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.

On this page

    What ACC covers

    What ACC covers transcript

    About cover

    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.

    Using the right 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.

    Treatment we can help pay for

    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.

    Injuries we cover

    Injuries we don't cover

    Injury examples Caused by an accident, an identifiable event involving one or more of the following: What we can't cover
    • Sprain
    • Strains
    • Bruises
    • Lacerations
    • Abrasions
    • Amputations
    • Dislocation
    • Breaks
    • Concussion
    • Foreign body in eye
    • Burns
    • Poisoning
    • Self-inflicted harm.
    • Application of force or resistance external to the body (including gravity)
    • Sudden body movement to avoid force or resistance, eg jumping out of the way of a falling object
    • A series of related events within a defined timeframe, which is not usual for that person eg digging the garden over the weekend
    • Inhaling or swallowing something.
    • Injuries caused by the ageing process (degeneration)
    • Pre-existing developmental or bio-mechanical abnormalities
    • Accidents without an injury
    • Injuries not caused by an accident, eg coughing – an internal force – which causes a strain
    • Pain where there is no identifiable physical injury or accident eg woke up with a stiff neck
    • Injuries occurring outside of New Zealand to non-New Zealand citizens or residents
    • Injuries before 1974.

    Complex claims include:

    • sensitive claims
    • mental injury
    • accidental death
    • dental injury
    • hearing loss
    • work-related gradual process injury
    • injuries that could have many causes.

    A cover decision on a claim such as these may take up to nine months.

    Injury Caused by Claim example What we can't cover

    Treatment injury

    Treatment injury claim lodgment flowchart

    Note: Treatment injuries occurring overseas should be discussed with DHB ACC contact.

    Treatment given by a registered healthcare professional, including omission of treatment and failure of medical equipment.
    • Some post-surgical infections
    • Bowel nick during surgery
    • Pressure injuries
    • Some adverse medication reactions
    • Some birth injuries.
    • Necessary parts or ordinary consequences of treatment
    • Where there is no evidence of physical injury, eg pain alone
    • Clinical trials agreed to in writing.
    Gradual process, disease, or infection Work tasks or environment.
    • Tendonitis from muscle overuse caused by heavy lifting at work
    • Knee osteoarthritis caused by carpet laying
    • Exposure to asbestos in the workplace, developing into mesothelioma or asbestosis.
    Medical conditions or gradual process injuries not caused by work tasks or environment

    Mental injury – a clinically significant behavioural, cognitive, or psychological dysfunction

    • Covered physical injury where the effects of the injury have led to a mental injury
    • Sudden, traumatic event while at work
    • Treatment injury.
    • Leg amputation after a car accident, subsequently developing depression due to the injury
    • A dairy owner is robbed at knifepoint while working and develops Post Traumatic Stress Disorder
    • Witnessing death or severe injury of a colleague at work.
    • Pre-existing mental health issues
    • Mental health issues that aren’t attributable to injury or workplace event, eg mental injury to a person who witnesses a car accident but didn’t sustain physical injuries and was not at work
    • Injuries occurring outside of New Zealand to non-residents or citizens.

    Mental injury - sensitive claim

    Certain criminal acts, commonly sexual assault.

    Disclosure of any event as defined in Schedule 3 of the Accident Compensation Act 2001. The event doesn't need to be formally reported to the police or there to be any evidence of physical harm.
    Schedule 3 on NZ Legislation website.

    Mental health issues that aren't attributable to a criminal act.
    Hearing loss
    • Covered physical injury
    • Work type or employment history.
    • Head injury results in loss of hearing
    • Deafness caused by noise at work.
    • Age-related hearing loss where there is both injury and age-related loss, ACC may contribute towards the proportion that is injury related
    • Less than 6% hearing loss.
    Cardiovascular or cerebrovascular events Excessive physical strain at work whilst working. An office worker is asked to carry heavy boxes upstairs and resulting in a heart attack. Events that did not occur at work and while working.
    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
    • An accident eg hit in the mouth with a ball, damaging teeth
    • Treatment injury, eg removal of the wrong tooth.
    • Normal wear and tear
    • Dental disease or decay
    • Normal use of teeth, eg biting into hard food.

    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.
    • Underlying allergy or health conditions
    • Chronic inflammatory conditions.
    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
    • By accident
    • Treatment injury.
    Wear and tear.
    • Rape
    • Treatment injury eg failed tubal ligation.
    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.

    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.
    • Death not attributed to a covered injury or accident
    • Medical events.

    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.

    Criteria for cover resources

    Last published: 2 December 2020