Nearly 200 people contacted the Herald yesterday to claim ACC had unfairly rejected their claims. We will be running some of their stories over coming days.
CHANELLE TRUST, 18
INJURY Knee
REJECTED Developmental condition'
Unitec student Chanelle Trust had to wait 12 months through the public system to have surgery for a knee injury after her surgery was rejected by ACC.
Three years ago, when she was 15 years old, she fractured her kneecap while playing soccer.
Less than a year later, she was playing football in her backyard when she fell and tore the tendons in the same knee.
Her mother, Petra Trust, said ACC covered all her physiotherapy and further treatments with a podiatrist and a sports specialist. However, when her knee did not respond to physiotherapy, ACC then referred her to an orthopaedic surgeon.
"It was only when we got to the point of surgery that they then decided it wasn't an accident after all."
Mrs Trust said she was baffled ACC would refuse surgery claiming her daughter's injury was a "developmental condition" after originally identifying her injuries as the result of an accident.
Two weeks ago Ms Trust had surgery to correct her knee injury.
LOUISE DIXON, 43
INJURY Shoulders torn rotator cuffs
REJECTED Degeneration
It's been absolutely horrendous. They don't treat you
like a person.Louise Dixon was in so much pain after tearing her shoulder muscles she couldn't take off her own bra - but she was told ACC was "just not doing shoulders at the moment".
The 43-year-old office supervisor said she had been fit and never had shoulder problems before her accident.
In late 2008, she was "playing silly buggers" with her partner when she fell forward and he grabbed her arms.
"My arm went backwards. My body went one way and my arms went another. It tore my rotator cuffs," Ms Dixon said.
She tried physiotherapy for nine months with cortisone injections but decided she needed surgery on both shoulders.
But ACC turned her down, and people at her clinic told her that shoulder injuries had little chance of getting approved.
"They told me, 'they're just not doing shoulders at the moment'," Ms Dixon said.
She ended up in a teleconference with ACC during a disputes process, where the officer would only say "no comment", she said.
"It's been absolutely horrendous. They don't treat you like a person."
ANDREW JONES, 22
INJURY Knee
REJECTED Degeneration
Andrew Jones found ACC great to deal with after he injured his knee in an indoor netball game - that was until he needed surgery.
In December last year Mr Jones fell causing a knee injury that could not be diagnosed.
ACC swiftly referred him to a physiotherapist, where he managed to correct the injury by strengthening the muscles around the knee.
However, three months ago Mr Jones started to have pains in his left knee again.
ACC referred him to series of specialists until he saw an orthopaedic surgeon who recommend surgery for what was determined to be a complex cartilage tear in his knee.
"I have no complaints about how my case has been treated until it got to this stage," he said. ACC wrote to Mr Jones' advising they would not be paying for his surgery until they had more information to prove his injury was not due to degeneration.
Mr Jones says his relapse was clearly the result of his accident.
His private insurance will not pay for surgery because the injury is the result of an accident.
LAUREN WILLIAMS, 23
INJURY Knee torn cartilage
REJECTED Degeneration
A 23-year-old woman has had to put her life on hold for 18 months after ACC labelled her netball injury as "degenerative".
Lauren Williams, who works at the Elam School of Fine Arts, tore cartilage in her knee when she fell during a netball game in July 2009.
But ACC said her injury was degenerative because she had once fallen over when she was 12.
She fought ACC to try to get surgery on her knee, looking for some kind of medical documentation from the fall 10 years ago, but when she became a victim of assault earlier this year and injured her back, the battle became too much.
"I hate that it came to a point that I had to give up the fight. It's not like me, but it wears you down," Ms Williams said.
Her knee has dislocated five times while waiting for surgery and keeps getting worse.
Ms Williams recently visited a second surgeon who confirmed to her that her injury was "100 per cent not degenerative", she said.
She is now on a waiting list to have surgery at a public hospital.
PAUL SCOTTING, 39
INJURY Ankle ligaments
REJECTED Due to previous injuries
Paul Scotting successfully overturned an ACC judgment that his rolled ankle had been the result of old injuries to his other ankle and his knee.
Mr Scotting, a car salesman in Newmarket, was walking down a grass bank in December last year when he twisted his left ankle.
But ACC ruled that the injury had not been caused by the accident. As Mr Scotting appealed against its decision, ACC used in its defence past injuries to the wrong joints.
At one hearing with the Disputes Tribunal, ACC surprised Mr Scotting by introducing as new evidence a medical document that Mr Scotting had to try to understand in mere minutes.
The document turned out to be about a knee injury 15 years prior, and the Disputes Tribunal quashed ACC's decision to deny Mr Scotting cover.
Its decision said that an orthopaedic surgeon on ACC's clinical advisory panel, had advised that "there is history of repeative (sic) ankle sprain ove (sic) a number of years".
This related to his right ankle and the tribunal ruled "there was scant evidence of relevant previous left ankle injury".
MADELEINE FLANNAGAN, 37
INJURY Neck injury from car crash
REJECTED Degeneration
A 37-year-old mother of four was dismayed to be told her pain was the result of "degeneration" and not a car crash which caused a herniated disc in her neck.
In April, Madeleine Flannagan was called to a meeting with an ACC-chosen specialist to assess the wage compensation she had been receiving after a car crash in March 2008.
Mrs Flannagan underwent surgery after the accident but continuing pain forced her to give up a legal assistant job at Sanitarium. Because the operation did not fix her pain, ACC reasoned its cause was degeneration, and declined Mrs Flannagan further compensation.
She said this was despite her surgeon indicating that she would recover two to four years after her surgery.
"It can't be degeneration if it's improving. It's at a snail's pace, but if I look back over the last six months, I can see real progress."
Mrs Flannagan said she never had any back or neck problems before her accident, and even rode a "feisty half-Arab" horse the weekend before her crash.
She said she had started legal action against ACC, and was waiting for a hearing date.
ADELE BEVERIDGE, 51
INJURY Chronic pain syndrome stemming from back injury
REJECTED Degeneration
After nearly 10 years of seeing specialists and dealing with review tribunals and a court case, Adele Beveridge has lost all faith in ACC.
The 51-year-old suffered a back injury when she tried to move a trailer, but slipped and fell under it while working for a hire company in 2005. Doctors determined she had a tear in the soft tissue in her spine and a bulging disc which left her with chronic pain syndrome.
They also found she was suffering from osteoporosis. She found the pain made work unbearable so ACC agreed to pay 80 per cent of her wages until in 2007, when they sent her to a specialist who dismissed chronic pain syndrome and blamed the osteoporosis.
The new diagnosis meant the end of her ACC payouts. She took the case to the Auckland District Court, where the judge dismissed the diagnosis given by the ACC-appointed doctor because it was at odds with the medical opinion of other professionals.
Ms Beveridge was awarded back payments for the three years she was without ACC funding.
MIKE ROBERTS, 24
INJURY Shoulder dislocation
REJECTED Previous degenerative injury
How could it be degenerative for any other reason than... being denied the corrective procedure in the first place?It took Mike Roberts three years to get ACC to approve surgery for his shoulder, by which point it had dislocated more than 80 times and his surgeon remarked it should have been fixed years ago.
Mr Roberts first dislocated his shoulder when he was 20 while playing beach rugby in Tauranga in 2007, and since this accident it became injury-prone.
It got to the point where the shoulder popped out as he leaned to get under his car, or he swung his arms to balance himself while playing paintball.
He needed surgery and applied to ACC but was rejected because he had previously broken a collar bone.
He appealed and applied again, told this time the condition was degenerative because the shoulder had dislocated so many times since the original accident.
"How could it be degenerative for any other reason than the excessive dislocations due to being denied the corrective procedure in the first place?" he said.
"It was really frustrating being bounced around all the departments... I was upset and it had to be done."
AMANDA WILSON, 23
INJURY Knee
REJECTED Degeneration
A 23-year-old woman bears heavy costs for doctors' visits and rehabilitation after ACC rejected funding for her knee surgery.
Amanda Wilson was active and "could do anything" before she fell during a netball game in April, with her only previous problem being growing pains when she was 16.
But this was enough reason for ACC to reject supporting her through her surgery.
"The bummer is once they say no, all your rehabilitation costs aren't being paid for," Ms Wilson said.
She had surgery under private insurance but faces recurring costs for ongoing visits to surgeons and physiotherapy every fortnight.
Ms Wilson had the option to take her case to the Disputes Tribunal, but she said that as a 23-year-old hiring a lawyer out of her own pocket was too difficult.
"The ACC isn't aiming to help people, it's purely trying to figure out as many ways as possible of getting out of paying," she said.
The most difficult period was after surgery, when she was on crutches for six weeks and unable to drive. - Reports by Michael Dickison, Katherine Irvine, Nicholas Jones
WHAT ACC SAYS
ACC's purpose is to help treat and rehabilitate New Zealanders who have been injured as the result of an accident. And we are paying for more than 37,000 of them a year to have elective surgery - the overwhelming majority of the requests we receive. Those who we do turn down will be helped either by the public health system or a private insurer.
REASONS FOR DECLINED CLAIMS
Herald articles suggest we have no basis for declines. That is wrong. ACC legislation clearly sets out that we cannot pay for injuries caused by degenerative or pre-existing conditions.
We also base our decisions on medical evidence such as MRI scans and reports from independent medical experts.
MEDICAL ADVISERS
The Herald states that "we use a handful of retired surgeons" to make surgery decisions. ACC advisers all have current practising certificates and in some cases are members of the NZ Orthopaedic Association.
WHEN THEY MAKE THEIR DECISIONS THEY
1. Look at the information provided by the surgeon and other medical providers to see if it supports the causal link between the condition and the original injury.
2.Refer the client for further assessment or a second opinion if they consider there is not enough information.
It is the job of the surgeon to show how the condition that requires surgery is linked to the original injury. In many cases, they are unable to show that.
REVIEW PROCESS
Your article suggests that not everyone has equal access to our review process. Every decision letter clearly describes the review process. This is an opportunity for clients and surgeons to have a free, independent assessment of ACC's decision and to provide any further information they may have.
Our staff make decisions on hundreds of surgery requests a week and we sometimes get those decisions wrong. That's why we have a review process.
WHO PAYS?
Between 2005 and 2009 the cost of elective surgery for ACC grew from $128 million to $240 million. The bottom line is that if we don't control our surgery costs and pay for surgery and other services outside of ACC's legislation then the trade-off is higher levies.
ACC director of clinical services Dr Kevin Morris
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