ACC claims for anaphylaxis

Information for health professional and patients

Diagnosis process

ACC cover is decided on an individual basis and requires a clinical diagnosis. ACC considers that medical practitioners are the appropriate people to make the clinical diagnosis in an allergy related claim. This can entail clinical testing and other means of investigation to determine the diagnosis. ACC may seek input from a range of practitioners including dermatologists, immunologists and occupational physicians. The balance of probabilities is applied in situations where the cause is not clear.
If the medical practitioner is unable to verify an allergen as the cause, even though the patient has previously had a diagnosis of an allergy related condition, a second opinion can be sought.

When a claim is declined, for whatever reason, the person has a right to review the decision.

What does ACC provide cover for?

• Work-related allergies and anaphylaxis
  

Under section 30 of the Injury Prevention, Rehabilitation, and Compensation Act 2001 (IPRC Act), allergic reactions and anaphylaxis caused by exposure to allergens in a work setting can be covered. Cardiovascular and Cerebrovascular episodes consequent upon anaphylaxis at work are generally covered.

• Non-work related anaphylaxis
  

In a non-work setting, ACC covers anaphylactic reactions caused by food and insect venom allergens. Subsequently if the claimant suffers a cardiovascular or cerebrovascular episode as a result of anaphylaxis, this is generally covered.
Severe reactions during treatment, triggered by latex or contrast media, for example, are covered under the treatment injury provisions of ACC’s legislation.

However, ACC does not cover general allergic conditions e.g. swelling, skin rashes, hay fever, asthma, triggered by allergens such as house dust mite, cats, pollens etc. Nor is cover provided for allergic reactions that are cold-induced, exercise induced or idiopathic.

Cover is not provided for these general allergic conditions as they are regarded as wholly or substantially caused by gradual process or disease which is excluded from cover unless they are work related.

Entitlements & Associated costs

ACC can meet the costs for investigating and assessing a person’s claim for cover, if required by ACC. Other costs associated with attending the assessment, e.g. travel, can also be reimbursed to the person.

Where cover has been approved, claimants may be entitled to the whole range of entitlements available under ACC. This includes weekly compensation, lump sum compensation, treatment, social rehabilitation, vocational rehabilitation and funeral and survivor’s grants.

ACC provides assistance for the provision for aids and appliances as a result of a covered condition. These items must be purchased at a reasonable cost and be necessary for the rehabilitation of the claimant to independence. ACC’s prior approval is required. For Epi-Pen purchases, the claimant is reimbursed once the Epi-Pen is used.
In cases that are covered as work related claims, the costs of allergen management advice by nurses can be covered and also the cost of medic alert bracelets as part of an ‘Anaphylaxis Action Plan’.

The New Zealand Injury Prevention Strategy provides some information on allergen management in a work setting.

Recommendations from Allergy New Zealand

Making claims

ACC claims should be lodged by the doctor and/or emergency service involved at the time of the anaphylactic reaction. Patients or family members should check as soon as possible if a claim has been made on their behalf. If an ACC claim was not lodged, you should query this with your G.P. and/or your local ACC office.

Generally ACC will cover the costs of the ambulance (if used) and the emergency medical care and treatment. This means they will pay for these services rather than the patient being charged. If you are charged for medical or transport costs in association with an anaphylactic reaction (other than additional fees which might be charged by a private A&E service) you should advise the service concerned that these should be included in the ACC claim.

We have heard that sometimes claims for anaphylaxis have been declined by ACC. This may be for reasons such as the claim not being correctly coded, or they may only be declining part of the claim e.g. for the cost of an EpiPen. It is important to request a review.

Entitlements and costs

We recommend patients seek ACC cover to include a referral to an allergy specialist service following an anaphylactic reaction, to be (re) assessed and provided with an individualised Anaphylaxis Management Plan including training on use of an EpiPen, and advice on avoidance of the allergen concerned.

EpiPens

ACC have advised they will reimburse the cost of an EpiPen used by a patient as treatment for an anaphylactic reaction. It is therefore important to keep receipts for the purchase of EpiPens, and to ensure that medical records relating to the ACC claim for anaphylaxis show that the patient’s own EpiPen was used.

At this stage, however, we understand ACC won’t fund an EpiPen prescribed and/or purchased following an anaphylactic reaction.

Let us know

While we continue to develop clearer guidelines with ACC for claims we would be grateful if people who have made or are making a claim to ACC for anaphylaxis for themselves or their child could let us know how they got on including good news and/or any issues that have arisen. We are also happy to assist with further information if possible. Just email us on anaphylaxis@allergy.org.nz.