Editorial: Has ACC become too focused on making savings?

OPINION: Since ACC began operating 36 years ago its principle of providing comprehensive no-fault personal injury cover has been the envy of many other nations.

Increasingly over recent months, however, ACC's continued commitment to this principle has been called into question on a range of fronts. The latest, which has been highlighted by Wigram MP Jim Anderton, relates to the number of patients refused surgery cover.

The Press this week reported on an experienced surgeon's claim that a man was refused surgery cover for a shoulder injury, based on the belief that a rotator-cuff was unlikely to be injured in a fall. A concerning feature of this case is the surgeon's insistence that the research relied on by ACC in its decision was carried out more than 75 years ago and was out of date.

Then there was the case of a 15-year-old Christchurch schoolgirl who was refused surgery cover for a hip injury incurred while playing netball. ACC justified its refusal by claiming that the girl had a pre-existing condition because her hip was an unusual shape.

Yet, as Anderton noted, this pre-existing condition was clearly not significant enough to preclude her from playing a rigorous sport like netball. One ACC consultant also maintained that too many rejections for surgery were arbitrary and that those aged over 30 with back, shoulder or knee injuries would invariably be declined an operation by ACC.

Presumably they would be regarded as having a pre-existing condition or their injury might be deemed to be age-related degeneration.

The impression left is that ACC is too eager to find reasons, such as a pre-existing condition, to decline surgery cover and that this has been driven by a Government message to the corporation to restrain spending increases.

ACC points to the fact that 77 per cent of its decisions taken to appeal were upheld and, despite claims of cost-cutting moves since late last year, this figure had not changed.

It also defends itself by arguing that each review costs $500 and that it would not spend this money if it thought a decision would be quashed.

But these figures can be read another way. Since October last year some 265 or almost one quarter of surgery appeals have been successful. Even taking into account ACC's view that medicine is not a precise science this is still a significant number.

And how many other injured people are refused surgery and might have a case to challenge the decision but do not appeal because of the cost of the process? The $500 cost to ACC of an appeal, moreover, is small change compared to the savings made in surgery costs each time a declined person with a good case for appeal does not do so.

Those refused surgery cover after an accident might also require an even more expensive operation if their condition deteriorates over time. This would have to be paid for, if not by ACC then by the public health system or through private insurance or savings.

Those refused surgery cover on questionable grounds must bear the pain of their injury. Those who are tradesmen, working in environments where injuries can occur and which require a fit body, might also face the economic cost of not being able to work.

The suspicion that ACC is too focused on making savings is not confined to surgery cover. Other areas of its operations have, since late last year, also come under scrutiny. These include curtailing the rise in physiotherapy costs, pruning its long-term client list and tightening its application of the ACC eligibility criteria for those with mental injuries caused by sexual abuse.

ACC must, of course, weed out frivolous claims. But it must also be more transparent about the processes and criteria it uses to determine whether to approve or decline claims.

This would provide reassurance to the public that ACC itself is not acting frivolously by rejecting legitimate claims and that it is not eroding or diluting for financial reasons the noble principle with which it was set up back in 1974.

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