ACC is declining genuine claims for surgery on "unfair and unreasonable" grounds, a respected Wellington neurosurgeon says.
Martin Hunn, a specialist at Wellington and Wakefield hospitals, has had three patients turned down for spinal surgery since January, with ACC saying their injuries were caused by pre-existing wear and tear, not accidents.
"These are three cases where I've been more than surprised at the decision that's been made."
One of the patients, Wellington man Brandon Dixon, had his claim rejected despite ACC paying for physiotherapy for the injury before he applied for surgery.
Mr Dixon, 39, suffered a prolapsed disc in his neck during a collapsed scrum in a club rugby game last year.
He can no longer play sports and is unable to sit down for more than a few minutes because of pain in his neck and right shoulder, which also keeps him awake at night.
He is worried about his partner, Tess Bates, who is six months' pregnant with their first child. "What I can do around my home is limited. I mow the lawn and then I'm buggered for the rest of the weekend.
"My fear is I won't be able to help [Tess] when the baby arrives."
His claim was declined because his medical scans also showed there was degenerative damage near the injury – despite Mr Hunn's assessment that the degeneration was normal and not the cause of the injury.
In a letter to ACC, Mr Hunn expressed his "strong disagreement" with its decision.
"[The injury] is entirely consistent with cervical disc prolapse caused by the force imparted to his neck at the time of the scrum collapse and any other interpretation would be unfair and unreasonable."
Mr Hunn told The Dominion Post ACC's decision set a dangerous precedent. "Virtually everybody who's 40 or over is going to have some wear and tear in their neck."
Once ACC declined someone, there were "all sorts of other repercussions", he said.
"The longer treatment is delayed, the lower the chance of getting a good outcome." Because he was declined, Mr Dixon was also no longer eligible for the physiotherapy he had been having to treat his neck.
ACC has angered patients and surgeons by assessing surgery claims more strictly since October last year.
It turned down more than 8500 claims for surgery in the last financial year, compared with about 5000 the year before.
Sue North, ACC's acting director of operations, said ACC was still approving more than 80 per cent of surgery claims. It would fund about 40,000 elective surgeries this year.
ACC's costs had become unsustainable, rising from $100 million in 2003 to $250m last year, she said. Mr Dixon's GP notes had not mentioned a "specific traumatic event" during the rugby match.
However, ACC was now reconsidering its position after receiving more information from Mr Hunn. Mr Dixon could also ask for an independent review, Ms North said.
Jean-Claude Theis, New Zealand chairman of the Australasian College of Surgeons, said the college had requested a meeting with ACC to discuss how claims were being assessed by the organisation's medical advisers.
A spokesman for ACC Minister Nick Smith said the minister could not comment on cases under review.
- The Dominion Post
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