Little hope for patients denied ACC

Orthopaedic surgeons are concerned about rising ACC denials for surgery, saying patients have little chance of getting help in the public system.

This month The Marlborough Express ran a story about Blenheim woman Yvonne Everson who had ACC refuse to pay for surgery to a broken foot, when it had accepted previous claims for treatment relating to the injury.

The ground for refusal was that the accident had exacerbated an earlier injury.

However, Ms Everson's orthopaedic surgeon confirmed it was more likely that the dropped firewood caused the fracture.

In last Friday's letters to the editor, Marie Lutherus of Picton said her husband hurt his shoulder while loading his truck and had doctors' visits, acupuncture and cortisone injections covered by ACC. However, when surgery was suggested ACC would not pay for surgery or wages while he was off work. Again, the ground was that this was an old injury.

Christchurch orthopaedic surgeon John McKie said ACC was increasingly turning down surgery claims, often on the basis of pre-existing conditions. This was putting increased pressure on public hospital orthopaedic services, which were not receiving any additional funding.

One surgeon he knew had 80 patients on a waiting list for shoulder surgery, Mr McKie said.

Anyone needing a hip or knee-joint replacement received good service in the public system, but for others it was "much more impaired".

People who could not get cover through ACC could be booked for a specialist appointment only if they could be seen within six months of a GP's referral letter, he said. From there, they could go on the waiting list for surgery only if they could receive it within six months.

The department was referring a third of patients who had specialist assessments recommending surgery back to their GPs because they did not fit those criteria.

People's hopes were often raised when they were granted initial treatment cover by ACC. However, they could then be denied surgery cover if ACC decided part of the problem was due to a pre-existing condition, Mr McKie said.

Ten years ago, more than 99 per cent of ACC claims were accepted, representing about 1.5 million claims for the 1998-99 year. Just over 11,000 were declined.

Over the past financial year, more than 1.7 million claims were accepted and about 40,000 declined, lowering the approval rating to 96 per cent. More than 8500 claims for surgery were declined in the past financial year, compared with 4957 in 2007-08.

Soft-tissue injuries, including strains or sprains, accounted for nearly 58 per cent of accepted claims 10 years ago and nearly 60 per cent over the past year.

ACC operations director Graham Bashford said ACC had been scrutinising requests for surgery more closely to ensure they were actually caused by an injury.

"That is appropriate since ACC levies are only meant to cover injury and not other causes such as degeneration," he said.

This year the corporation received more than 56,000 surgery requests, up from 40,000 just two years ago. Eighty-four per cent of those were approved, at a cost of more than $220 million.

"The funding for surgery not covered by ACC should always have come from the person's private insurer or the wider public health system," Mr Bashford said.

Health Funds Association New Zealand president Roger Styles said the high number of ACC denials was increasing claims costs by 2 to 3 per cent.

Private insurance excluded anything accident related, so patients had to apply to ACC and get a rejection letter before they could get private cover.

"It's concerning to the degree that there might be further push-backs," Mr Styles said.

"From this month, ACC will require co-payments from patients for physiotherapy, which will also have an impact on insurers who cover top-ups for ACC in their policies."

-With Fairfax

- The Marlborough Express