Submissions

To prepare your submissions, please make sure you have the following information:

• The review number

• The applicant name

• The decision you want reviewed

• Why the review is necessary

• The outcome you would like

To prepare your submissions, please make sure you have the following information:

• The review number

• The client name

• The decision being reviewed
  

• The outcome you would like

Let's get started!

Identification
This section matches your submissions to the review application.

Please carefully check the digits in the review number and the spelling of your name (as per your application). It’s very important these are correct so your submission is matched to the right review.

Let's get started!

Identification
This section matches your submissions to the review application.

Please carefully check the digits in the review number and the spelling of the applicant’s name as per the application. It’s very important these are correct so your submission is matched to the right review.

Email address: *
Please enter your email address in the box provided below.

This is the address you will be contacted on regarding the review, so please ensure it is correct.

Applicant name: *
Please provide your full name
Type your name, or if you are completing the submissions on behalf of the applicant , type the name of the applicant in the box below.
When an ACC applicant is deceased the meaning of applicant expands to include the spouse or partner, any child, and any other dependants of the deceased applicant.

Click here for more information.

Claimant Name:*

Please provide a full name

Please type the name of the claimant (the person who claims to have suffered a work injury whilst working for the employer) in the box below.
When an ACC applicant is deceased the meaning of applicant expands to include the spouse or partner, any child, and any other dependants of the deceased applicant.
Click here for more information.

Organisation: *
Please type the name of the organisation that has made the decision regarding this review in the box below.
e.g.  ACC, an employer or another organisation that made the decision regarding this review.

Organisation: *
Please type the name of the organisation on whose behalf this submission is being filed in the box below.
e.g. ACC, or another organisation who made the decision regarding the review

Introduction

This section outlines why you have sought a review.

Introduction

An employer only has a limited right of review, namely:
- The right to review a decision that a claimant’s injury was a work-related personal injury.
- As a levy payer, for instance relating to levies payable of claimed by ACC.

This submission builder assists with more frequent injury cover dispute.

Introduction

This section outlines the reason for the review.

I filed the review application to:*
Please select why you have filed the review application from the list below.
Try to focus on the heart of the issue.

I filed the review application to:*
Please select why the review application was filed from the list below.
Try to focus on the heart of the issue

The client filed the review to:*
Please select why the review application was filed from the options below.
Try to focus on the heart of the issue.

Introduction: Looking at a decision made

This section identifies the decision that is being reviewed

Click here for more information

About the decision made: *
Please tell us about the decision made in the box below.
e.g. ACC made a decision to decline the funding of shoulder surgery.

Please note: You will have an opportunity later on to explain in detail the facts about your dispute,
so keep the introduction short and focus on clearly describing the decision.

The reason for the decision:
Please share the reason provided for the decision in the box below.
e.g.  ACC believes that the symptoms are not accident related.
e.g.  ACC believes that surgery would be treating a non-accident related degenerative condition.

I am disputing this decision because:*
Please type the main reason/s you have requested this review in the box below.
e.g. the claimed accident did not happen at the workplace

Introduction: Considering an unreasonable delay in processing an entitlement

An applicant may apply for a review of any delay in processing entitlements that is believed to be unreasonable.
Click here for more information.

Introduction:  Considering an unreasonable delay in processing an entitlement
A client may apply for review of any delay in processing entitlements that is believed to be unreasonable.
Click here for more information.

A review under this section focusses on three points: the entitlement; the covered injury; and the delay.

Why is the covered injury important?
You are only eligible to receive entitlements if the need for it can be linked to a covered injury. It is therefore important to identify in your submission:
- The covered injury
- The entitlement claimed

What is meant by entitlements?
Entitlements include for instance: rehabilitation, treatment, weekly compensation and/or lump sum payments.
Click here for more information.

How must I explain the delay?
There are three pieces of information you should provide:
- The date you requested the entitlements;
- The date you have provided the necessary information to enable ACC or its delegate to consider the requested entitlement;
- The length of time between ACC or its delegate receiving that information and the time of your review application.

Please note: You will have an opportunity later on to explain in detail the facts about your dispute, so keep the introduction short and
focus on the injury, entitlement, and delay.

Type of injury: *
Please enter the type of injury you have (which is covered under the Accident Compensation Act) in the box below.
e.g.   a shoulder sprain
e.g.  post-traumatic stress syndrome
e.g.  wound infection following a gastric leak.

Click here to see injuries covered by the Accident Compensation Act.

Type of injury: *

Please enter the type of injury cover the client has associated with the claimed entitlements in the box below.

e.g. The client has injury cover for a shoulder sprain.
e.g.The client has injury cover for post-traumatic stress syndrome.
e.g. The client has injury cover for wound infection following a gastric leak.

Click here to see injuries covered by the Accident Compensation Act.

Type of entitlement: *
Please enter the type of entitlement you have claimed in the box below.
e.g.   A claim for the entitlement of weekly compensation.
e.g.   A claim for  the entitlement of 12 treatment sessions.

Type of entitlement: *
Please enter the type of entitlement that has been claimed.
e.g.   A claim for the entitlement of weekly compensation.
e.g.   A claim for  the entitlement of 12 treatment sessions.

Reasons for the delay: 
Please select which of the following statements, if any, relate to your submission:
If none of these statements relate to your submission, click next.
Please select as many options as apply below.

Date of decision, or reason for no decision: *
Please select whether or not a decision has been made about this client's requested entitlement from the options below.

Introduction: Raising other issues

The Act limits the scope of review to:
- Looking at a decision made by ACC on a claim; or
- Considering ACC's (or its delegate’s) unreasonable delay in processing an entitlement ifor a claim.

Introduction: Raising other issues
The Act limits an employer’s review rights to two grounds, namely:
- The right to review a decision that a claimant’s injury was a work-related personal injury.
- As a levy payer, for instance relating to levies payable of claimed by ACC. 

If a dispute does not fall into one of these categories a reviewer would need to consider whether he or she has the authority (also known as jurisdiction) to hear your dispute. 
This means that the review hearing will still be held, but the first decision will be whether the reviewer has the authority to consider your review. 
It is therefore essential for you to clearly identify the reason for your review application.

Click here for more information.

Please Note: You will have an opportunity later on to explain in detail the facts about your dispute, so keep your  introduction short and focus on the reason you are seeking a review.

If a dispute does not fall into one of these categories a reviewer would need to consider whether he or she has the authority (also known as jurisdiction) to hear the dispute. 
This means that the review hearing will still be held, but the first decision will be whether the reviewer has the authority to consider the review. 
It is therefore essential to clearly identify the reason for the decision that is being reviewed.

Click here for more information.

Please Note: You will have an opportunity later on to explain in detail the facts about the dispute, so keep your introduction short and focus on the reason for the review.

I have filed the review to: *
Please share what you want to achieve with this review submission in the box below.
e.g.  I have filed the application to receive confirmation of a decision.

I have filed the review to: *
Please share what you want to achieve with this review submission in the box below.
e.g.  ACC has accepted that Mr X has suffered a back sprain at work and continues to fund several physiotherapy treatment session to treat Mr X’s injury, but I believe the treatment is not necessary.

The client has filed the review to: *
Please share what the client wishes to achieve with this review submission in the box below.
e.g. The client has filed the application to receive confirmation of a decision.

The following events led to this review: *
Please explain what caused you to file for a review in the box below.
e.g  My claim has still not been accepted.

The following events led to this review: *
Please explain what caused the client to file for a review in the box below.
e.g.  The client broke their arm.
e.g.  The client's claim has still not been accepted.

Background

This section allows you to expand on the issues identified in the introduction.

- When describing the background describe what, why, when, where, who and how.
- Your submission will read better if is divided into paragraphs each containing one idea.
- Describe events in the order they occurred.
- Include only necessary detail. Check that the information you add is directly relevant to the issues you have identified in the introduction section.
- Ensure you identify relevant information that will prove or disprove the issue/s. Check that the information will assist the reviewer to find in your favour.

If your review is about ACC’s decision not to fund shoulder surgery focus on:
Accident: How the accident happened (sometimes referred to as the mechanism of accident), try to answer as many as the following:
What happened?
Who was there?
Why did it happen?
When did it happen?
Where did it happen?

Medical evidence: Explain why the surgery is required to treat an injury suffered during the accident. This would normally be a report from your treating surgeon.
Who is the surgeon?
When did you consult with the surgeon?
What was the surgeon’s diagnosis?
How did the surgeon propose to treat the condition?
Why did the surgeon say the diagnosed condition was caused by the accident?

Why do you believe ACC’s decision is wrong?

What evidence do you have to support your case?

When did the claimed accident happen?

Where did the claimed accident happen?

Who was involved in the accident and was the person an employee?

If the review is about ACC’s decision not to fund shoulder surgery focus on:

Accident: How the accident happened (sometimes referred to as the mechanism of accident), try to answer as many as the following:
What is the mechanism of accident?
Why did it happen?
When did it happen?
Where did it happen?

This information can normally be found in the ACC claim (ACC45)

Medical evidence: Explain why the surgery is not required to treat an accident related injury. This would normally be a report from a medical specialist.
Who is the person providing the opinion?
What are that person’s qualifications?
What is that person’s diagnosis?
What is that person’s view on the appropriateness of the proposed treatment?
Why did the surgeon say the treatment was not required to treat an accident related condition?

Background: *
Please provide the background to the review in the box below. 
Provide a summary in chronological order of the events and relevant facts leading to the review application.
Remember to be concise and do not add unnecessary detail.

Summary of argument

In this section state the reasons why your review should succeed.

Summary of argument

This section allows you to state the reasons why the review should not succeed.

- Keep it simple. Summarise each of your main points in an order that makes sense. 

- For each identified issue write one or two sentences that briefly explain why your argument is correct.

Arguments to support a review of ACC’s decision to decline to fund left shoulder surgery:

I believe that surgery proposed by my specialist is required to treat an injury suffered as a result of my April 2017 accident. I support this view based on the following reasons:
- Prior to the accident my left shoulder was completely pain free. However since the accident I can hardly use my arm. The fact that my shoulder symptoms happened immediately after the accident suggests that the symptoms, and the cause of the symptoms, are accident related. 
- My specialist, in his report of July 2017, confirmed that:

- The manner in which I injured my shoulder placed sufficient force on the shoulder tendon to cause it to tear. 
- The degenerative changes noted on the MRI-scan were to a different part of the shoulder that would not have caused the tear; and
- The fact that the MRI showed fluid and debris to the area of the tear supported the view that tear was caused by trauma.

Although ACC relies on Dr Y’s view to suggest the tendon tear was caused by degenerative changes, my specialist's reasons are more detailed and supported by the radiological findings.

The issue at review is whether Mr X had suffered a work-place injury on 24 March 2017, working for Company Y.

It is accepted that Mr X had worked for Company Y; however, it is disputed that Mr X was employed by Company Y at the time of his injury.

It is Company Y’s case that Mr X had resigned with immediate effect on 15January 2017, a resignation accepted by Company Y. It is therefore argued that ACC incorrectly accepted that Mr X had suffered a work-place injury on 27 March 2017, for the simple fact that Mr X did not work for Company Y at the time of injury.

Arguments to contest a review of ACC’s decision to decline to fund left shoulder surgery:

The issue at review is one of causation, in other words whether or not the injury caused by accident on 24 March 2017 created the tendon tear that now requires surgery.
ACC accepts that Mr X sprained his shoulder on 24 March 2017. However it does not accept that the March accident caused the tendon tear.
ACC believes the accident has triggered a pre-existing degenerative condition and relies on the medical opinion of Dr Q in support of its view.
In Dr Q’s opinion the covered injury had resolved and the ongoing symptoms and need for surgery were not caused by the accident. Dr Q noted that the MRI showed calcification and that the torn tendon was frayed, without any trace of fluid or debris. In her detailed reasoning she explained that these finding suggested that it was more likely than not that the torn tendon was caused by non-accident related degeneration.
The treating surgeon’s comment that the accident cause the tendon tear is solely based on the onset of Mr X symptoms, without any reference to the MRI findings.  On that basis Dr Q’s view should be preferred.

Costs

You can only claim certain review costs. If you're not sure what costs can be claimed, ask your reviewer at the hearing.

Costs

Section 148 provides for the reviewer to award costs and expenses in accordance with the regulations, whether or not there is a hearing.

- Present receipts to the reviewer to show the costs you incurred.

- The costs that can be awarded are limited to the amounts contained in the Regulations - click here for more information.

- You can only claim costs associated with the review application. This means you cannot claim entitlements i.e. weekly compensation, surgery funding etc. as part of the review costs.

Costs incurred must be awarded when the review is successful.

When a review is unsuccessful the reviewer has discretion to award costs if he or she finds that the review was brought on reasonable grounds.

Click here for more information.

Costs:

Please select one of the below options in regards to ordering of costs.

Review your submission

Please confirm that all information entered on the previous pages is correct before clicking 'submit'. If not, go back to change your answers.
Note: You will not be able to go back once you click 'submit'. A copy of your submission will be sent to your email address, and to Fair Way Resolution.