Costs covered by ACC: Treatment, compensation and other support

 

If your injury is covered by ACC, then you’re entitled to medical treatment; compensation for loss of wages or salary; rehabilitation to help you regain your independence at work and outside work; and other assistance. The ACC scheme calls these your “entitlements”.

Accident Compensation Act 2001, s 69

The main ACC entitlements are:

  • treatment and rehabilitation – both vocational rehabilitation and social rehabilitation)
  • weekly compensation for lost wages or salary
  • lump-sum compensation for permanent disabilities (“impairment”)
  • support for family members after a fatal injury.

When ACC can refuse you an entitlement

Accident Compensation Act 2001, ss 117-122

ACC can refuse you entitlements in certain cases, including for as long as you unreasonably refuse or fail to:

  • meet a requirement under the ACC laws to do with your claim (like having an assessment)
  • have medical or surgical treatment for your injury, or
  • agree to or follow an individual rehabilitation plan (see “How your rehabilitation plan is decided”).

You can also be refused an entitlement if you:

  • deliberately injured yourself, or
  • were injured committing a crime that carries a maximum jail term of two years or more (even if you’re sentenced to less than two years or to home detention), or
  • are in prison, or
  • have claimed compensation (“damages”) for your injury through the courts in certain situations.

After you start receiving ACC entitlements, ACC can suspend or cancel an entitlement if they’re not satisfied on the basis of the information they have that you’re entitled to go on receiving it. If they intend to do this ACC have to give you advance notice in writing, a reasonable amount of time before they suspend or cancel the entitlement.

Medical bills

What kinds of treatment are covered by ACC?

Accident Compensation Act 2001, ss 6, 7, 73, 74, Schedule 1, clauses 1-6

Typical examples of treatment include:

  • emergency treatment at hospital A&E departments
  • other hospital treatment
  • visits to GPs and physiotherapists
  • visits to specialists, such as surgeons.

If you get emergency treatment at a hospital A&E after an accident, you don’t need to make a specific ACC claim for this. This is because emergency hospital treatment is bulk-funded by ACC.

Other treatment providers you can see under the ACC scheme include: acupuncturists, audiologists, chiropractors, counsellors, dentists, doctors, medical laboratory technologists, nurses, occupational therapists, optometrists, osteopaths, physiotherapists, podiatrists, and speech therapists.

Checklist for whether your specific treatment is covered

ACC has to pay for your treatment if the treatment is:

  • given to restore your health as far as possible
  • necessary, appropriate and of the required quality
  • performed only as often as necessary
  • given at appropriate places and times
  • of a type normally provided by doctors and other treatment providers
  • provided by someone who’s qualified and who normally provides it, and
  • provided only after ACC has agreed to it (except for emergency treatment and some other special cases).

ACC may also have to cover some or all of the cost of other services related to the treatment (“ancillary services”), such as accommodation, transport, medicines and lab tests.

In deciding if your treatment meets these requirements, ACC takes into account:

  • how serious your injury is
  • the generally accepted treatment for these types of injury in New Zealand
  • other treatment options available in New Zealand
  • the costs compared with the benefits you’re likely to get from the treatment.

Loss of income

Weekly compensation (weekly ACC payments)

Accident Compensation Act 2001, ss 97-106, 112, 113; Schedule 1, clauses 32-53

Weekly compensation is compensation for loss of income or loss of the ability to earn money as a result of your injury. You’re paid 80 percent of your pre-injury weekly earnings, up to a weekly maximum.

ACC starts paying weekly compensation only after your first week of being off work. However, if you were injured at work, your boss has to pay you compensation in the first week. If your injury didn’t happen at work, you don’t get any compensation for the first week, either from ACC or your boss.

If you have some income during the period of incapacity from your injury, ACC will reduce the amount of weekly compensation they pay you.

You qualify for weekly compensation both if you’re an employee and if you’re self-employed. (This includes independent contractors.).

You may also qualify for weekly compensation even though you recently stopped working. This applies if:

  • your final pay covers the period since you stopped work
  • you were injured within four weeks after stopping work and you’d arranged to return or start a new job within three months (or within 12 months if you’re a seasonal worker)
  • you were injured while on parental leave.

Qualifying for weekly compensation: The “incapacity” test

If you were working when you were injured and you’re unable to work because of the injury, you’ll qualify for weekly compensation.

You’ll also qualify if you were on parental leave when you were injured, if your injury means you’re unable to go back to work when your parental leave ends. Your entitlement to weekly compensation begins from the date you would otherwise have had to go back to work at the end of the parental leave.

The test is different if:

  • you had stopped working for a short time
  • you had bought the right to weekly compensation
  • you were under 18 when you were injured, or were in full-time study that you began when you were still under 18 (you’re called a “potential earner” in those situations).

In those cases, the test for whether you’ll get weekly compensation is: Does your injury stop you doing the kind of work you’re qualified for?

How long will I get weekly compensation for?

Usually, you’ll get weekly compensation until you’re able to do your job again. But if you’re permanently incapable of doing your pre-injury job, ACC doesn’t usually allow you to get weekly compensation indefinitely (although this does happen in some cases – for example, with serious brain or spinal injuries).

Instead, when your vocational rehabilitation is finished, you’re assessed on the basis of the “vocational independence” test – that is, whether you’re capable of working full-time in a job for which you’re suited by your experience, education or training. In deciding what kinds of jobs you’re suited for, the assessors have to take into account how much you were earning before you were injured.

If the assessors decide you do have vocational independence, your weekly compensation will continue for another three months and then it will stop.

If you can’t find a job during those three months, you’ll need to register with Work and Income to apply for a benefit, such as jobseeker support (see the chapter “Dealing with Work and Income”).

If your condition gets worse later on, so that you no longer have vocational independence, you can reapply to ACC for weekly compensation.

Rehabilitation: Helping you regain your independence

Accident Compensation Act 2001, s 70

If you’re covered by ACC, you’re entitled to rehabilitation services to help you regain your health and your independence as much as practicable. You’re responsible for taking an active part in your rehabilitation with the goal of leading as normal a life as possible, given your injuries.

Accident Compensation Act 2001, s 6

You’re entitled to:

  • social rehabilitation, to restore your independence in your everyday life
  • vocational rehabilitation, to restore your independence in your working life.

How your rehabilitation plan is decided

Accident Compensation Act 2001, ss 75-80 & Schedule 1, clauses 7-10

If you need longer-term support (more than 13 weeks), ACC will prepare an Individual Rehabilitation Plan for you as part of deciding what treatment and rehabilitation you need. The plan will set out targets and appropriate services and support. It will be updated so that it records the steps as you get better, including the results of occupational and medical assessments.

Your Individual Rehabilitation Plan must include:

  • the outcome that’s aimed for and a target date (for example, going back to your old job in three months)
  • necessary initial assessments (occupational and medical)
  • any treatment or rehabilitation that’s in place or about to be approved, and whether ACC will fund this
  • the services that are appropriate in your case, and
  • when you and your ACC case manager will meet next to monitor your progress.

ACC must meet the cost of preparing the plan as well as the cost of any assessments agreed in the plan.

ACC must develop the plan “in consultation with” you (and with your representative, if you want to have one). You have a right to negotiate the contents of the plan with ACC. If ACC simply presents you with a draft plan to sign, this probably falls short of real “consultation”. An Individual Rehabilitation Plan is sometimes described as a “contract”, with rights and responsibilities for both parties.

Note: You should normally get advice from a lawyer before you sign an Individual Rehabilitation Plan.

Developing an Individual Rehabilitation Plan involves negotiation. You may need mediation to reach a reasonable resolution to disputes around the contents of the plan. If you unreasonably refuse to agree to the plan ACC have proposed, ACC can finalise the plan and treat it as if you agreed to it, or it can refuse to provide you with something you’d otherwise be entitled to, such as weekly compensation.

If you have a problem with your Individual Rehabilitation Plan, including if ACC take away entitlements because you didn’t follow the plan, you can apply for a review (see “Challenging an ACC decision” in this chapter).

Independence in your everyday life: Social rehabilitation

Accident Compensation Act 2001, ss 79, 81-84, Schedule 1, clauses 12-23

Social rehabilitation is help provided by ACC to make you independent again, as far as possible, in your everyday life, outside work.

You’re entitled to:

  • aids, appliances and equipment
  • personal care (“attendant care”)
  • childcare (for children under 14)
  • education support if your injury is causing you difficulties at school
  • home help (including help with cleaning, laundry and shopping)
  • modifications to your home (like adding handrails)
  • training – for example, in how to use the equipment you’ve been given
  • transport – including the cost of public transport, and help with buying or modifying a vehicle.

ACC also has discretion to provide other social rehabilitation, if this other rehabilitation would help you become more independent. This could include help to restore your independence in: cognitive tasks of ordinary daily living (like listening, planning your day, and getting tasks done); communicating; domestic activities; taking part in education; managing money; health care; keeping clean; mobility; motivation; keeping safe; and sexuality. For example, ACC can agree to provide you with sexual dysfunction products such as Viagra, to help restore your independence in the area of sexuality.

There will be assessments and reassessments to ensure that the social rehabilitation you’re getting is:

  • required as a direct result of the personal injury (caused by accident) that is covered by ACC
  • intended to restore your independence to the greatest extent (within reason)
  • necessary, appropriate and good enough to do the job
  • of the type normally offered by a provider
  • agreed in the Individual Rehabilitation Plan (if you have one).

Helping you get back to work: Vocational rehabilitation

Accident Compensation Act 2001, ss 6, 80, 85-96, Schedule 1, Part 1, Clauses 24-29

Vocational rehabilitation is help provided by ACC to restore your independence in your working life. It’s aimed at helping you either:

  • keep your current job, or
  • find a job that’s suitable and appropriate for your training and experience, or
  • regain your “vocational independence” – this means being able to work full-time (30 hours or more a week) in work that you’re suited to because of your experience, education or training.

ACC has to provide you with vocational rehabilitation if you:

  • are unable to work in your pre-injury job and so are entitled to weekly compensation (see “Weekly compensation, including first-week compensation”, below in this section)
  • will have to stop work and get weekly compensation if you don’t get vocational rehabilitation
  • are injured while on parental leave.

    Note: Vocational rehabilitation usually isn’t available if you weren’t working at the time of your injury.

Vocational rehabilitation is always provided as part of an Individual Rehabilitation Plan, which should include an appropriate rehabilitation path (see above).

ACC must identify whether it’s reasonably possible for you to go back to your pre-injury job with the same employer. If it isn’t, ACC must work out which of the following four other options are appropriate for you:

  • finding a different job with the same employer
  • finding the same type of work with a different employer
  • finding a different job with a different employer, using your existing skills, or
  • getting additional help from ACC for you to use your pre-injury skills to find work.

Examples of vocational rehabilitation include:

  • transport to and from work
  • special equipment for the workplace
  • occupational assessments
  • medical assessments
  • preparing to look for a job
  • programmes to build skills and confidence.

The types of help you’ll get will depend on the rehabilitation path that’s been chosen, your particular needs and the particular barriers you face. For example:

  • if the rehabilitation is directed at keeping you in your pre-injury job, it may include a workplace assessment and help such as special equipment or short-term transport assistance to get you to and from work
  • if you can’t go back to your old job, you’ll have an initial occupational assessment to identify your skills and work options. In deciding what work options are suitable for you, the assessor must take into account, among other things, how much you were earning before your injury.

When does vocational rehabilitation come to an end?

If you can’t go back to your old job and you can’t find a new job, the vocational rehabilitation provided by ACC stops when you’re able to work full-time in some job for which you’re suited by your training, experience and so on (that is, when you have “vocational independence”).

But ACC doesn’t have to keep helping until you actually have a job.

The maximum period of time for ACC-funded vocational rehabilitation is usually three years.

Lump-sum payments for permanent disabilities

Accident Compensation Act 2001, s 69, Schedule 1, clauses 54-62

Lump-sum compensation is payable for permanent disability (called “permanent impairment” in the ACC laws) – for example, if you lose a finger in a machine accident at work. These are one-off, non-taxable payments that are paid on top of other ACC entitlements.

These lump-sum payments don’t include compensation for pain and suffering, or for loss of enjoyment of life, resulting from the disability. However, “permanent impairment” can include not only physical disabilities but also mental harm caused by rape and sexual abuse: see “Sexual abuse: Cover for resulting mental harm” in this chapter.

Eligibility for lump-sum compensation is based on a medical assessment of the claimant’s impairment. The ACC-appointed assessor must decide if the claimant is permanently impaired, and if so, to what degree or “percentage”. In assessing impairment, ACC uses the American Medical Association guidelines. To qualify for lump-sum compensation, a claimant must have suffered a minimum threshold of 10 percent degree of impairment.

Usually, assessment for lump-sum compensation takes place after ACC receives information, from a registered medical practitioner, that the claimant’s personal injury has stabilised, and that it is likely that there is permanent impairment.

Alternatively, if after two years the practitioner states that the claimant’s personal injury has not stabilised but that permanent impairment is likely, an assessment can take place.

Death by accident: Entitlements for family and whānau

If a person dies in an accident, a number of grants and ongoing financial support are available from ACC: for more details, see the chapter “A death in the family”, under “Financial support for bereaved families”.

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