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How we make cover decisions

When we get your claim, we look at the rules set out in the Accident Compensation Act 2001 to see if we can cover your injury. The Act has different rules for different types of injuries.

On this page

    One-off physical injuries

    Your injury must be caused by:

    Your injury can be caused by:

    • an outside force on your body
    • twisting your body
    • inhaling or swallowing something
    • burning or radiation
    • absorbing chemicals through your skin
    • exposure to extreme weather or temperatures.

    Your injury must not be caused by:

    • inhaling or swallowing a virus, bacterium or protozoa unless it’s a criminal act by another person.

    Flowchart on cover decisions - one-off physical injuries

    Conditions that come on gradually from work

    Your injury must:

    Your work must have:

    • a specific characteristic that contributed to your injury
    • made it more likely you'd get this injury.

    Your injury must not be:

    • caused by a pre-existing condition.

    Your injury can be a heart or brain-related issue if it:

    • happened at your place of work
    • was caused by excessive physical strain from your work.

    Flowchart on cover decisions - gradual process injuries

    Mental injury caused by a physical injury

    Your injury must be:

    • diagnosed as a mental condition by a health professional
    • caused by a physical injury we’re covering.

    Flowchart on cover decisions - mental injuries caused by physical injuries

    Work-related mental injury

    We can also cover mental injuries if you've experienced, seen or heard a traumatic event at work. This is even if you haven't been physically injured.

    Your injury must be:

    • diagnosed as a mental condition by a health professional
    • caused by a single event, or a series of events with the same cause.

    You must have:

    • seen, heard or experienced the event first hand – not through television, pictures, radio etc.
    • got the injury at work.

    The work-related event must:

    • be something that would distress, horrify or alarm most people
    • happened with little or no warning.

    Flowchart on cover decisions - work-related mental injuries

    Sensitive claims

    Your injury must be:

    • diagnosed as a mental condition by a health professional
    • caused by a criminal act we cover.

    Relevant legislation

    Section 21 of the Accident Compensation Act 2001

    See the full list of criminal acts we cover:

    Schedule 3 of the Accident Compensation Act 2001

    Flowchart on cover decisions - sensitive claims

    Injuries caused by treatment

    Your injury must be:

    • caused by treatment from a registered health professional.

    Your injury must not be:

    • a normal side-effect of the treatment
    • caused by a clinical trial you agreed to in writing.

    Flowchart on cover decisions - treatment injuries

    Hearing loss

    Your injury must have:

    • caused the hearing loss – this includes work-related injuries, head injuries and treatment injuries we cover
    • made you lose at least 6% of your hearing.
    Last published: 31 January 2018