When you’re covered by ACC, and when you’re not

 

The vast majority of ACC claims are for physical injuries caused by accidents – like broken, fractured or dislocated bones, muscle tears and strains, lacerations (deep cuts or tears), and sprains.

Most claims involve an “accident” in the everyday sense of the term, like a car crash, or falling off a ladder at work or at home. But sometimes there are less straightforward cases, and whether you’re covered or not will depend on the detailed definition of “accident” in the ACC laws: for a summary of the legal definition, see below under “Injuries caused by accidents”.

Usually ACC only covers injuries caused by a specific event, rather than by a long-term, gradual process. But sometimes ACC will cover conditions caused by long-term exposure to something harmful at work or by an action repeated over a long time as part of your work: see below, “Conditions caused gradually: Covered only if work-related.

In a few situations, non-physical injuries like panic disorders or depression will also be covered, depending on how they were caused: see below, “Nervous shock and other mental conditions: Sometimes covered.

Injuries caused by accidents

What kinds of things does “accident” cover?

Accident Compensation Act 2001, s 25

An “accident” means a specific event where your body is subject to some force or resistance outside your body (including when you’re injured in a fall), or where you move suddenly to avoid an external force or resistance, or where you twist your body in some way.

The term “accident” also includes:

  • breathing in or swallowing a gas, liquid or foreign object on one specific occasion (long-term exposure at work to harmful substances like asbestos can also be covered under a separate ACC category: see below “Conditions caused gradually: Covered only if work-related”)
  • burns, or exposure to radiation or rays on one specific occasion (but usually not sunburn: see below, “What aren’t ‘accidents’?)
  • absorbing chemicals through your skin over a period of up to one month.

What aren’t “accidents”?

The following things aren’t “accidents” and won’t be covered by ACC:

  • injuries not caused by any specific event – for example, if you develop muscle pain after a long drive
  • injuries like slipped discs that are caused by sneezing or coughing fits (because they’re caused by forces inside your body, not external forces)
  • catching common illnesses like colds or flu by breathing in viruses or bacteria
  • sunburn, hypothermia and other conditions caused by exposure to the elements (sun, rain, cold, wind and so on), unless your normal activities are restricted by the condition for at least a month
  • damage to your teeth or dentures (false teeth) that’s caused by natural use of those teeth or dentures. So if you break a tooth while eating, ACC won’t cover you.

Note: In the past, ACC had accepted claims if teeth had been damaged by biting on a foreign object that had gotten into food, like a small stone or piece of glass, because they saw this as not being “natural use” of teeth (they wouldn’t accept your claim if it was through biting on something hard that was part of the food, like a piece of bone or a peach stone, as they saw that as “natural use”). However, recent court decisions have taken a narrower approach to “natural use”, and so in 2017 ACC announced there would never be cover for damage to teeth caused by biting on something hard in your food, whether it’s part of the food or a foreign object like a stone.

Nervous shock and other mental conditions: Sometimes covered

Accident Compensation Act 2001, ss 21, 26, 27

Although most ACC claims involve physical injuries, significant mental conditions (“mental injuries”) can also be covered in some cases. This includes mental conditions caused by the following events:

  • Rape and sexual abuseACC covers mental harm like depression and anxiety disorders resulting from rape or sexual abuse. We explain this in more detail in the next section: see “Sexual abuse: Cover for resulting mental harm.
  • Physical injuries – Mental conditions are covered by ACC if they’re caused by physical injuries that are themselves covered under the ACC scheme. This might include depression caused by a physical injury that restricts your movement and enjoyment of life, or a panic disorder that was caused by scarring from a serious car accident and that prevents you going out in public. Mental injuries caused simply by the experience of being in an accident aren’t covered. There’s also no cover for mental injury resulting from physical injuries suffered by someone else.
  • Sudden traumatic events at work – A mental condition is covered if it’s the result of an event at work that you saw or heard directly and that could reasonably be expected to cause you mental harm – for example if the bank you work in is robbed, or if you’re a train driver and you unavoidably run over and kill someone lying on train tracks.

Sexual abuse: Cover for resulting mental harm

ACC cover for mental harm caused by sexual abuse

Accident Compensation Act 2001, s 21, Schedule 3

ACC covers you if you’ve suffering from depression or other mental harm because you’ve been sexually abused. You don’t have to have suffered any physical injury, but to get the full range of ACC assistance you must have a diagnosed mental injury, like depression or post-traumatic stress disorder (PTSD). The sexual abuse you’ve experienced doesn’t have to be the only cause of your mental injury, but it does have to be a cause.

There’s a special claims process for this type of claim, which is dealt with by a special unit at ACC.

How do I start the process of getting ACC help?

You start the process by talking to a therapist or other health professional. If you feel comfortable talking to your GP, you can begin with them, or instead you can contact a therapist who specialises in this area. To find a therapist, contact a support organisation like Sexual Abuse HELP or Rape Crisis, or go to ACC‘s “Find Support” website (https://findsupport.co.nz – click on “Find a therapist”).

What therapy and financial help is available for mental harm caused by sexual abuse?

You’re entitled to some initial therapy sessions paid for by ACC before ACC does an assessment of whether you’ve suffered a recognised mental injury as a result of the sexual abuse. Those initial sessions can help you decide if you want to go through an ACC assessment, which will include giving ACC full information about yourself and what happened. If you do go ahead with an ACC assessment, the assessor will usually be a clinical psychologist, but sometimes a different type of therapist.

If the assessment concludes that you’re covered by ACC, you’ll have access to a full range of ACC entitlements, such as long-term therapy or counselling, compensation for loss of income if your ability to work has been affected (see “Costs covered by ACC: Treatment, compensation and other support” in this chapter), “lump-sum” compensation for permanent harm caused by the abuse (see “Lump-sum payments for permanent disabilities”), and also help for your family or whānau.

Your right to an independent review if ACC reject your claim

As with ACC decisions for other types of claims, you can appeal to an independent reviewer if ACC turns down your claim for mental harm caused by sexual abuse. For example, if ACC‘s assessor decides there’s not a strong enough causal link between your mental condition and the abuse you suffered, you can challenge that on appeal. You can also appeal if ACC accepts your claim generally but refuses you a specific form of assistance like lump-sum compensation. For more details, see “Challenging an ACC decision”.

Conditions caused gradually: Covered only if work-related

Cover for work-related conditions, diseases and infections that are caused gradually

Accident Compensation Act 2001, s 30

In general ACC doesn’t cover conditions, diseases or infections that are caused gradually, rather than by a specific event. However, there are some exceptions to this, and a key one is when you’re exposed to something harmful at work over a period of time and as a result you develop a disease or infection or a condition like hearing loss or repetitive strain injury (RSI). For your claim to succeed you’ll have to show:

  • that your work tasks or work environment had a particular characteristic (like the presence of a harmful substance, or loud noise) that caused the harm, and
  • that this characteristic isn’t found to any real extent outside your work, and
  • that the risk of suffering the harm is significantly greater for people who do your particular work tasks or have your particular work environment than it is for other people.

    Note: For some specific occupational diseases, you don’t have to prove that your work tasks or environment were the cause. These diseases include conditions caused by asbestos, lead, arsenic or mercury. Here you only have to show that your job exposed you to the particular substance.

Because conditions that are caused gradually are only covered if they’re work-related, this means ACC won’t cover you if you develop a condition like RSI or hearing loss from a hobby or other activity in your non-work life.

Illnesses and infections are also covered if they were caused by medical treatment (see below, “Injuries caused by medical treatment: ‘Treatment injuries’”). Otherwise, illnesses and infections aren’t covered by ACC.

Injuries caused by medical treatment: “Treatment injuries”

Accident Compensation Act 2001, ss 32, 33

You’re covered by ACC if you suffer an injury while getting medical treatment from a doctor or other health professional. The cover doesn’t include things that are a necessary part or ordinary consequence of the treatment. You’ll also be covered if the medical staff failed to give you medical treatment when you needed it.

You don’t have to show that the doctor or other health professional made a mistake when they treated you.

Treatment injuries include infections that are passed directly to some other person (for example, a partner or child).

You won’t be covered if your injury was caused by an underlying health condition, or by you unreasonably withholding or delaying your consent to treatment. You also won’t be covered if your injury was caused by a lack of medical services as a result of resourcing decisions made in the health sector – for example, if a hospital emergency department has been closed down.

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