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Denied Cover And Entitlement? Anyone been denied COVER and entitlement

#1 User is offline   yesno 

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Posted 10 March 2006 - 11:03 AM

It appears that ACC tries to make decisions under section 117, rather than under s65 (1).

This is very significant as in 2005, Parliment passed laws to extend how ACC can decline entitlements under s 117, that was previously a penalty provision of the IPRC. It is now used by ACC as a black whole of entitlement and cover.


I am interested to know if anyone else has been declined, or has come across COVER being declined?

Thanks. If anyone has been declined cover, it would be great to understand why cover was declined. I am trying to figure out whyACC declines cover. This especially applies if ACC made a decision with regard to section 65 of the IPRC.

Please be brief if possible. I am trying to figure out why they decline cover. If they did decline cover, did they do so under section 26 of the Act.

I am especially interested as to any reasons why ACC declined cover such as pre-existing condition which have no basis in the IPRC.

Thanks

yesno
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#2 User is offline   yesno 

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Posted 10 March 2006 - 12:03 PM

I will briefly explain why this is important.

IF ACC MAKE A DECISION ABOUT COVER, OR COVER AND ENTITLEMENTS

Any decision under section 65 must comply with sections 54 and 56. What this means is that ACC must investigate to the extent reasonably necessary to make a decision (section 56).

Then ACC must make every decision on a claim on reasonable grounds, and in a timely manner, having regard to the requirements of this Act, the nature of the decision, and all the circumstances(section 54).


IF ACC MAKE A DECISION ABOUT ENTITLEMENTS.

ACC can make any decision they want under section 117 without having to justify it. It falls under part 4 of the IPRC which relate to how entitlements are to be provided. They then feel that they don't have to justify their decisions

If anyone want to read the legislation, you can go to ACC website or to
http://www.legislation.govt.nz/

and look up injury prevention
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#3 User is offline   Hatikva 

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Posted 10 March 2006 - 12:07 PM

Yesno

A bit of semantics here, however a critical point.

By cover - (denying cover) ... what exactly are you looking for

* ACC advising that they reject the ACC45 form outright and deny that the injury exists,

or

* ACC accept the claim, give you a claim number and subsequently refuse to provide cover in terms of paying medical costs, failing to provide treatment and/or rehabilitation etc (or for that matter ERC)?

or

*ACC refuse to accept doctor's medical form for incapacity and deem someone fit for work (effectively denying compensation/treatment/cover and assistance post-injury and forcing them to either go to WINZ for help and be placed on sickness/invalid benefit or go back to work with an unresolved/untreated injury?)

PS - I have some "amusing" documents from ACC that I shall scan and forward to you in this regard.

The following is a clause in 117 that causes me some concern - Sub para(3) in regards to may decline to provide any entitlements.... see (B) below. If a claimant refuses treatment (of any kind that a claimant is entitled to receive) .. ACC can decline to provide entitlements .. the key is in the use of "unreasonably refuses ... fails to...)

Quote

(3)The Corporation may decline to provide any entitlement for as long as the claimant unreasonably refuses or unreasonably fails to— 
    
(a)comply with any requirement of this Act relating to the claimant's claim; or

  (b)undergo medical or surgical treatment for his or her personal injury, being treatment that the claimant is entitled to receive; or    

©agree to, or comply with, an individual rehabilitation plan. 


ARGHH keep forgetting to turn off emoctions! Get some STRANGE things happening with text with brackets ....
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#4 User is offline   yesno 

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Posted 10 March 2006 - 12:16 PM

Hatikva

You raise some very interesting points regarding ineffective communication.

The critical point here is what ACC actually tell you. The strongest evidence is in their own communication to you.

THIS IS DENYING COVER, but it is in a stange manner.
* ACC advising that they reject the ACC45 form outright and deny that the injury exists,

or

THIS IS DENYING ENTITLEMENT WITHOUT DENYING COVER (A TRICK OF ACC'S USUALLY PRESENTED TO YOU AS DENYING ENTITLEMENT)
* ACC accept the claim, give you a claim number and subsequently refuse to provide cover in terms of paying medical costs, failing to provide treatment and/or rehabilitation etc (or for that matter ERC)?

or

THIS IS AN INTERESTING ONE. IT IS DENYING TO ACCEPT A CLAIM. THERE IS NO LEGAL BASIS FOR THIS AT ALL.
*ACC refuse to accept doctor's medical form for incapacity and deem someone fit for work (effectively denying compensation/treatment/cover and assistance post-injury and forcing them to either go to WINZ for help and be placed on sickness/invalid benefit or go back to work with an unresolved/untreated injury?)
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#5 User is offline   Tomcat 

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Posted 10 March 2006 - 05:48 PM

Greetings,
This is well documented...
Work accident... fall/slip down slope 20m. aggravating disk injury from 1977. and more.
5 days later, while being paid the first week by employer and having started treatment, that had been accepted by ACC.
Was told as I had been diagnosed 6 years earlier with Ankyolosing Spondylitis,
I HAD NO RIGHT TO ERC. ???? and got none, but went on a sickness benefit, and Treatment via the Hokianga FREE health system.

Now... recent MRI scan report... "There is no evidence in MRI to suggest a diagnosis of A.S." ??? but evidence of Herniated disks (L4/5)... this is from the 1977 accident.
Prolapsed disk(s) was diagnosed by ACC assessor in 1977.
ACC used a blood test to say it was A.S.... A pre exiting condition.... and exit.
Dr.'s at Middlemore Hosp. after a Radiculargam xray(Myodil), were not sure of what was causing pain, and only said it was "possibly" early A.S.
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#6 User is offline   doppelganger 

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Posted 10 March 2006 - 06:11 PM

Yes /No very intresting point.

I was addmitted to hospital due to injury in Nov 2004. the ACC sent out a new claim number and advised me that they were going to send me for a medical report

that report has never came and neither has the compensation.

The ACC refuse to reply or administer the claim.

I know that they have all of my Medical information and they have been advised that the condition that they used to kick me off was completely healed in 1981.

Had lump sum payment in 1982 (not the healed part of the injury) and second lump sum for the healed part of the injury that was no causing any problems.

Personally in my case they are in the shit.
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#7 User is offline   Paradigm Shift 

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Posted 10 March 2006 - 06:22 PM

In reference to the corporation accepting an ACC 45 form but denying cover on the basis that the description of the cause of injury was not to their satisfaction. They wanted the doctor to change the cause of the injury from an accident event causing injury to one of gradual process. When both doctor and claimant refused the corporation then declined cover on the basis that information regarding gradual process was withheld.

The matter went before a review hearing whereupon the corporation attempted to change his decision to prevent the reviewer from having jurisdiction. The review hearing was changed to a hearing regarding jurisdiction. After some weeks the reviewer rejected that there had been a change of decision but instead of having a review hearing the review are decided the matter based on the prehearing submissions to the extent that it was the claim his responsibility to provide additional information.

Should the corporation wish additional information over and above the ACC 45 form and subsequent medical certificates the funding of all further information is the liability of the corporation. This is a case where the corporation has been seeking to generate wrong information for a pecuniary advantage and the only as a result of the medical professionals coverage did this case maintained factual integrity.

The matter is now waiting for a district court appeal one year after the submission of the ACC 45 form. The appeal relates to the reviewer doing their job to review the case rather than being a mechanism for the ACC to divert or redirect liability for the providing of information from the ACC to the claimant who can ill afford to pay for expensive medical assessments.

Yes/no is this the type of thing you mean?
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#8 User is offline   yesno 

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Posted 11 March 2006 - 10:21 AM

It is a very difficult one...

Basically this is my hypothesis...

ACC is a large organisation, most of their "decision makers" are not in fact decision makers, more people that fill in formulas into whatever the "real decision makers" decisions are.

The real decision makers are the ACC leadership teams, they then send their decisions or policy, as set out in ACC business plan, to Lawyers who work for ACC who put them into small packages that the case managers can then use.

(Another small problem is that the ACC Case Managers KPI have their basis in the same ACC business plan.)

But, these small packages that the case managers use to exit the claimant have come accross a problem.

For example, for injury X, their is a set ACC forumla for denying cover because this injury is very expensive to rehabilitate and eventually the claimant may get treated in the public health system.

Having reviewed around 30 cases in full from the district court for injury X, and a couple from the high court, it appears that ACC use exactly the same wording etc, most of which was developed during the late 1990's when there was a competitive insurance market.

injury X was excluded a few times then, very sucessfully as a pre-existing condition. What happended was the insurance company or ACC would just stall a decision into "no mans land" by making a decision under part 4, section 117 of the IPRC act (or it's equivalent), this worked quite well for ACC for many years, under section 117, ACC doesn't have to justify their decisions etc.

The amendment from late 2005, gave ACC even more scope under section 117, which was originally designed as a penalty clause where ACC could suspend entitlements in you were being bad. But ACC are using it as a black whole. (this is very immoral, but was never picked up in any cases that have been published)

The problem is, for a decision under section 117 to work, ACC must communicate to you that they are "suspending" entitlements. They would usually suspend all entitlements.

But there was an upgrade of Pathway where the Formula was updated, by someone who didn't understand why entitlement was suspended. What this means is that recently ACC started telling claimants that they have "declined cover" instead of "suspending entitlements".

What this means is that it is the entire process of how ACC must make decisions about Cover, as set out in Part III of the IPRC, this gives the protection to the claimant of Section 54 and 56, and 65 of the IPRC.

Therefore their black whole no longer exists and ACC must Justify their decisions.

I hope this explains it a little better...


YESNO
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#9 User is offline   Gloria Mitchell 

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Posted 11 March 2006 - 11:50 AM

Hi Yes/no,

"Cover" is inalienable. Once cover is granted, it cannot be recanted.

entitlements.....thing is, they suspend erc, but cover still remains....medical treatment is an entitlement, but they still pay for gp appointments and referrals as "cover" still stands. They also pay for pharmecutical charges....you send them in attached to the proper form and the money...most of it anyway gets credited to your bank account. In my experience anyway.

Gloria.
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#10 User is offline   yesno 

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Posted 11 March 2006 - 12:07 PM

thanks Gloria,

But the problem is, if they don't deny cover, then there is no recourse except through the IPRC. That would mean that nothing can be done except complain and review.

But what they have done is made a decision to decline cover and entitlements. This was upheld at review. Time has passed so ACC cannot now change their mind.

This means Recourse outside the IRPC is possible. This means suing ACC, the individual case managers and the crown for their bungling of the case.

So, it is actually a very good thing that they have decided to deny cover.
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#11 User is offline   MadMac 

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Posted 11 March 2006 - 04:30 PM

:wub: Hi yesno and everyone else ... I have been denied cover and entitlement on numerious occasions ... ACC know I have Permanent Disabilities and recquire treatments they still keep on changing claim no's, ACC45 no's and hoping I will accept and agree to one of many ACC created bullshit claim no's that are full of lies so I may recieve entitlements.

I believe that they are busy minimising my injuries , how where my accident happened so that they pay out the minimal yet collect shit loads in revenues under the guise that serious injuried long term ... ======== :wacko: HUGE PROFIT for ACC ... getting a bit tired of standing in the far queue for ACC to sort out their shit.

MMMMMMMMMMMM Maybe ACC should take shares in a mushroom farm ... they create enough shit and keep everyone in the dark , even themselves.

;) Have a bueatiful day ...
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#12 User is offline   gaffa09 

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Posted 11 March 2006 - 04:35 PM

big mac do up mean the ===far queue or the ===farque is that still polite or not
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#13 User is offline   muttlee 

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Posted 10 July 2006 - 12:15 AM

Hello,
I was denied help after I was run over by a car at a giveway sign in Invercargill.
The driver lost his licence for 6 months and fined but I am not in NZ and was a student.
No help.
Muttlee :wacko:
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#14 User is offline   Alan Thomas 

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Posted 10 July 2006 - 01:21 PM

Those of us on the site are more than happy to provide help.

Please provide the details of what this case and you have done so far. If you want to keep it private just contact one of us directly.

The site is designed to provide free help to each other utilising our residual capacity to the best of our ability.

Cheers
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#15 User is offline   MG 

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Posted 10 July 2006 - 02:12 PM

It is not correct to say that cover is inalienable. ACC does have the power to revoke it if it believes a person did not suffer "personal injury" as defined in the legislation. ACC usually does so after receiving a retrospective medical report from one of its doctors, sometimes without the doctor even seeing the patient.
As a further refinement of cruelty, a few years back, ACC used to follow up its revocation of cover decisions with demands for repayment of weekly compensation. I have seen letters demanding six figure sums from ACC. The effects of this correspondence on injured citizens will be apparent to anyone with a modicum of moral sense. After a long battle, ACC abandoned its demands for money after revoking cover and Parliament passed s65(2) of the IPRCA banning the practice.
But the reason I mention all this is to show that cover can be revoked and to remind people how wicked the bureaucracy can be if its actions are not scrutinised carefully by the people and their elected representatives.
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#16 User is offline   wayne1 

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Posted 10 July 2006 - 03:19 PM

MG

You are right they can at anytime obtain a opinion to suit their own aims and revoke cover with a stroke of a pen. Then the claimant has to fight like hell for re-instatement. No one is safe they can at any stage re-examine entitlements and bang.

Remember their aim is to reduce the number of claims and the onus is on this. How many people keep getting reviewed on an ongoing basis where the goal posts keep shifting to help ACC with this process.

Hundreds of thousands are spent with the sole aim ....EXIT... EXIT !!!

It makes me so f.......g angry that this is happening.
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#17 User is offline   MG 

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Posted 10 July 2006 - 05:02 PM

I have to say that ACC doesn't seem to revoke cover as often as it did back in the late 1990s. Of course, it has many other ways to get claimants off the books, including witch-hunts (aka "fraud investigations"), which successfully hound people into giving up their entitlements. I think this tactic is probably as wicked as the cover revocation exercises ACC engaged in a few years ago.
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#18 User is offline   doppelganger 

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Posted 10 July 2006 - 05:52 PM

I have a letter that says that if ACC don't get a concent form that they can't supply entitlements.

Intresting is that the letter say that its not a reviewable decision.
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#19 User is offline   MG 

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Posted 10 July 2006 - 06:56 PM

Put in a Code Complaint saying ACC won't comply with the Privacy Act 1993 allowing you the right of informed consent. When the complaints office issues its whitewashed decision letter apply for review of it. That way you'll get the matter reviewed. If the reviewer doesn't uphold your complaint contact your MP and say the bureaucracy is trashing your fundamental human right to privacy.
Remember ACC can only say you are preventing rehabilitation if you unreasonably withhold your consent from it. IMHO, you cannot give informed consent unless ACC tells you why it needs to seek or disclose your personal information. It is entitled to seek and disclose your personal information but only to the extent strictly necessary for it to manage your claim. ACC misuses personal information when it goes on fishing expeditions or discloses your personal information wider than necessary.
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#20 User is offline   MadMac 

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Posted 10 July 2006 - 07:58 PM

:wub: Hi everyone ...

ACC Whangarei sent me here and there to different treatment providers ...

And then in some other documentation ACC wrote that I was ...

:( Provider Jumping ... Non Compliant.

I would be lead to believe that to have effective rehabilitation their is a need to establish the extent of injury[ies] caused by accident and to manage a claim appropiately all details , including personal information , would have to be given as true , accurate , correct ... and recorded and managed in an approiate helpful style.

;)
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