Saturday, May 14, 2011

ACC admits 44 per cent of reviewed elective surgery decisions were wrong

ACC has said that too many ACC decisions rejecting elective surgery have been “overturned on review”, after being declined due to the injury apparently displaying substantial aspects of degeneration.

The report of a review on ACC elective decision making is here [PDF].

What ACC should have said was that too many more claimants have been handed down incorrect decisions in the first place and there are many more that could have been overturned had the claimants bothered to go to review.

About 10,000 fewer elective surgery ACC claims were paid than the same period the previous year. Between July 2010 and March 2011 an average of 44 per cent of surgery decisions were overturned at review – meaning they shouldn’t have been made in the first place. Of those that had their request for surgery declined, 53 per cent believed ACC had not provided a clear explanation as to why they were declined.

That doesn’t sound all that good.

ACC maintains it was applying the legislation strictly. In reality it was using the review process to determine tough decisions –and riding roughshod over those who didn’t review decisions they disagree with.

This is not strict application of legislation, its blatantly incorrect application of legislation in attempts to control spending on elective surgery. So spending controls on elective surgery are administered by a hope that few would go to review, and those that did go to review have the decision upheld due to dodgy medical opinions that would say the medical condition was caused by degeneration. All at a cost of several thousand dollar for each review.

About 800 claimants apply to review ACC decisions each month. In recent times 4000 people have complained to the NZ Herald about elective surgery review alone. In the year to March, millions of dollars were spent defending ACC decisions that should never have been made in the first place – but could have gone to things like, well… elective surgery, perhaps.

When a case goes to review, ACC should really be revisiting the decision in line with s65 of the ACC Act to see if it should be overturned before review. It appears that this is not being done at all.

ACC appears to be, in the words of Beattie J, too quick to “ seize on that identified state of affairs ( i.e. degeneration) and use it as a reason for declinature".

And he should know, he presides over cases that are upheld at review that go to Court. Overall, around 40 percent are overturned. In fact, as an example, in October last year, of 25 decisions 10 were overturned, meaning ACC and its subsidiary, Disputes Resolution Services, each make many incorrect decisions that are not rectified for some months - even years - later.




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