Tag: ACC Case Law
William Wyatt v Accident Compensation Corporation (ACC)
Wellington District Court 2006
On 19 November 2002, Mr Wyatt suffered a back injury during his work as a welder. Mr Wyatt applied for and received weekly compensation. In November 2004, ACC commenced the vocational independence process. The occupational assessor identified twelve jobs options for Mr Wyatt. The medical assessor stated that Mr Wyatt had vocational independence in three job options. The job options were Employment Programme Tutor, University and Higher Education Lecturer and Wholesale and or Retail Buyer.
Section 107(1) of the Accident Compensation Act 2001 gives ACC the ability to determine a claimant’s vocational independence where that claimant is in receipt of weekly compensation. The purpose of this assessment under s. 107(3) is “to ensure that comprehensive vocational rehabilitation, as identified in a claimant’s individual rehabilitation plan, has been completed and that it has focused on the claimant’s needs, and addressed any injury related barriers, to enable the claimant” to either maintain or obtain employment or alternatively regain or acquire vocational independence.
ACC believed it had sufficiently trained and rehabilitated Mr Wyatt to assist him back into employment. ACC believes it had done this by providing Mr Wyatt with an extensive activity based programme aimed at strengthening the applicant’s work fitness; training in computer operation; and assistance to find employment. They believed this assistance was “significant, comprehensive and directly applicable to his needs.”
Mr Wyatt did not believe he was capable of the job options recommended in his vocational independence assessment. Mr Wyatt had been provided training in a twelve hour computing course. He had also in his position as a welder sometimes shown a less experienced welder an easier way to weld a joint. However, he had attended only two years of high school and had no formal training, experience or skills relevant to conducting classes, delivering lectures and instructing students. Nor did he have any experience in designing training courses which is a requirement to become an adult tutor. Further to this he had never been employed as a retail or wholesale buyer.
Decision: Judge Cadenhead, believed the issues in this case were whether Mr Wyatt had received adequate rehabilitation, whether he was suitable for the prescribed job options and, whether he was physically able to sustain the position for 35 hours a week.
• Job suitability
Judge Cadenhead stated that, “it is important when nominating suitable alternatives that a vocational assessor analyses with some particularity in a realistic manner the specific requirements against the known background of work experience, education of the appellant against the marketability to a prospective employer.”
The judge believed it was unrealistic to think Mr Wyatt could work as a lecturer or tutor given his limited education and background. The judge also believed that Mr Wyatt would not be able to work as a retail or wholesale buyer as he had no experience in this area. In regards to this Judge Cadenhead stated “realistically, in my view, no employer having regard to the background and experience of the appellant would entertain a job application from [Mr Wyatt].”
The Judge stated that for ACC to discharge their obligations under the Accident Compensation Act, they needed to provide Mr Wyatt with suitable rehabilitation. In particular Judge Cadenhead, believed ACC should have provided Mr Wyatt with specific training in respect to the nominated occupations, rather than the generalised training he received. Judge Cadenhead believed that the point of the rehabilitation should have been to “show that the nominated options were realistically within the grasp of [Mr Wyatt].”
• Ability to work 35 hours
Judge Cadenhead, noted that the medical assessor should have provided reasons in his assessment that the appellant could work the required 35 hours in any of the occupations. This is because the judge believed that, “where pain is a factor pertaining to capacity to work then that issue has to be dealt with as it is an important factor concerning the physical capacities of a claimant.”
Conclusion: A vocational assessment must be realistic. It must also look at a claimant’s individual skills which they have acquired through education, training and experience. Rehabilitation of a claimant should involve suitable training to ensure the claimant is prepared for the job options nominated. The medical assessment should also address the claimant’s ability to work a position for the required 35 hours.
Cases Referred to:
Ramsay (Christchurch Registry, AP 412/14/02) the High Court held that assessments of physicians qualified pursuant to the legislation will be preferred unless clear and cogent evidence to the contrary by a duly qualified physician can identify a flaw in that assessment.
Robert Ballagh v Accident Compensation Corporation (ACC)
Wellington District Court 2009
Mr Ballagh, sought medical treatment for a back injury on 2 May 2007. Mr Ballagh was diagnosed as having a L3/4 disc prolapse. In his course of treatment, Mr Ballagh, was seen by his GP, a doctor and a surgeon. Mr Ballagh disclosed during a complete history assessment in January 2008 that he had been in a skiing accident in January 2007. Mr Ballagh’s surgeon felt the disc prolapse was a result of the skiing accident. Because of this Mr Ballagh lodged a claim with ACC.
Prior to the 2007 skiing accident Mr Ballagh had an extensive history of back pain. In 1976 he had an L5/S1 discectomy; this was followed by two operations relating to fusion in 1984 and 1988. Until he consulted his surgeon, Mr Ballagh had believed his back pain in 2007 was a continuation of earlier problems. Mr Ballagh stated this was why he had not disclosed his skiing accident earlier.
ACC’s medical assessor disagreed to the cause of Mr Ballagh’s disc prolapse. The assessor felt that the L3/4 disc prolapse was the result of gradual deterioration and had been occurring prior to the skiing accident in 2007. The assessor believed given Mr Ballagh’s history, it was likely the disc prolapse was symptomatic of a degenerative back problem.
• Causal nexus
Judge Beattie stated the only issue for consideration was, “whether there is sufficient evidence of a causal nexus between the skiing accident and the subsequent diagnosis of a lumbar disc prolapse.”
Judge Beattie examined the evidence and concluded that there was substantial evidence that Mr Ballagh had a history of degenerative back pain. However, ACC had failed to provide evidence that the L3/4 disc prolapse was part of this degenerative condition. ACC had also failed to show that the prolapse had occurred prior to the skiing accident in 2007. The judge noted there was also no mention in the surgeon’s notes, or in the MRI scan that the L3/4 disc was in a degenerative state.
Judge Beattie believed that the Medical Examiner’s report provided by ACC was too simplistic. The judge rejected the assessor’s suggestion that Mr Ballagh’s injury could only result from non-traumatic causes. The judge felt that as Mr Ballagh’s surgeon had been the treating surgeon who identified the problem, his assessment must be given due weight.
Mr Ballagh’s surgeon had noted that the nature of the skiing accident was consistent with it having caused the disc protrusion. He also advised this disc prolapse was the source of most of Mr Ballagh’s pain subsequent to the accident. The Judge felt that with no evidence to the contrary, Mr Ballagh’s surgeon had sufficiently shown a causal nexus between the accident and the injury.
Conclusion: When examining the evidence, the Judge gave due weight to the “treating surgeon[‘s]” opinion. The Judge felt that ACC had not proven on the balance of probabilities that the prolapse was the result of a degenerative disorder. He also found there was no evidence to show that the L3/4 disc prolapse had occurred prior to the skiing accident in 2007.
Therefore, on the balance of probabilities there was a reasonable “causal nexus,” between the skiing accident and the subsequent back injury.
Graeme Blair v Accident Compensation Corporation (ACC)
District Court Wellington 8 February 2010
On 7 April 2008, Mr Graeme Blair went to see his doctor and was diagnosed an inguinal hernia. Mr Blair consulted his doctor several times over the following months in regards to the tumour. However, it was not until December 2008, that Mr Blair explained to his Doctor the hernia was a result of a pruning incident. Mr Blair had been standing on a ladder pruning branches of a tree. When he was stretching upwards to cut a branch he felt a sharp pain in his groin. At this time Mr Blair’s doctor advised he could claim for cover for his hernia. Subsequent to this Mr Blair lodged a claim with ACC.
The ACC branch Medical Advisor did not believe that the hernia had occurred as a result of an accident. The adviser noted that Mr Blair was “diagnosed with a hernia some 5 days after this accident without any indication that an accident had caused the hernia.” The medical adviser also felt it was important that Mr Blair did not describe the pain as “significant or severe”.
Based on the Assessor’s report, ACC declined Mr Blair’s claim. For the appeal ACC sought further expert evidence from a General Surgeon with a large hernia practise. The surgeon believed Mr Blair had not “met the requirements of contemporaneous account of accident/trauma at the first GP consultation in April 2008. While there is still a small chance that the hernia was accident related there is no way to prove or disprove this clinically at this stage, and on the balance of probabilities it is far more likely that the hernia development was associated with aging related weakening of fibrous tissues.”
The appellant stated that he had not originally discussed the background to his hernia as he was not aware he could lodge a claim with ACC for it. Mr Blair submitted the evidence given by his doctor was that in his opinion the hernia had resulted from a traumatic event. Mr Blair also stated that he fulfilled the policy guidelines for hernia cover that are set out in ACC’s publication “ACC News” Issue 59 August 2003.
Decision: Judge Beattie believed that on the balance of probabilities Mr Blair’s hernia had occurred as a result of accident. The Judge stated that Mr Blair had fulfilled all of ACC’s policy guidelines for hernia cover which gave indication as to whether the hernia was an accident. He also found that ACC had put too much weight on the fact there was no “contemporaneous account of accident/trauma at the first GP consultation.” The judge did not find this fact “insurmountable if a reasonable and believable explanation is given.” Judge Beattie, found that in Mr Blair’s case a believable explanation was given and on the balance of probabilities the hernia was caused as a consequence of a traumatic event.
Conclusion: Despite medical evidence to the contrary, a lack of evidence or a delay in recall of evidence of a contemporaneous account of an accident/ trauma is not “insurmountable if a reasonable and believable explanation is given.”
On 28 June 2006, Mr MacDonald was employed as a chef. During the course of his employment he lifted a 30-litre bucket full of parsnips. It was at this time Mr MacDonald noticed a right inguinal hernia in his groin. He reported the incident to his work as a muscle strain. Mr MacDonald was diagnosed with a hernia by his doctor on 3 July 2010. ACC had a medical professional prepare a report on Mr MacDonald’s hernia. The medical professional stated that, “the case law states that in order to obtain cover for a personal injury caused by accident there must be an injury to the abdominal wall over and above the appearance of a hernia.” On this basis ACC, declined the claim stating it did not believe that the hernia was the result of a traumatic rupture of the abdominal wall. Mr MacDonald submitted that ACC was applying the policy guidelines for hernia cover too strictly. Mr MacDonald referred to the Brock evidentiary test for hernias stating that he fulfilled all four evidentiary criteria. He also referred to the case of Stanbury which states “the court cannot accept that such policy criteria must be rigidly adhered to when all other evidence points to a genuine case.” Mr MacDonald believed on the balance of probabilities his hernia was caused by a specific event. Mr MacDonald’s doctor and surgeon also believed that Mr MacDonald’s hernia had occurred because of a specific event. Policy and Evidentiary Guidelines for Hernias When deciding to cover for hernias, ACC apply the policy guidelines for hernia cover that are set out in ACC’s publication “ACC News” Issue 59 August 2003. These guidelines are:
1. A single strenuous event is claimed to have caused the hernia
2. If the accident occurred in a workplace, an incident of muscle strain is officially reported.
3. Significant groin pain was present at the time of the accident.
4. A medical practitioner diagnoses traumatic inguinal hernia within 30 days of the accident but preferable within 10 days.
5. There is no history suggestive of gradual onset or congenital inguinal hernia.
In Brock (240/2004) Judge Cadenhead said that there were 4 evidentiary guidelines that should be utilised (although not applied rigidly) when considering what had caused a hernia. These four guidelines were:
1. An officially reported incident of muscle strain.
2. Severe groin pain at the time of the strain.
3. Diagnosis of a hernia by a doctor within 30 days.
4. No previous history of hernia
The Act: Section 8 of the 2001 act states that a person has cover under that Act if he or she satisfies any of the criteria contained in sections 20, 21 or 22 for personal injury suffered after 1 April 2002. Section 20 concerns cover for personal injury suffered in New Zealand and is relevant to this review. In particular, it refers to personal injury (defined in section 26) caused by an accident (defined in section 25).
The Decision: Judge Cadenhead stated “that the medical evidence of the operating surgeon must be given considerable weight.” On a balance of probabilities the operating surgeon believed the hernia was caused when Mr MacDonald lifted the parsnips. Judge Cadenhead believed that the operating surgeon’s evidence was preferable to the ACC Assessor’s evidence because, the ACC Assessor was not an expert in the field of hernias and had never examined Mr MacDonald. Judge Cadenhead believed that the surgeon’s opinion along with the other facts of the case satisfied the onus of proof in favour of Mr MacDonald.
Conclusion: A Judge will give more evidentiary weight to an operating surgeon who has examined a claimant, over a medical expert who has not.
Cases referred to: Brock (240/2004) stated there were 4 evidentiary guidelines that should be utilised (although not applied rigidly) when considering what had caused a hernia. Stanbury (28/00), In Stanbury Judge Beattie states that the court can understand ACC having policy criteria for certain types of injury, but ACC should not be to strict in its adherence, when there is a genuine case of accident. Smith v ACC (23/8/04 Judge Beattie, DC Wellington 255/04), a claimant must prove on a balance of probabilities that their injury is a result of an accident.
District Court Wellington 25 August 2010
On 21 June 2008, Mr Lyth fell three metres to the ground from a ladder. In the fall he sprained his neck. Mr Lyth claimed for the neck sprain and was covered by ACC. In July 2008, Mr Lyth’s GP ordered an x-ray and an MRI Scan, the GP then referred Mr Lyth to an Orthopaedic Surgeon. Initially the pain was treated conservatively. However, in November 2008 the surgeon recommended to Mr Lyth that he have a right C6/7 discetomy and instrumented fusion. On 24 November 2008, the surgeon sought approval from ACC for the surgery.
ACC’s orthopaedic surgeon believed that the neck pain was a “degenerative condition rendered symptomatic following an accident”. ACC has also stated that the MRI scan identified widespread degeneration in the appellant’s cervical spine including a prominent disc herniation at c6/7. Because of this ACC declined to cover the surgery. Mr Lyth still underwent the surgery in March 2009.
After the surgery My Lyth sought a review of ACC’s decision and provided a thorough report from his surgeon stating the neck pain was a result of an accident. The report stated that there was no evidence of Mr Lyth having problems with his C7 nerve root prior to the injury. Mr Gordon believed that degenerative change would have contributed to his injury but that the accident caused more than 25% of the problem. ACC had a second medical assessment done, which reaffirmed the opinion of the first and they re-declined to pay for the surgery.
Decision: For the elective surgery to be covered under the Accident Compensation Act the claimant needed to establish that the surgery was to treat a medical condition caused by accident for which the claimant had cover under the act.
The judge acknowledged that Mr Lyth’s spine was showing degeneration at the time of his accident. However, he believed that the degenerative changes were asymptomatic and not causing pain to the appellant prior to the fall.
The judge noted that the degenerative spine injury was more likely to “tip the nervous system over the edge,” than it would be with someone young and healthy. However judge noted that you must take a claimant as you find them and he believed it was important that radiculopathy is not asymptomatic. Therefore Judge Beattie believed there is a clear causus nexus between the fall and the onset of the C7 radiculopathy.
Conclusion: That a claimant must be taken as he is found and “the fact that the pathology had produced the nerve impingement is pre-existing and degenerative, does not affect the fact that if the impingement is caused by the trauma of the fall, then that impingement is a personal injury for which cover and treatment can be had.”