say ACC has cracked down on the number of patients being granted free surgery in the past 14 months, with many turned down despite having legitimate claims.
But ACC spokesman Laurie Edwards said of the 50,000 surgery applications dealt with last year, only a few hundred decisions were overturned on review.
He said ACC assessed every case individually and hired around six extra staff last year to make sure no one was taking advantage of the system.
He said: "It's not just a question of the medical facts, we have to ask if they fit ACC legislation."
In the case of the Tauranga teenager, he said there might not have been enough information supplied with the original application.
He said: "I am sure we have apologised to the girl's family for the delay that might have caused."
Michael Caughey, an Auckland orthopaedic surgeon and president of the NZ Shoulder and Elbow Society, says ACC's cost-cutting drive had targeted shoulder surgery with only 55 per cent of applications being approved. The approval rate on all surgery is around 75 per cent.
Caughey said: "We have certainly seen some very angry and frustrated patients, a number of whom have paid ACC premiums all their working lives and they feel they have been unfairly treated. While in the past they may have been lenient, the pendulum has swung too far the other way in terms of declines."
Caughey said the odds were stacked against patients who appealed against the judgment, when they went up against expert testimony from an ACC panel.
"It's very difficult for the patient to win without expert assistance."
Kept in limbo by 'ageist' approach
Sprightly 72-year-old Dan Bustard was "fit as a fiddle" - until he fell 4m from a bridge he was building in the Waitakere Ranges last June.
The self-employed contractor suffered a broken shoulder that continues to keep him off work.
Bustard was initially denied assistance from ACC, and said his injury was due to wear and tear. But the decision was overturned after his private insurance company appealed.
He said: "They do take an ageist approach. If you are a bit older, they hold it against you.
"The thing that annoys me is that my injury is genuine and yet I'm being punished because there are so many people sucking from the system."
The father of two from Waikino, 10km west of Waihi, has closed down his contracting business while he waits to find out if ACC will cover an operation on his ankle, which was also injured.
"I have no idea when that decision will be made ... I'm basically in limbo. Everyone at ACC seems to be passing the buck."
bevan.hurley@hos.co.nz