Understanding claims and cover
When we accept a claim for cover it means there’s been an identifiable accident causing personal injury. Find out more about how we make cover decisions.
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What ACC covers
Video transcript for What ACC covers
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Screen shows What ACC covers. Clock shows watch time of 3 minutes 5 seconds.
Text displays Dr Dilky Rasiah Strategic Clinical Advisor.
Dilky is sitting in a chair facing the camera. A pot plant, water jug, cup of water and pen and notepad sit on a small table beside her.
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Dr Dilky Rasiah: Cover can be a bit of a tricky area and it’s a term you’ll probably hear a lot. We’re going to get into the basics of what we mean by cover. What’s included and what’s not.
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At its core, cover means the claim meets the criteria set out in our legislation. If it does, we’ll contribute to, or fully fund, the treatment or support you provide.
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Screen changes to show Anyone injured in an accident.
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Anyone in New Zealand injured in an accident is eligible for cover. It doesn’t matter who they are or what they were doing at the time. That also extends to those visiting us from overseas.
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Screen changes to show Physical injuries caused by accidents.
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To cover a claim, we need to know that the person’s injury is caused by an accident. That’s what we call causation. For simple claims, like if someone falls off their bike and dislocates their shoulder, causation is easy to see and we can make our decision quickly. But there will be times we will need more information from you or another clinician. Injuries should have evidence of physical damage from the accident.
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But we don’t just cover one-off physical injuries. We also cover mental injury linked to physical harm, a traumatic event at work or a criminal act. It also extends to when a person is injured during treatment, and diseases or infections linked to a person’s job or work environment.
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Screen changes to show Anything not caused by an accident.
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While we do cover a lot of different injuries, there are some things we can’t cover. Generally speaking, these are things not linked to accidents, are part of the natural ageing process, or are pre-existing conditions.
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If your patient is covered and their diagnosis changes, you need to let us know. The support we provide is based on their current injury so if things change, we might need to adjust their level of support to meet their new needs. So, there you have it. That’s the basics of cover, covered!
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Screen shows Chapter two What ACC covers.
Screen changes to roll through four statements: Cover is when a claim meets criteria in legislation. Cover needs causation – a link between injury and accident. Cover also includes mental and treatment injuries. A change in diagnosis could mean a change in support levels.
Screen changes to show For more information and resources visit acc.co.nz/health-providers.
Screen changes again to show the ACC logo and tagline He Kaupare. He Manaaki. He Whakaora. Prevention. Care. Recovery.
Understanding causation
Video transcript for Understanding causation
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Screen shows Understanding Causation. Clock shows watch time of 3 minutes 30 seconds.
Text displays Dr Milly Hanlon, Medical Advisor
Milly is sitting in a chair facing the camera. A pot plant, water jug, cup of water and pen and notepad sit on a small table beside her.
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After you lodge a claim with us there are a few things we need to think about before we can decide on cover for your patient. One of those key things is causation which is very closely linked with cover. Essentially, we need to be sure there's a direct link between the person's injury and their accident. To help explain what we mean by causation, we're going take you through what we consider when making cover decisions.
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When we talk about causation, what we mean is that it's more likely than not, the person's identified injury was caused by their accident. In some instances, drawing a link between the injury and the accident is simple. For example, if a person falls off a ladder and breaks their arm, we can be confident we’ve identified causation. In these cases, we'll be quick to approve cover, meaning the person can receive the appropriate support they need for their recovery. But we know people get injured in many different ways or have pre-existing health conditions which can make this decision trickier.
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In situations where causation isn't immediately clear, we'll need to be satisfied the accident was the material cause of the injury. If the injury is complex or if the claim was lodged more than 12 months after the injury happened, it might take us a bit longer to do that. That's because we consider the evidence for each claim before we make a decision. For example, if a person with a background of osteoarthritis has a fall and suffers a meniscal tear to their knee, causation might be more difficult to determine. While time between the injury and accident is important in most cases, there are other factors we may consider. These include: How the accident or injury happened, whether the force of the accident was enough to cause the person's acute injury and whether there were any underlying conditions or factors which contributed to the injury.
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Our legislation doesn't allow us to cover pre-existing conditions which have been aggravated by an accident. But cover may be possible if the accident has caused a new injury.
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The ACC-funded treatment, rehabilitation and care our clients receive is based on their unique injury-related needs. That could be a range of services such as home help, physiotherapy, rehabilitation equipment and in some cases weekly compensation. Over time, your patient's needs might change too so it's important to let us know if you need to update their diagnosis. Understanding causation helps us tailor the appropriate support to get our clients back to independence. So there you have it, the basics of causation. Thanks for watching.
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Screen changes to roll through three statements: Causation: Means the accident more likely than not caused the injury. Is considered on a case-by-case basis. Allows clients to receive appropriate supports.
Screen changes to show For more information and resources visit acc.co.nz/health-providers.
Screen changes again to show the ACC logo and tagline He Kaupare. He Manaaki. He Whakaora. Prevention. Care. Recovery.
Quick guide: Causation
Before deciding on cover, we need to be confident it’s more likely than not the person’s injury was caused by their accident. The link between the injured person's personal injury and the accident is known as causation.
Making cover decisions
We make cover decisions based on the Accident Compensation Act 2001.
How we make cover decisions based on legislation
We cover a claim when there's a personal injury from an identifiable accident. The link between the client's personal injury and the accident is known as causation.
With simple claims, causation is easy to establish and making a cover decision is quick. If the injury type is more complex or there's a delay in making a claim, establishing causation can take longer.
Sometimes we'll need to ask a specialist to help establish causation. There are pathologies or diagnoses that we don't cover, including conditions caused by the ageing process and pre-existing conditions.
When working with our clients, you'll need to consider whether the support you are providing is for the injury we have covered. The covered injury is identified by a Read code.
Cover and support
If we accept a claim, the client can receive supports they need to recover from their covered injury. Supports may include treatment, weekly compensation, or rehabilitation.
Supports must:
- be necessary
- be appropriate
- be timely
- be of the required quality
- not be excessive in number or duration
- follow evidence-based guidelines.
Change in diagnosis
It's important you tell us of any change in the client's diagnosis as soon as possible. A change in diagnosis could impact the supports they receive, for example a sprain may need different supports over a shorter period than a fracture or break.
Updating or changing a diagnosis
It's also important you tell us of situations where the client needs support that isn't linked to the covered injury so we can work with you to help them further.
Types of claims we cover
We've provided below an overview of straightforward, complex, and other types of injuries we cover, as well as examples.
This is not a definitive list. We assess each claim on its merits, the circumstances of the case, and any underlying conditions the client may have. If in doubt, you should lodge the claim with as much relevant information as possible or refer the client to a medical practitioner who can to allow us to make the appropriate cover decision.
Examples of straightforward claims lodged by allied health and/or medical practitioners
| Injury examples | Caused by an accident, an identifiable event involving one or more of the following: | What we can't cover |
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Examples of complex claims lodged by medical practitioners
| Injury | Caused by | Claim example | What we can't cover |
| Mental injury - defined in AC Act 2001 as a "clinically significant behavioural, cognitive or psychological dysfunction" |
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| Treatment injury |
Treatment given by, or at the direction of, a registered healthcare professional. This includes omission of treatment and failure of medical equipment |
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| Work-related gradual process injury | Work tasks or environment which happens over time |
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Examples of other claims including dental and allergy
| Injury | Caused by | What we can't cover |
| Dental – damage to teeth or dental prosthetic, which must have been worn at the time of injury |
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Allergic reactions, eg local allergic or anaphylactic reaction Cover for allergic reactions caused by an accident (ACC7822) |
An accident, eg puncture to the skin from a bee sting. |
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| Exposure to elements where injuries result in death or restriction of ability to perform normal duties for more than one month | Exposure to sun, wind, or extremes of temperature, lasting less than one month. | Common sunburn-unless incapacity lasts for more than one month. |
| Damage to prosthetic or implant that replaces a part of the body |
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Wear and tear. |
| Pregnancy |
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Cover is limited to the physical and mental consequence of the pregnancy after the date of the personal injury to the mother and doesn’t extend to medical costs for the child or the cost of raising the child. |
| Inhaling or swallowing a virus, bacterium, or protozoa | Criminal act by another person. | Where there is no criminal act. |
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Accidental death Note: These claims are commonly lodged via undertakers or the DHB. |
By accident, including self-harm covered mental injury and work-related gradual process disease or infections. |
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Criteria for cover
We have specific clinical considerations for a range of injuries, including for some surgical requests.
Using these guidelines will help us to make a quicker decision for your patient.