How we work with ACC
Private and public healthcare
New Zealand has a public healthcare system that treats acute health conditions and provides some elective surgery. We also have a public, no-fault accident insurance scheme (ACC) covering accidental injury.
These are effective in providing healthcare support for accidents and acute and urgent care. But public hospitals cannot do everything for everyone.
Private health insurance complements these public services by making private healthcare available.
How we work with ACC – the Southern Cross Member Advocacy team
Southern Cross cares about the health and wellbeing of our members. In an effort to support you when you undertake an ACC review, the Southern Cross Member Advocacy team is there to help.
One of the ways Southern Cross helps is by offering all members a no-cost advocacy service to review an ACC decline from either a personal injury caused by accident, treatment injury or a work-related gradual process.
If the medical evidence shows that your ACC decline may be incorrect, and your treating specialist is willing to provide a supportive opinion, the Southern Cross Member Advocacy team may be able to assist. We can guide you through the process of an ACC review, providing knowledge of the system and support with the goal of having the ACC decline overturned and the treatment funded by ACC. If successful, you may be able to request backdated compensation and other entitlements from ACC.
We generally assist members who have recently received an ACC decision declining funding for surgery, or a decline of cover for a physical injury related to this. If you have received an ACC decision about something else, we may not be able to assist.
Who covers what?
ACC has two categories of cover: personal injuries caused by accident or gradual work-related stresses, and personal injuries caused by medical treatment (treatment injuries). The different categories of cover are treated differently by ACC and therefore by Southern Cross.
Southern Cross health insurance policies do not cover treatment for injuries which ACC has agreed to cover. If your treatment relates to an injury or health condition which is covered by ACC, you or your doctor must, therefore, apply to ACC for treatment funding in the first instance.
In circumstances where ACC does not pay the full amount charged for treatment you may be able to claim the remainder under your Southern Cross policy. These may include ACC surcharges and partial payments.
If ACC declines to cover a treatment for personal injury caused by accident
If your claim is declined by ACC and the treatment you require is covered under your Southern Cross policy, Southern Cross may agree to cover the cost of that treatment. The Southern Cross Member Advocacy team may also work with you to apply for a review of ACC’s decision. A review can take place either before or after treatment is provided and will not delay your access to treatment.
If you or your doctor think that ACC’s decision is incorrect, and your treating specialist is supportive of your case, please contact the Southern Cross Member Advocacy Team. We will review the decline documentation and offer advice as to whether a review of ACC’s decision is worthwhile. If there is a case for review of the decision, the Southern Cross Member Advocacy Team can work with you to guide you through the review process.
Please find the personal injury caused by accident (PICBA) process below:
If ACC declines to cover a treatment injury
Occasionally, a patient suffers an unexpected injury during medical treatment or surgery. If a registered health professional was treating you and the treatment directly caused your injury and is not a normal side effect of your treatment, you may be eligible for ACC cover for a treatment injury.
As in the case of an injury caused by accident, you need to first lodge a claim with ACC for a treatment injury (see chart below). For more information visit the ACC website.
Unlike a personal injury caused by accident, ACC does not require a claim to be lodged or a decision on cover or treatment funding to be made before you can undergo treatment for your treatment injury. This reflects the fact that treatment injuries often need urgent treatment and it would not always be possible or appropriate to lodge a claim or request for prior approval prior to treatment. However, if ACC has already accepted cover for your treatment injury, approval for treatment funding must then be sought from ACC before treatment can take place.
Treatment injuries can be complex, and it is often difficult to determine whether a particular injury meets ACC’s criteria for cover. If you have any questions about whether you may have a treatment injury, you can contact the Southern Cross Member Advocacy team for advice.
You may be eligible for ACC entitlements
If your ACC decline is overturned, you may be eligible for ACC entitlements that may include the following:
- Weekly compensation
- Rehabilitation (eg physiotherapy, occupational therapy, nurse)
- Transport costs (eg treatment, rehabilitation or getting to and from work)
- Mobility equipment (eg crutch hire, wheelchair hire)
- Home help
- Other (eg Return to Work programme, pain management programme)