Surgeon questions ACC decision

ACC used outdated, 1934 research to reject surgery cover for an electrician's shoulder injury, an orthopaedic surgeon says.

The experienced surgeon, who did not want to be named, said the research was cited by ACC medical experts in a man's appeal.

The electrician had injured his shoulder in a fall and was denied surgery cover.

The surgeon said the 1934 research – which contended a rotator-cuff was unlikely to be torn in a fall – was out of date.

"It has been shown to be untrue. That was dispelled many years ago," the surgeon said.

"That is the level of competence we seem to be getting from these guys ... It is very hard to argue rationally when dealing with such unreasonable statements.

"Patients are getting a really poor deal ... Often they have lost their business over the injury because they are tradies."

ACC has sparked anger by assessing surgery-cover claims more strictly since October, and rejecting more claims that may have been caused by a pre-existing condition.

The orthopaedic surgeon said since the change, 85 per cent of patients needing shoulder surgery had been refused ACC cover.

The surgeon did not want to be named as the New Zealand Orthopaedic Association said it wanted to discuss the concerns privately with ACC.

Christchurch MP Jim Anderton, who raised the surgeon's concerns, said the public "have been kept in the dark" over the ACC-assessment changes.

"The typical patient being rejected is fit and well, and has been involved in occupations like the construction industry up until the time of their injury," Anderton said.

"There's no money saved here; specialists predict that up to 50 per cent of these people who don't get treatment straight away will have marked deterioration as they get older and will require much more expensive surgery later in life."

New figures show that since October, one in four appeals against surgery-cover rejection has been successful.

There have been 1141 appeals through the Disputes Resolution Service since October, with 265 (23 per cent) successful.

Christchurch ACC consultant Ross Harland, who has won 10 appeals in the past few months, said many rejections were arbitrary.

"If you are over 30 and you have a shoulder, knee or back injury, you can guarantee your surgery is going to be declined," he said.

"A lot of people do not challenge decisions because they are put off by the cost.

"ACC are playing a numbers game and hope some people walk away from it rather than pursue it."

ACC director, operations, Graham Bashford said it rejected any suggestion it was turning down legitimate claims and forcing people to go to review.

"ACC pays $500 for every single review. Why would we waste that money if we thought the reviewer would quash our decision," he said.

Bashford said about 77 per cent of ACC decisions taken to review were upheld, and the figure had not changed.

"Medicine is not a precise science and there can be different opinions on the cause of a problem," he said.

He said ACC employed practising doctors, surgeons and other specialists to make sure its decisions were robust, but at times independent reviewers were of a different opinion.

Bashford said ACC had found many requests were caused by pre-existing conditions that were not covered.

- © Fairfax NZ News