When the Southern Cross Member Advocacy team successfully challenge an ACC claim, it’s not just our member who wins – their employer can too. It’s another good reason why it pays to look after your team with a Southern Cross health insurance work scheme.

What is the Southern Cross Member Advocacy team?

It’s a no-cost service that advocates to have ACC review claims for members, which we believe have been incorrectly declined. These claims can relate to a personal injury caused by an accident, treatment injury or a work-related gradual process.

Over tfhe past 12 months, the team has:

• supported over 200 Southern Cross members with advocacy services
• recovered $4.95 million in funds from ACC for the Society and over $300,000 in co-payments for members.

Employers benefit from a successful challenge too, because:

• it helps us keep premiums down for members and employers
• employers can often recover funds too, like the cost of additional leave
• employees may be able to access additional entitlements that could help them with managing their recovery and returning to work sooner.

Accessing ACC entitlements

A successful ACC claim may also include entitlements not covered by a member’s health insurance, such as:

• weekly compensation
• rehabilitation (e.g. physiotherapy, occupational therapy, nurse)
• transport costs (e.g. treatment, rehabilitation or getting to and from work)
• mobility equipment including in the workplace (e.g. crutch hire, wheelchair hire)
• home help
• childcare
• other help, such as the return to work programme or a pain management programme.

It’s good to be aware of ACC’s return to work programmes which can help individuals recover from an injury and get back to work sooner. These programmes typically involve an Occupational Therapist making recommendations on activities, equipment, changes to a workplace or tasks, or identify areas to ease the person back into their role.

Advocacy in action - a case study

To better understand how the team can help, let’s look at a real situation. Arthur’s* case is a typical one the team deal with every day.

The situation

Arthur slipped in a feed-out wagon and fell onto his shoulder, requiring a rotator cuff repair. Because Arthur was part of a farming corporate group, his claim went to a private ACC claims management organisation. They stated that because Arthur was not acutely incapacitated at the time of the accident, the tear in his rotator cuff was not traumatic. They were also of the view that, as Arthur is a ‘stoic’ individual who carried on working and managing his pain without surgical intervention, it suggested the tear was not accident-related.

Arthur approached Southern Cross to get approval for his surgery. The Southern Cross Member Advocacy team saw that his declined ACC claim was worth challenging, so helped Arthur through the process.

The outcome

ACC revoked the decision and accepted the claim, which resulted in:

1. Arthur receiving on-going physiotherapy and rehabilitation for the shoulder.
2. ACC reimbursing Arthur’s employer for special leave pay (between two to six weeks’ pay).
3. Southern Cross Health Society being reimbursed $20,000 for the cost of the shoulder surgery.

To find out more about the Southern Cross Member Advocacy team email [email protected] or call 0800 800 181.

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