Have you had an injury or medical event, and you have found you haven't been treated as quickly as you expected, with the result you are now living with some level of permanent impairment?

Over the years, this situation has arisen regularly, prompting some interesting responses from our medical and health systems.

Many will be aware that the ACC covers treatment injuries, which are loosely referred to as medical misadventure. Technically, medical misadventure is not correct; treatment injury is the term.

This distinction is quite important, as it refers to what is or is not covered.

What Does ACC Cover?

ACC covers many things. Most people know and understand accident injury treatment. ACC also supports other "injury" situations; some of what is covered are not accidental.

• Sexual abuse is considered for treatment and support with psychological services not usually provided for with accidental injury claims.
• Trauma from events: ACC responded to the Christchurch terror attacks in ways most people haven't seen or understood. We all heard the government was helping and assisting, but mostly, it was ACC doing that work.
• ACC also considers suicide for both funeral grants and fatal entitlements for surviving spouse and children.
• And medical misadventure in the form of treatment injury.

Treatment Injury 

The thing to understand here is that treatment injury covers precisely what the name implies: treatment injuries.

Where you have a diagnosis and the treatment you are provided causes more harm in ways that are not expected for that treatment.

What's not covered?

Which has a range of interesting issues that stem from that that are not covered:

• If the issue from the treatment is an established, known, regular, and reasonable risk of the treatment, then it is not covered by ACC. 
• If there is a misdiagnosis and the treatment provided for that misdiagnosis doesn't cause more harm, the harm still comes from the underlying condition. ACC does not cover this either.
• If there is a misdiagnosis and no treatment is provided for that misdiagnosis, like a viral infection, the harm from the progression of the medical condition is not covered by ACC either. 
• If you have a medical event and there are delays to accessing diagnosis and treatment causing deficits or impairment that could have been prevented, yup, ACC doesn't cover that either.
• If you have a medical event, you have a diagnosis, and treatment is delayed, causing further deficits or impairment, yup, ACC doesn't cover that either. 
• The impact on family members and parents when kids have accidents and parents have to take time off work to look after them. That, too, isn't an ACC claim. 

What Does This Look Like?

Three examples that have crossed my desk in recent times.

• A 40-year-old male had a medical event that looked like a stroke, was not diagnosed as a stroke and was discharged with a diagnosis of post-viral symptoms, expecting to recover. No follow-up from the DHB, and 12 months later, the patient returns to their GP; this hasn't improved; what's going on?
  • It was a stroke, and the initial period after the event window meant that there was no hope of rehabilitation that many would have had if diagnosed and treated. 
  • This client is permanently disabled on disability insurance claim and unable to return to work.
  • A gastroenterologist initially treated this client and his registrar or intern. A CT was done, but it was inconclusive, and a neurologist was not consulted for a second opinion. However, the CT did have evidence of the stroke on retrospective review.
    • I have also found out that the miss on the CT isn't unusual, and radiologists consider this an acceptable risk that neurologists know and understand. So much for the gold standard on our CT and MRI imaging
• A 45-year-old fell with an injury and landed in the hospital. Lack of treatment for infection resulted in his leg being amputated. 
  • ACC covers the treatment but is not liable for the delay in treatment that caused the progression to losing the leg. All of this was in the hospital.
  • Because the patient was not working at the time, between jobs, there is no ACC weekly compensation. Additionally, they now have a much harder job returning to work than they would have otherwise.
  • This person also didn't have family to support or assist them.
  • This person came to us as a new client after the amputation. 
  • Lack of knowledge and understanding of medical services made this patient unable to advocate for themselves.
• Client with a broken ankle, ten days waiting for surgery to set the break, making the surgery worse and recovery longer.
  • What should have been 6 weeks to return to work became 17 weeks, putting the client's job at risk. 
  • ACC paid weekly compensation.
  • This client had insurance in place that assisted with the income gap and additional rehab support.

While ACC was involved in some of these medical events, delays and misdiagnoses resulted in significant impairments or extended recovery. ACC didn't pay for the additional harm. However, in the case of the broken ankle, they paid weekly compensation for the extended time off work.

The System Has Hidden Failure Points 

The challenge with all of these situations is the public system failed in some way, either through demands causing delayed services or clinical incompetence.

This leaves most people in these situations angry and frustrated. No one wants to take responsibility, and the system does not go out of its way to help. 

You have to know what you need and are entitled to and ask for it!

In the cases above, they all contacted ACC for support on the additional issues, to no effect.

They have all made complaints to their respective DHBs and the Health & Disability Commission, and largely, nothing has changed. 

Many of our public health services are underfunded and under-resourced, and so, under pressure, they regularly make mistakes. 

It's not that we don't have good clinical people; we do. It is the environment they are being forced to work in that is driving this additional harm, with no recourse for most people.

What Can You Do?

This leaves people to do one of three things:

1. Put up with the situation and make the best of it.
2. Pay privately for their treatment and rehab.
3. Pay for insurance so it can respond if called upon in these situations. 

The harsh reality is that while we have ACC to manage issues and prevent us from becoming a litigious society like the US, there is still the option of taking a civil case for harm that ACC is not covering, either directly at ACC or the DHB. 

• Most people don't have the resources to take on a case of this nature, so they choose option 1. 
• Those with means typically avoid these situations by accessing private clinicians faster and more effectively by paying out of pocket. 
• Those in the middle, yes, likely you reading this, have insurance that responds to provide access to medical treatment, rehabilitation services and income support. 

The question for you right now is, what will you do about it?

1. Leave it to chance because it won't happen to you? Remember, you are a fragile human like the rest of us. No one gets out alive.
2. Call us and make some time to discuss your options so that you can have an affordable plan in place for the unexpected. 

The smart ones choose option two. You are one of the smart ones, right?