How we make cover decisions based on legislation
When we receive your claim, we look at the rules set out in the Accident Compensation Act 2001 to see if we can cover your injury. The Act has different rules for different types of injuries.
On this page
The relevant sections of the Accident Compensation Act 2001 guide us when we make cover decisions about different injuries.
When may get specialists' opinions or assessments
We also base our decisions on expert advice. Sometimes it can be hard to tell if an injury has been caused by an accident, illness, or general wear and tear. In this situation, we'll get specialists' opinions or assessments before we can make a decision.
One-off physical injuries
Your injury must be caused by:
- an accident
- a specific event or series of events.
Your injury can be caused by:
- an outside force on your body
- twisting your body
- inhaling or swallowing something
- burning or radiation
- absorbing chemicals through your skin
- exposure to extreme weather or temperatures.
Your injury must not be caused by:
- inhaling or swallowing a virus, bacterium or protozoa unless it’s a criminal act by another person.
Relevant legislation
Download or print the flowchart on cover decisions - one-off physical injuries
Conditions that come on gradually from work
Your injury must:
- be caused by a work-related gradual process, disease or infection.
Your work must have:
- a specific characteristic that contributed to your injury
- made it more likely you'd get this injury.
Your injury must not be:
- caused by a pre-existing condition.
Your injury can be a heart or brain-related issue if it:
- happened at your place of work
- was caused by excessive physical strain from your work.
Relevant legislation
Section 30 of the Accident Compensation Act 2001
Section 28(3) of the Accident Compensation Act 2001
See a list of possible work-related diseases we can cover:
Download or print the flowchart on cover decisions - work gradual process injuries
Mental injury caused by a physical injury
Your injury must be:
- diagnosed as a mental condition by a health professional
- caused by a physical injury we’re covering.
Relevant legislation
Section 27 of the Accident Compensation Act 2001
Section 20(2) of the Accident Compensation Act 2001
Section 26(1)(c) of the Accident Compensation Act 2001
Download or print the flowchart on cover decisions - mental injuries caused by physical injuries
Work-related mental injury
We can also cover mental injuries if you've experienced, seen or heard a traumatic event at work. This is even if you haven't been physically injured.
Your injury must be:
- diagnosed as a mental condition by a health professional
- caused by a single event, or a series of events with the same cause.
You must have:
- seen, heard or experienced the event first hand – not through television, pictures, radio etc.
- got the injury at work.
The work-related event must:
- be something that would distress, horrify or alarm most people
- happened with little or no warning.
Relevant legislation
Download or print the flowchart on cover decisions - work-related mental injuries
Sensitive claims
Your injury must be:
- diagnosed as a mental condition by a health professional
- caused by a criminal act we cover.
Relevant legislation
Section 21 of the Accident Compensation Act 2001
See the full list of criminal acts we cover:
Download or print the flowchart on cover decisions - sensitive claims
Injuries caused by treatment
Your injury must be:
- caused by treatment from a registered health professional.
Your injury must not be:
- a normal side-effect of the treatment
- caused by a clinical trial you agreed to in writing.
Relevant legislation
Download or print the flowchart on cover decisions - treatment injuries
Hearing loss
Your injury must have:
- caused the hearing loss – this includes work-related injuries, head injuries and treatment injuries we cover
- made you lose at least 6% of your hearing.