How we assess claims

Assessing claims

We use a system that will help identify and accept straightforward claims. We identify complex claims, and one of our people will review and assess the claim. The system won’t decline any claims.

Each injury in the system has a score based on the analysis of 12 million previous, anonymised ACC claims. This score is the probability that a person assessing a claim would accept the claim. You’ll see this score on your claim information.

Explaining your claim information

By using a system to fast-track straightforward claims, our people have more time to spend on claims that need a review or assessment. This also creates a greater level of consistency in the decision-making process.

Straightforward claims are fast-tracked

Each year, we receive an average of 2 million claims.

Of the 2 million claims we receive each year, 1.8 million are easily identified as fitting within the rules of the Accident Compensation Act 2001. We approve these claims without the need for further information or investigation.

We're using the system to identify and fast-track the acceptance of straightforward claims. These are claims where it’s clear an accident has caused the injury.

It helps us to make decisions faster so that you can get help quicker. If we have your mobile number or email address, you may receive information telling you what’s happening with your claim much sooner.

For example, while John was out walking his dog he tripped and sprained his ankle. He went to his doctor who submitted a claim to ACC. We received the claim and made an immediate decision. John receives a text message letting him know his claim is accepted. John can take his claim number to his physiotherapist and start treatment as soon as he can.

Our people review and assess complex claims

When we identify claims as complex, one of our people will review and assess the claim. Types of complex claims include:

• sensitive claims
• accidental death
• dental
• hearing loss
• gradual process
• serious injuries
• claims relating to injuries that could involve multiple causes.

For example, Jane fell off a cliff when tramping. She has sustained multiple injuries, including a blow to the abdomen which has caused a hernia. The emergency department at the hospital has lodged a claim with ACC. Hernias are not often caused by an external force and generally not covered by ACC. The claim is identified as complex and a staff member will assess whether treatment of the hernia is covered.

Review of claims by staff is dependent on the diagnosis and details of injuries. In this example, Jane's injury is one that needs further investigation and an ACC employee will review her case.

If we need specialist 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.