Payments Outside Scope of Statutory Entitlements
Policy v3.0
Summary
2.0 Serious service failure
a Service failures can occur when:
Objective
Payments outside the scope of statutory entitlements are pay-
• a client’s entitled to a payment, but for some reason this
ments made by ACC to manage potential liabilities under Crown
wasn’t identified early enough
Entities Act 2004, Section 17. These payments were previously
• the client isn’t entitled to a payment but we’ve incor-
referred to as ‘wrongful action’ or ‘ex-gratia’ payments.
rectly advised them they are.
This page provides information on:
Both of these scenarios result in a loss for the client. If
they request payment from what they see as a service
• criteria required for a client to be paid outside ‘the scope of
failure, we need to see if this can be resolved through
statutory entitlement’
statutory entitlements.
• what defines a serious service failure
• what defines a financial loss
See AC Act 2001, Section 69
• how we compensate the client
A serious service failure requires more than a simple
Please note that privacy breaches are not addressed through
omission or delay. It requires ACC to have fallen well
this process. All enquiries around privacy breaches and poten-
below reasonable service standards. The following cri-
tial compensation must be addressed through the Privacy
teria normally should be met when considering if a se-
Team.
rious service failure has occurred:
For information on payments for backdated weekly compen-
• there’s serious failure by ACC to do so something that
sation, go to 'Backdated Weekly Compensation' process group
was a legislative requirement or an error in the way
folder under: Claims Management> Manage Client Payments >
something was done
Operational Policies > Weekly Compensation > in Promapp.
• the failure falls outside the scope of a normal rectifiable
human error (serious error is negligent and risks putting
If we consider issuing a decision to decline weekly compen-
ACC under threat of law liability).
sation after a review/appeal or a settlement has indicated that
weekly compensation should be paid, then this case must be re-
ferred to the Weekly Compensation Panel to:
3.0 Measurable financial loss
a As well as a serious service failure occurring, a client
• check that the decision made to decline was robust
must be able to demonstrate that due to ACC’s service
• recommend whether a payment outside the scope of statutory
failure they experienced a measureable financial loss.
entitlement should be considered (if appropriate).
This could include:
Owner
Cheryl Gall
• income that could have been earned from a rightful
entitlement that’s been delayed due to ACC’s inaction,
Expert
Cheryl Gall
payment of interest on late payment of weekly compen-
sation does not apply
Policy
• additional costs incurred by the client whilst trying to get
their entitlement
1.0 Criteria for payments outside the scope of sta-
• incorrect advice provided by ACC that resulted in a
tutory entitlements
financial commitment for the client
• ACC committing to pay for something with no entitle-
a For a payment to be made outside the scope of statutory
ment.
entitlements, the following criteria must be met:
• ACC committed a serious service failure, and
• the client experienced a measurable financial loss be-
cause of ACC’s actions.
If you receive a payment request that can’t be resolved
through statutory entitlement, and ACC runs risk of court
action due to the service failure, you should refer the
matter to your a Technical Specialist. The delegation to
approve a payment in excess of $2,000 or to reject a re-
quest is made on the recommendation of a Technical
Specialist.
ACC > Claims Management > Manage Claims > Operational Policies > Managing Claims at ACC > Claim management > Payments Outside Scope of Statutory Entitlements
Policy
Uncontrolled Copy Only : Version 3.0 : Last Edited Thursday, November 14, 2019 1:53 PM : Printed Tuesday, 2 June 2020 3:21 PM
Page 1 of 3
4.0 Reimbursement of bank fees
NOTE Example: Rest home costs incurred
a This is a common issue considered as a payment outside
The client fractured her hip 2004. This year she
the scope of legislation. The following provides infor-
returned to hospital for removal of rods. Prior to
mation how to manage these cases:
her discharge a needs assessment was com-
pleted. The assessor recommended 7 hours
• If a client receives bank fees due to a delay in ACC
home help and 10 hours attendant care assis-
paying an entitlement (eg weekly compensation) this is a
tance per week.
failure in service. These cases wouldn’t be considered a
‘serious error’ and therefore not meet criteria for payment
Instead of returning home, the client was dis-
outside scope of statutory entitlement.
charged to a rest home. A short time later, ACC
was advised that the client had died. ACC ad-
• Where a client incurs costs resulting from poor service,
vised the client’s daughter, that ACC would pay
the Branch manager can decide if a reimbursement is
the rest home costs.
needed.
It had since been determined that there was no
• Reimbursements should be made from the branch’s
injury-related need for rest home care. However,
operating budget, not against a claim file. To do this, the
ACC had given a clear undertaking to the family
branch manager needs to send a memo to Accounts
that ACC would meet this cost.
Payable. They’ll need the amount, payee, and other rele-
vant details like the bank statement.
NOTE Example: Reimbursement for duplicate
prescription receipt if ACC loses original
• Delegation for payments from the branch operating
A client has sent their application for reim-
budget is covered in Delegations.
bursement of prescription fees to their case man-
ager. In turn, the case manager has sent the
• Branch Managers should confirm if there’s additional
application to the processing centre.
sign off needed (unlikely based on the usual amount but
should be checked).
However, after three weeks of not hearing back
from ACC the client contacts the case manager,
who discovers the application cannot be found.
5.0 Specific claim examples
NOTE Example: Unlawful suspension of indepen-
The client now has to submit a new application.
dence allowance
When they go to the pharmacy to get a duplicate
of their original receipt the pharmacy charges
In Stewart (337/2004), the District Court found
them a fee for the duplicate.
that ACC couldn’t suspend entitlement to the
independence allowance on medical grounds
This fee is not a prescription cost, but a cost in-
without going through the statutory indepen-
curred by the client due to ACC having lost the
dence allowance reassessment process.
original application. ACC will then reimburse for
the prescription fee as well as the costs of ob-
QBE stopped paying the client’s independence
taining the duplicated receipt.
allowance entitlement in 2005 without going
through the proper process. This alone consti-
tuted a serious error. However there was also
the issue about whether or not this decision
should have been made in the first place. There
6.0 How to pay the client - the submission
was a wealth of medical information supporting
a If you identify a case where there has been a serious ser-
the client’s on-going incapacity being related to
vice failure resulting in a quantifiable loss to the client, a
the original covered injury. However his entitle-
submission for ‘payment outside the scope of statutory
ments were suspended on the basis of a file
entitlements’ should be prepared.
review.
The submission needs to include:
The case met the criteria in relation to serious
error despite the decision having originally been
• amount the client is seeking
made by a private insurer. Once QBE files were
• details surrounding the claim
handed back to ACC, the Corporation was ob-
• alleged errors ACC made
liged to notify the insurer of any liabilities within
• quantified losses incurred by the client.
20 days of becoming aware of them. As that
timeframe had passed ACC was now liable for
For amounts under $2,000 the submission is referred to
any payment outside the scope of statutory
the Unit Manager to approve.
entitlements due.
In regards to the quantifiable loss this was calcu-
For amounts over $2,000 the submission is referred to
lated on the basis of the interest from the date of
the Technical Services team for consideration and
suspension of the independence allowance to
submission to the delegation holder.
the date it was reinstated.
ACC > Claims Management > Manage Claims > Operational Policies > Managing Claims at ACC > Claim management > Payments Outside Scope of Statutory Entitlements
Policy
Uncontrolled Copy Only : Version 3.0 : Last Edited Thursday, November 14, 2019 1:53 PM : Printed Tuesday, 2 June 2020 3:21 PM
Page 2 of 3
7.0 Making the payment
a Once written approval’s been given, the Case Manager
needs to:
1) send a letter to the client advising them of the deci-
sion, noting that as it is a decision outside the scope of
statutory entitlements, review rights do not apply
2) create a purchase approval in EOS, using the fol-
lowing details:
• Client or representative (in [Vendor] field)
• Entitlement code WA02
• One month from now (in [To Date] field)
• Amount to be entered as directed by Manager/Technical
Services (In Unit Price field)
3) email the Unit Manager/Delegation Holder contact (de-
pending on amount) to request authorisation of the pur-
chase order
4) complete an ACC161 Proforma invoice form, once the
authorisation’s been given
5) forward ACC161 to the local payments centre for
processing. Refer to Who processes client reimburse-
ments.
6) check a week later to make sure the payment’s re-
ceived by the client and if not, follow up with payments
team.
ACC161 Proforma invoice form
Who Processes Client Reimbursements Policy
ACC > Claims Management > Manage Claims > Operational Policies > Managing Claims at ACC > Claim management > Payments Outside Scope of Statutory Entitlements
Policy
Uncontrolled Copy Only : Version 3.0 : Last Edited Thursday, November 14, 2019 1:53 PM : Printed Tuesday, 2 June 2020 3:21 PM
Page 3 of 3
