The first step in having any ACC decision overturned is to simply ask the ACC ‘decision maker’ to reconsider. Indeed the standard decision letter issued by ACC gives this as a first option. However, this author’s experience is that in most cases the ‘decision maker’ or cover assessor is simply following a predetermined process dictated by policies contained in ACC’s business software ‘ProMapp’.
In most cases, once ACC’s process from ProMapp has been followed, which often includes seeking internal ‘advice’ from ACC employed medical advisors, pharmacy advisors, technical support and accountant), the decision maker’s ability to overturn the initial decline is extremely limited.
To overturn a decision it is almost always necessary to lodge an application for review. This triggers a statutory process to resolve the matter, either by negotiation, mediation or through a hearing with an Independent Reviewer. Importantly, the Reviewer sets aside the ProMapp policies and re-investigates the decision based on the available information, legislation and previous case law.
Once lodged, a review application is managed by an ACC Review Specialist who is supposed to check the correctness of the decision and resolve the dispute early if possible. They have the authority to change the decision either directly or by way of conciliation meeting with an independent mediation service such as Talk Meet Resolve or one of the review providers below.
If the dispute can’t be resolved early then ACC must prepare a bundle of case documents and appoint an Indpendent Reviewer with either FairWay Resolutions or the Independent Complaint Review Authority (ICRA) and have a date for a hearing set within 3 months (or you win automatically).
Whilst the hearing date must be set within 3 months, usually at a preliminary case conference, the hearing itself is generally held some time later, to allow further reports, evidence and preparation of written legal submissions. Once held the Independent Reviewer has a further 4 weeks to issue a decision, after which ACC will take several further weeks to take action (change the decision) if instructed to do so.
Hearings are generally more informal than court proceedings, taking about an hour which gives ample opportunity to point out why ACC got the decision wrong. There are no strict rules around evidence, but the Applicant must persuade the Reviewer that their claim should more likely than not be approved. Reviewer’s are usually legally trained, but not medical experts, so they base there decisions on the expert evidence available and the requirements of the ACC Act.
Because this is generally the best chance of overturning an ACC decision, advocates and lawyers avoid presenting a case at hearing until they have obtained sufficient expert opinion to counter ACC’s internal advice. This can sometimes delay obtaining an outcome.
Independent Reviewers can overturn, modify or uphold and ACC decision, or they can direct ACC to re-assess the decision and issue a new one.
As a lawyer my duty to clients is to minimise delays to the review process whilst balancing the need to present the best supporting evidence at hearing, which is often dependent of very busy medical experts and their ability to provide reports. As such, early resolution of disputes through mediation rather than a hearing must be a consideration for advocates and clients alike.
If you think you need a lawyer to help you through the review process or have questions, contact ACC SOS today.
