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
We make cover decisions based on the Accident Compensation Act 2001.
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.
- 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.
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.
|Injury examples||Caused by an accident, an identifiable event involving one or more of the following:||What we can't cover|
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|
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.||
|Gradual process, disease, or infection||Work tasks or environment.||
||Medical conditions or gradual process injuries not caused by work tasks or environment|
Mental injury – a clinically significant behavioural, cognitive, or psychological dysfunction
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.
|Mental health issues that aren't attributable to a criminal act.|
|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||
Allergic reactions, eg local allergic or anaphylactic reaction
|An accident, eg puncture to the skin from a bee sting.||
|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||
||Wear and tear.|
||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.|
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.||
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.