Copyright is owned by the Author of the research report. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The research report may not be reproduced elsewhere without the permission of the Author. From lodgement to cover: a qualitative inquiry into the steps and factors that lead to cover decision for a leptospirosis claim in New Zealand A thesis presented in partial fulfilment of the requirements for the degree of Master in Veterinary Studies Abbie Stephanie S. Uy i Abstract Leptospirosis is an occupational hazard for people working with animals, and while occupationally-acquired leptospirosis is a compensable condition, the mechanics of the compensation process are not well understood by patients. In addition, much of the crucial decisions affecting the claim outcome are made by treatment providers and insurance claim assessors largely outside of the patient’s purview. This lack of understanding adds to the disease burden experienced by patients. This study was therefore designed to improve the understanding of the compensation process for leptospirosis, by first establishing what are the bases of a claim, and second, investigating how treatment providers and insurance claim assessors evaluate a case or claim. A qualitative approach was utilised in this study. Government reports and publications were analysed in order to determine the formal procedure and requirements of the process, while interviews with treatment providers and insurance claim assessors revealed how the actual process plays out in real life. The results showed that a claim is assessed against two main requirements: having a confirmed diagnosis and having an appropriate exposure. A claim must have sufficient information to support both of these requirements. The criteria for the exposure are set in legislation, but the diagnostic criteria may vary depending on which case definition is used. The results from the study showed that the assessment may be affected by factors like physician experience, laboratory test preference, and patient and employer compliance. ii Acknowledgement I would like to thank all of the participants as well as the consultant, for being gracious with their time and knowledge. I am truly grateful and beholden to their generosity. I am also extending this gratitude to the various ACC personnel who were approached for information and were quick to offer their assistance. Thank you very much. Writing this report has been illuminatingly challenging, but also extremely rewarding, and I am endlessly grateful to have had the support and guidance of my supervisors, Jackie Benschop, Julie Collins-Emerson and Gerard Prinsen. Many times, their comments and feedback have prompted me to re-consider things from another angle or to broaden (or narrow down) my inquiry, and it has no doubt enriched this report. Most of all, I am thankful for their untiring encouragement throughout the study; their continued belief in this project helped steady my resolve and pushed me towards the finish line. Next, I would like to acknowledge the persons and institutions who made it possible for me to come study in this beautiful country. Much thanks to the NZ Scholarship Programme of the Ministry of Foreign Affairs and Trade, and to the people of New Zealand, for sponsoring the academic development of scholars like myself. At the same time, I would like to express my gratitude to the Massey NZ Scholars Team, for their excellent assistance in providing us scholars with the tools to support our academic endeavours. Thank you too to my fellow students and to the friends I have made here. Thank you for commiserating with me during my moments of despair, and for also sharing and contributing to my moments of joy. Lastly, thank you to my family and friends in the Philippines, for all their love and support during the making of this report. iii Table of Contents ABSTRACT ......................................................................................................................................... I ACKNOWLEDGEMENT ................................................................................................................ II DEFINITION OF TERMS ................................................................................................................ 1 INTRODUCTION AND STRUCTURE OF THE REPORT ......................................................... 3 CHAPTER 1 ....................................................................................................................................... 4 1.1 OCCUPATIONAL LEPTOSPIROSIS IN NEW ZEALAND ................................................. 5 1.1.1 LEPTOSPIROSIS OVERVIEW ...................................................................................................... 5 1.1.2 DIAGNOSIS OF LEPTOSPIROSIS ................................................................................................. 7 1.1.3 LEPTOSPIROSIS AS AN OCCUPATIONAL HAZARD IN NEW ZEALAND ........................................ 9 1.1.4 THE DISEASE BURDEN OF OCCUPATIONALLY-ACQUIRED LEPTOSPIROSIS IN NEW ZEALAND . 10 1.1.5 THE “HIDDEN COST” OF OCCUPATIONALLY ACQUIRED LEPTOSPIROSIS ................................. 11 1.2 WORKER COMPENSATION AND ACCIDENT COMPENSATION CORPORATION OR ACC ............................................................................................................................................ 13 1.2.1 ACC OVERVIEW .................................................................................................................... 13 1.2.2 WORKER COMPENSATION WITHIN THE ACC SCHEME ........................................................... 16 1.2.3 ACCREDITED EMPLOYERS AND THIRD-PARTY ADMINISTRATORS ......................................... 17 1.3 COMPENSATION OF OCCUPATIONAL LEPTOSPIROSIS ........................................... 20 1.3.1 COVER VERSUS ENTITLEMENT .............................................................................................. 20 1.3.2 COVER FOR OCCUPATIONAL DISEASES AND THE ISSUE OF CAUSATION .................................. 21 1.3.3 LEPTOSPIROSIS AS A SCHEDULE 2 INJURY ............................................................................. 24 1.3.4 CASE DEFINITIONS FROM MOH AND ACC ............................................................................ 24 1.3.5 NEED FOR MEDICAL ASSESSMENT ......................................................................................... 26 1.3.6 LEGISLATIVE TIME FRAME .................................................................................................... 26 1.3.7 LEPTOSPIROSIS CLAIMS STATISTICS ...................................................................................... 27 1.4 CHAPTER SUMMARY ............................................................................................................ 28 CHAPTER 2 ..................................................................................................................................... 29 2.1 METHODS ................................................................................................................................. 30 2.1.1 STUDY GENESIS AND DEVELOPMENT OF THE RESEARCH QUESTION ...................................... 30 2.1.2 STUDY DESIGN. ..................................................................................................................... 31 2.1.3 DATA COLLECTION ................................................................................................................ 32 2.1.4 ETHICAL CONSIDERATIONS ................................................................................................... 33 2.1.5 SAMPLING STRATEGY ............................................................................................................ 33 2.1.6 RECRUITMENT OF TREATMENT PROVIDERS ........................................................................... 34 2.1.7 RECRUITMENT OF MEDICAL ADVISORS .................................................................................. 35 2.1.8 PREPARATION AND CONDUCT OF INTERVIEWS ...................................................................... 36 2.1.9 INTERVIEW TRANSCRIPTION .................................................................................................. 37 2.1.10 DATA ANALYSIS .................................................................................................................. 38 2.1.11 METHODS REFLECTIONS ...................................................................................................... 40 2.2.1 LEPTOSPIROSIS CLAIMS PROCESS – FROM CLAIM INITIATION TO COVER DECISION ................ 41 2.2.2 INTERVIEW FINDINGS – TREATMENT PROVIDERS .................................................................. 45 2.2.3 INTERVIEW FINDINGS – CLAIMS ASSESSORS (INSURANCE MEDICAL ADVISORS AND THE TEAM MANAGER OF ACC’S GRADUAL PROCESS CASE COORDINATORS) ................................................. 50 2.3 DISCUSSION ............................................................................................................................. 56 2.3.1 KEY FINDINGS ABOUT SPECIFIC STEPS IN THE PROCESS ......................................................... 56 2.3.2 KEY FINDINGS ABOUT THE FACTORS THAT AFFECT THE PROCESS ......................................... 57 2.4 CHAPTER SUMMARY ............................................................................................................ 65 CHAPTER 3 ..................................................................................................................................... 66 3.1 SUMMARY OF THE STUDY FINDINGS ............................................................................. 67 iv 3.2 STUDY REFLECTIONS AND RECOMMENDATIONS ..................................................... 68 REFERENCES ................................................................................................................................. 70 APPENDIX 1 LOW RISK ETHICS NOTIFICATION LETTER .............................................. 78 APPENDIX 2 ACC OIA RESPONSE ............................................................................................ 79 APPENDIX 3 INTERVIEW QUESTIONS FOR THE TREATMENT PROVIDERS ............. 87 APPENDIX 4 INTERVIEW QUESTIONS FOR THE MEDICAL ADVISORS ...................... 89 APPENDIX 5 PARTICIPANT INFORMATION SHEET AND CONSENT FORM ............... 91 1 Definition of Terms • AC Act 2001 – refers to the prevailing Accident Compensation Act 2001. • ACC – in this text, it may refer to the Accident Compensation Corporation as an entity, to the scheme that it oversees, or to the standing principal Act (see AC Act 2001). • Act – unless otherwise stated, all standalone references to ‘Act’ in this text pertain to the Accident Compensation Act 2001 (see AC Act 2001). • AE – Accredited Employers; refers to employers who are members of ACC’s Accredited Employer Programme. • AEs/TPAs – refers jointly to both Accredited Employers and third-party administrators (see TPA below); this term is used in this text to refer to both as a joint entity that is distinctly separate from ACC. • Case coordinator – refers to the insurance personnel who serves as the first point of contact for the claim; the case coordinator is tasked with obtaining further information for assessing the claim and for determining if cover is warranted. • Case definition – refers to the set of criteria for diagnosing leptospirosis. • Claim assessors – refers to insurance personnel who are tasked with assessing a claim to see if it is eligible for cover; in this text, it will refer to both case coordinators and medical advisors. • Compensation – see Entitlements. • Cover – Cover is defined in Section 8 (2) of the AC Act 2001: “When this Act says that an injury is covered by this Act, it means that the injury is a personal injury for which a claimant has cover”. In other words, the provisions for injury (see AC Act 2001 Section 20 (2), Sections 26 to 30, 32, 35) and provisions for cover (see AC Act 2001 Sections 20 to 24 and 34) are satisfied and the claimant is entitled to claim compensation. Cover is the first step in the life of a claim, for without cover, no compensation will be awarded. • DoL – Department of Labour; was previously the Crown entity tasked with administering labour laws. The use of this term in this text is in 2 reference to a 2007 DoL report entitled Leptospirosis: Reducing the impact on New Zealand workplaces (Keenan, 2007). • ELISA – Enzyme-linked immunosorbent assay; a laboratory test that detects antibodies produced against leptospires. ELISA tests are further described based on the type of antibodies it detects, e.g. an ELISA tests that detects IgM antibodies is called an IgM-ELISA. • Entitlements – refers to the types of compensation provided by AC Act 2001 Section 69. A claimant may receive any one or all of the types of entitlements, depending on their injuries and needs. • MAT – Microscopic agglutination test; a laboratory test that detects antibodies produced against leptospires. • Medical advisor – a physician who is employed by an insurer to offer advice on the medical information related to a claim. • MoH – Ministry of Health. • PCR – Polymerase chain reaction; a laboratory test that detects the presence of leptospiral nucleic acid. • TPA – third party administrators; these are private insurance brokers or companies that an Accredited Employer can hire to manage their workplace claims instead of ACC. • Treatment providers – refers to both primary care physicians (e.g. General practitioners or GPs) and secondary care physicians (e.g. hospital-based physicians). The compensation process for leptospirosis requires the involvement of treatment providers. • WorkSafe – New Zealand’s primary workplace health and safety regulator. 3 Introduction and structure of the report Leptospirosis is the most common occupational zoonosis in New Zealand. Working with animals, especially livestock, is a recognised risk factor for the disease, and majority of the reported cases are farmers, farm workers, and abattoir workers. Most cases of leptospirosis manifests as a mild, non-specific acute infection, but a proportion of patients may develop severe, life-threatening symptoms like shock or kidney failure. Severe leptospirosis often requires intensive care and hospitalisation. Recovery from severe leptospirosis can take weeks or months, during which time patients may be too ill to work. People who contract the condition from work activities or work environment are eligible for compensation under the Accident Compensation Act 2001. However, previous studies of occupationally-acquired leptospirosis have found that workers had poor knowledge of the compensation requirements and report dissatisfaction with the system of compensation. This project was therefore conceived as a way to improve the understanding of the whole compensation process for leptospirosis, by focusing on the steps of claim initiation and cover assessment. Due to the medical nature of a leptospirosis claim, those two steps require the involvement of treatment providers and medical advisors. What is more, the outcome for a leptospirosis claim largely depends on the actions and decisions made by these two key actors. For these reasons, the focus of this qualitative, exploratory study largely revolves around the decision-making criteria of said key actors. The report is divided into three chapters. The first chapter provides context into how leptospirosis fits into the general system of worker compensation in New Zealand and then establishes the bases for a leptospirosis claim. The second chapter presents the study methods and results, and then discusses the results in relation to the research question. The third chapter contains a summary of the study findings and the recommendations and suggestions for future research. 4 Chapter 1 Setting the context This chapter provides context to this study, using information from published literature and publicly-available government reports and documents as well as the information requested from ACC under the Official Information Act (see Appendix 2 ACC OIA response). This chapter is split into three sections: the first discusses leptospirosis as an occupational hazard in New Zealand and highlights its consequences on workers, the second gives an overview of ACC as whole, while the third section details the specifics of a leptospirosis claim – its legislative basis and diagnostic criteria as well as a recent history of leptospirosis claims. The goal of this chapter is to describe key components of the context in which leptospirosis claims are assessed in New Zealand. 5 1.1 Occupational leptospirosis in New Zealand 1.1.1 Leptospirosis overview Leptospirosis is a global zoonotic disease caused by the bacteria Leptospira. The bacteria are maintained in reservoir animal hosts and human cases result from direct contact with the urine of an infected animal or indirect contact via soil or water contaminated with urine from an infected animal (Haake & Levett, 2015). The bacteria can enter through cuts and cracks in the skin, e.g. through bare hands or feet, or through the mucous membranes like those in the eyes, nose, or mouth. Persons whose occupation puts them in contact with potentially infected animals, such as farm workers, abattoir workers, veterinarians, sewer workers, hunters and trappers, etc. are recognised to be at high risk for getting the disease (Haake & Levett, 2015). Other terms for leptospirosis – swamp fever, mud fever, field fever, swineherd’s disease, and cane-cutter fever (WorkSafe, 2015, p. 6) – point to both its common presentation as a fever and to its vocational association. Historically, leptospires have been classified according to their phenotypic characteristics (e.g. pathogenicity) and then further sub-classified according to their serological reactions, resulting in more than 200 different serovars (Haake & Levett, 2015, p. 12). In recent decades however, genotype-based classification has started to replace serovar classification (Vincent et al., 2019), although the latter system is still widely used in the clinical diagnosis and epidemiological profiling of the disease (Bharti et al., 2003). Some serovars have typically been associated with certain animal hosts, but this association is in no way absolute and is affected by the diversity and interaction of the animal and human populations in an area (Adler & de la Peña Moctezuma, 2010; Levett, 2001) and varies greatly by region (Bharti et al., 2003). Costa et al. (2015, p. 10) estimates 1.03 million cases occur worldwide each year, causing an estimated 58,900 deaths. Most cases of leptospirosis manifest as a mild, non-specific acute infection, and a proportion of infections may be inapparent or subclinical (Bharti et al., 2003). Incubation period averages 5 to 14 days but can range from 2 to 30 days (Ko, Goarant, & Picardeau, 2009, p. 3). Common symptoms include fever, chills, myalgia, and headaches; some patients may also experience non-productive cough, abdominal pain, nausea, vomiting, and diarrhoea. The acute infection normally lasts about a week (Ko et al., 2009; Spichler, Athanazio, Seguro, 6 & Vinetz, 2011). Leptospirosis is widely acknowledged to be an under-reported disease, as cases that manifest as a mild, acute, self-limiting infection with generalised symptoms would not often cause people to seek medical attention, and therefore the recorded incidence most likely represents a small portion of the true number of leptospirosis cases (Goris et al., 2013). People who do seek medical attention are often severely affected. Severe cases are estimated to make up 5-10% of globally recorded human infections (Costa et al., 2015, p. 12). Severe leptospirosis is a potentially fatal condition characterised by multiple organ dysfunction, most commonly involving the liver, lungs, and kidneys (Haake & Levett, 2015). Weil’s disease is a known severe form that typically involves a combination of jaundice and renal failure (Haake & Levett, 2015). Other serious manifestations include pulmonary haemorrhage leading to acute respiratory distress syndrome, myocarditis, and shock (Spichler et al., 2011). Severe leptospirosis can have high fatality rates, especially in developing countries, but early initiation of antibiotic treatment has been shown to reduce illness duration and severity (Bharti et al., 2003). A high degree of clinical suspicion, along with early diagnosis to distinguish it from viral infections, is therefore critical in managing the disease. The majority of leptospirosis cases resolve completely; however, there is growing recognition that some patients experience long-term symptoms. Torgerson et al. (2015, p. 4) defined chronic sequelae as likely to be lasting longer than two months, although some patients have reported suffering symptoms for years (Levett, 2001; Weston, Mocke, Collins-Emerson, & Benschop, n.d.). A study in the Netherlands reported that 68 out of 225 laboratory-confirmed patients (30.2%) complained of persistent symptoms, with 12 patients experiencing symptoms more than 24 months after being discharged (Goris et al., 2013). The most frequently reported symptoms were what the authors called depression-compatible complaints (e.g. extreme fatigue, headaches, and malaise) and those related to chronic pain (e.g. myalgia and joint paints). Other reports of long-term symptoms include a study where 11 patients were re- evaluated for possible delayed sequelae after recovery from acute leptospirosis (Levett, 2001, p. 306); four out of the 11 patients complained of persistent headaches 7 while two reported visual problems; the duration of persistent symptoms for that study ranged from 6 to 34 years. Another study of hospitalised patients in Brazil found two out of 47 patients still had complaints more than two months after being discharged – one still had profound general malaise after one year while another was diagnosed with new-onset panic disorder after his bout of acute leptospirosis and needed medication for more than six months (Spichler et al., 2011). However, despite the number of reported cases through the years, the mechanism and causal association for chronic symptoms remain poorly understood (Spichler et al., 2011). 1.1.2 Diagnosis of leptospirosis As mentioned above, the generalised symptoms of leptospirosis, especially in its early stages, makes it clinically difficult to distinguish from other causes of acute febrile illness (Torgerson et al., 2015). Treatment providers rely on a high index of suspicion, taking into account the patient’s risk factors, exposure history, and presenting signs and symptoms (Haake & Levett, 2015). Laboratory confirmation is needed to validate the diagnosis, but interpretation of the laboratory results also requires knowledge of which tests are appropriate for each phase of the disease. Unsuitable tests using incorrect samples taken at inappropriate times may lead to misdiagnosis (Musso & La Scola, 2013). Laboratory tests for leptospirosis are the following: • isolation and culture of leptospires from bodily fluids (blood, urine or cerebrospinal fluid), • molecular detection of bacterial nucleic acids (e.g. PCR), and • serological tests that detect antibodies produced against the bacteria (e.g. MAT and ELISA). Culture is not often used in therapeutic management, as it may take months before results can be obtained and is therefore no help for getting an early diagnosis. Serological tests and nucleic acid detection tests are more suited for rapid diagnosis; but the suitability of tests and samples vary depending on the stage or phase of the disease. 8 Leptospirosis is said to be biphasic: first, an acute phase characterised by leptospiraemia (presence of leptospires in the blood), and then an immune phase characterised by antibody production and excretion of leptospires in the urine (Levett, 2001). Leptospiraemia begins before the onset of symptoms, and usually tapers off beyond week one of illness. Blood sample collection for culture and PCR should be made at this stage because this is when leptospires are present in the blood; when blood for isolation or PCR is taken beyond this phase, it may produce false negative results and lead to misdiagnosis. An accurate retelling of symptoms onset helps treatment providers estimate which phase or stage the patient is likely in. After leptospiraemia, the immune phase begins, usually starting from week two and beyond; this is when serological tests like ELISA and MAT are more appropriate because it can take a couple of weeks before antibodies build up to detectable levels in the blood. The antibody titre gradually increases as the disease progresses, before peaking and then decreasing after recovery. Low titres could indicate either the very early or the late stage of the immune phase (World Health Organization, (WHO), 2003) and is why paired serum samples are recommended, in order to improve diagnostic certainty. If the date of symptoms onset can be precisely determined, an interval of 3-5 days between samples may be adequate, but in most cases, a 10-14 days interval is more appropriate (Haake & Levett, 2015, p. 83). MAT has historically been the gold standard test but preference for ELISA and PCR is increasing. Both tests are more novel and simpler to perform than MAT. MAT needs more specialised facilities and that has led to fewer laboratories capable of performing MAT compared to ELISA or PCR (WHO, 2003). Another advantage of the newer tests is that they may be used earlier than MAT: days 5-10 for PCR and days 6-8 for ELISA (Musso & La Scola, 2013, p. 248) versus days 10-12 for MAT (WHO, 2003, p. 78). However, both PCR and ELISA tend to become negative faster than MAT (Musso & La Scola, 2013). MAT is also capable of detecting both IgM and IgG type antibodies while most ELISA tests for use in early stages are IgM- specific (WHO, 2003). The later stage of the immune phase may also give rise to bacterial shedding in the urine. Urine samples for culture and PCR may be used at this stage but it should be noted that leptospires die quickly in the urine – WHO (2003, p. 81) recommends the 9 sample to be processed within two hours. Other things to consider when interpreting urine PCR results are that humans do not effectively shed bacteria in the urine (Ko et al., 2009, p. 25) and that antibiotic treatment (particularly doxycycline) has been shown to prevent bacterial shedding (Haake & Levett, 2015, p. 85). In summary, laboratory results are crucial for confirming diagnosis. However, they must be considered in conjunction with the probable stage of the disease, and a negative result may not always mean that the disease is absent. 1.1.3 Leptospirosis as an occupational hazard in New Zealand Leptospirosis is New Zealand’s most commonly notified occupational infectious disease (Borman & Xu, 2015, p. 6), with the majority of cases coming from people working in occupations related to the farming or meat processing industry (El-Tras, Bruce, Holt, Eltholth, & Merien, 2018, p. 165). The first cases of leptospirosis in New Zealand were reported on a farm in 1951, where at least six calves died and six human patients were hospitalised (El-Tras et al., 2018, p. 162). The number of reported cases grew from that first report, and at its peak in the 1970s, more than 800 cases were being reported annually (Dorjee, 2007, p. 42). A widespread animal vaccination campaign in the 1980s is widely attributed to have brought the annual incidence down in the following decades: 4.4 cases per 100,000 from 1990-8 (Thornley, Baker, Weinstein, & Maas, 2002, p. 29) and 2.2 cases per 100,000 from 2001-14 (Sanhueza, Heuer, Wilson, Benschop, & Collins-Emerson, 2017, p. 371). Eighty percent of the notified cases from 2001-14 were meat plant workers, dairy farmers, and other types of livestock farmers or farm workers (Sanhueza et al., 2017, p. 371). In 2017, there were 142 notified cases of leptospirosis; 128 of which reported their occupation; 91 of the 128 cases (71.1%) were patients working in high-risk occupations such as farmers, farm workers, livestock transporters, and meat plant workers (ESR, 2019, p. 26). An analysis of notified leptospirosis cases from 1990-98 by Thornley et al. (2002, p. 29) showed that while the overall annual incidence for the whole population was 4.4 per 100,000 persons, for meat workers and livestock farmers, the annual incidence was 163.5 per 100,000 (a 37-fold increase over the general population) and 91.7 per 100,000 (a 20-fold increase), respectively. Thornley et al. (2002, p. 34) went on to 10 estimate that within a 30-year career period, a meat worker has a 1:20 chance of developing a severe case of leptospirosis while a male dairy farm worker’s chances range from 1:14 to 1:28. Because of leptospirosis’ well-established zoonotic and occupational risk, the disease is notifiable under the Health Act 1956 and regarded as a significant hazard under the Health and Safety in Employment Act 1992 (WorkSafe, 2015). Attending medical practitioners and laboratories who encounter a suspected case of leptospirosis are required to immediately give notice, even without confirmation, to the local medical officer of health (MoH, 2017). The medical officer of health in turn is required to notify WorkSafe of confirmed cases if they believe them to be work- related (Health and Safety at Work Act 2015 Section 199). Despite its status as a notifiable disease, leptospirosis is still believed to be widely unreported. The Worksafe Guidelines for the Prevention and Control of Leptospirosis (WorkSafe, 2015, p. 10) notes that the actual cases may be 16-56 times higher than the reported number, as a large number of cases are either undiagnosed or misdiagnosed by patients and doctors for flu. Reported cases come from patients who feel unwell enough to seek medical attention, and these are often patients who experience severe symptoms and may require hospitalisation. Of the notified cases in 2017 with a recorded hospitalisation status (140 out of a total 142 notified cases), 63.6% (89/140) were hospitalised (ESR, 2019, p. 26). Severe leptospirosis can lead to fatalities, but deaths attributed to leptospirosis are rare in New Zealand (Dreyfus et al., 2014). 1.1.4 The disease burden of occupationally-acquired leptospirosis in New Zealand The health effects of severe leptospirosis do not immediately disappear upon hospital discharge. Keenan, in a 2007 report for the Department of Labour (DoL) on the impact of leptospirosis on New Zealand workplaces, noted that some patients may take 3–4 weeks to 6–8 months off from work (p.18). The WorkSafe (2015) Guidelines for leptospirosis recognises that 11 “Most people who are severely affected find it physically impossible to return to work within two months. Most do return to work but it can be at least a year before they regain the energy they had before becoming ill” (p.13) The WorkSafe Guidelines also acknowledges that some patients suffer long-lasting recurring symptoms, such as depression or muscle pains, and may have repeat hospital admissions over a period of years. (Everts, 2009) reported 12 patients from New Zealand and Australia that were diagnosed with a chronic fatigue syndrome (CFS) following an acute leptospirosis infection. The duration of CFS for the 12 patients range from six months to more than four years after the acute infection. Another study (Weston et al., n.d.) described five patients who reported experiencing persistent symptoms lasting at least six months after the acute infection. They described symptoms include chronic fatigue, headaches, body pain (especially back and legs), intolerance to light, mood swings, and weight loss. The patients in both studies were all working in occupations related to either meat works (abattoir worker or butcher) or farming when they acquired the infection, and all reported substantial disruption to their work and personal lives as a result of the long-term sequelae. This disruption of work has financial consequences; the 2007 DoL report calculated the direct cost of one case of leptospirosis in the meat industry to be $7,500 (Keenan, 2007, p. 19). In 2016, (Sanhueza, p. 107) estimated that the annual national cost to NZ of leptospirosis (lost wages plus treatment costs) for abattoir workers, farmers, and veterinarians was $3.99 million. An argument could be made that the amount is an over-estimation – the treatment cost was based on the average cost of a leptospirosis claim from ACC, which would already factor in cost of wages; therefore the cost for lost wages might have been accounted twice – however, if the indirect costs of the disease are included into the total costs of suffering, the amount may well surpass that estimate. 1.1.5 The “hidden cost” of occupationally acquired leptospirosis Indirect costs are difficult to define, but the concept may be easier to understand by looking at indirect costs as all other costs except direct costs. Butcher (2002, p. 67) defines direct costs as “visible, tangible costs that appear on the accounting balance”, meaning they are quantifiable and identifiable. In contrast, indirect costs are 12 “invisible, intangible costs that are real but have no dollar value assigned to them”, i.e. they are subjective and incalculable. Indirect costs have been estimated as being three to eight times as high as direct costs (Driscoll et al., 2004, p. 13; Keenan, 2007, p. 19) For occupationally-acquired leptospirosis, some of these indirect costs were identified by Adams (2002). Adams interviewed ten workers (of which eight were meat workers while the remaining were a farmer and an animal transporter) on the effects the illness has had on their personal lives, their families, and their workplaces. Adams called these health, social, psychological and economic consequences as the “hidden cost” of occupationally acquired leptospirosis. Some of these findings are as follows: • All ten patients still suffered from ongoing symptoms such as fatigue, migraines, irritability and depression (p71). Despite the persistent fatigue, eight out of the ten went back to work within four months of the infection. For most, this was because they had run out of sick leave and had yet to receive compensation (p 101). • The ongoing symptoms have impacted on their mental health (e.g. increased mood swings, being more irritable) which in turn has affected their familial and social relationships. • There was a pervading finding of participants feeling “not as strong as before” (p72, 75). All patients report a reduction or loss of their previous ability to engage in work or leisure activities that they used to participate in before (e.g. sport); this has led some to change their work (p 69) or lifestyle (p75). • In the periods when they were off-work, the participants had less social interaction and felt increased isolation (p95). • In some, the inability to work has led to a lower self-esteem because of the loss of a socially-valued role (p 95); this was exacerbated in those who did not receive compensation and had to apply for unemployment or sickness benefit, which they felt to be “degrading” (p75). 13 Adams (2002) found that for most of the participants, their experiences with compensation contributed to the overall negative experience of the disease. The compensation-related stress the participants experienced was both financial and emotional. Some felt that the compensation was too complicated, unnecessarily lengthy, and was unsympathetic to persons who were already ill. It was also found that for those participants whose claim was denied or in dispute, no concessions about their ill health were made once they returned to work, even though some of them were still feeling the effects of the illness. Five of the participants encountered delays in getting their claims recognised as work-related by the insurer while three had their claim denied. For some, the delay or claim denial was due to the bureaucratic nature of some of the claim requirements, e.g. need to rule out other exposures, need for multiple testing, long waiting time for the laboratory results. For others, the delay was caused by employers disputing the claim. Adams (2002) attributed the delays and disputes to leptospirosis being a poorly understood disease, not just by employers but also by the participants and treatment providers. The participants also appeared to have limited knowledge of how the compensation system works. The same observations were made by Keenan (2007) in the DoL report. This twin lack of knowledge of the disease as well as of the compensation process contributed to feelings of “powerlessness” by the participants and added to their stress (Adams, 2002, p. 113). 1.2 Worker Compensation and Accident Compensation Corporation or ACC 1.2.1 ACC overview In developed countries, worker compensation is synonymous with insurance, and the same is true for New Zealand. What makes New Zealand unique from other countries, however, is the state monopoly that is the Accident Compensation Corporation or ACC, a legally mandated governmental entity charged with providing a 24-hour, no-fault, accident compensation scheme for all persons in the country. The ACC era began with the enactment of the Accident Compensation Act 1972, as it was that particular act that created both the scheme and the entity that gave it its 14 name, the Accident Compensation Commission (later renamed as the Accident Compensation Corporation). There have been many amendments of the principal act throughout the years, namely, • the Accident Compensation Act 1982, • the Accident Rehabilitation and Compensation Insurance Act 1992, • the Accident Insurance Act 1998, and • the Injury Prevention, Rehabilitation, and Compensation Act 2001 which was later renamed to Accident Compensation Act 2001 and serves as the prevailing act. However, the overriding principle of a 24-hour, no-fault, comprehensive compensation scheme persists from its inception up to the present day. The main features of the scheme are as follows: First, the scheme covers injuries from accidents of any kind. The scheme takes care to highlight what it means by accident, the exact parameters of which are set in AC Act 2001 Section 25, but loosely speaking, an accident refers to a specific event or sequence of events that is “unexpected and unintended” (Campbell, 1996, p. 100). Over the years, the scheme has broadened to include cover for certain cases of mental injuries and treatment injuries (i.e. injuries contracted in the context of medical treatment). What has stayed the same is the distinction between injuries that can be traced to an accident, i.e. covered, and injuries caused by gradual processes like illnesses or ageing, i.e. not covered except for occupational diseases. Occupational diseases are diseases due to the nature of a person’s employment (Dew, 2002, p. 164). Provisions relating to occupational diseases will be discussed in later sections. The second feature of the ACC scheme is that any person in New Zealand who suffered an injury that is covered under the Act can claim compensation. The third feature is the no-fault nature of the scheme such that injury is the sole criterion for compensation. So long as the injury is proven to be an injury covered under the Act, then compensation is awarded regardless of fault. The focus then shifts from fault to cause; and causation becomes the pre-requisite for cover (Duffy, 15 2003). This emphasis on causation is even more important in the context of occupational diseases and will be discussed in later sections. The fourth feature of the scheme is what is often referred to as a social contract, where, in return for a system that provides greater certainty and speedier and more extensive compensation, New Zealanders gave up the right to sue for damages for all injuries covered by the Act. This social compromise has remained in place since the scheme’s inception, although an exception for exemplary damages was included in the latter acts. Another side to this contract and the last feature of the scheme is that people no longer have the option of picking insurance providers. The law made it so that ACC is the sole provider for accident compensation. ACC, the corporation, is responsible for the management of the scheme. Essentially, that means determining cover, providing entitlements, and overseeing funding of the scheme (AC Act 2001 Sec 165, 262). These duties are similar to insurance services, but the law is adamant that even though it provides insurance-related services, it is “not a function of the Corporation…to provide insurance” (AC Act 2001 Act Sec 262 (2)). Tennent (2012, p. 5) explains that this distinction is because the Act made compensation a legal right, compared to merely a contractual obligation, and that unlike true insurance, the policy owner cannot negotiate the terms of the policy (Vennell, 1993 in Campbell, 1996; Wilkinson, 2003). Others have argued that the distinction is merely a matter of semantics (Campbell, 1996) this paper follows the latter view and will at times use the term insurer to also refer to ACC. ACC’s statutory origin and identity has meant that, unlike profit-oriented insurance companies, its role as a provider of insurance-related services is overlaid with a broader purpose of social welfare. This dual purpose has led to the scheme becoming increasingly comprehensive and complex; and within this behemoth of a scheme, resides the current worker compensation system. While the ACC scheme as a whole was heralded as a revolutionary social policy, in terms of worker compensation, many of its features closely resemble those of market-based insurance systems. 16 1.2.2 Worker compensation within the ACC scheme Despite being only one part of the whole ACC scheme, worker compensation was actually the antecedent to the whole scheme. The establishment of ACC directly stems from recommendations aimed at improving the system of worker compensation. The pre-ACC compensation system was dominated by privately-run insurance companies. Criticisms levelled at that system were about its administrative inefficiency leading to waste and delays as well as its prioritisation of profit over compensation (Woodhouse, Bockett, & Parsons, 1967, pp. 80-81). For example, around 40% of the total costs was consumed by insurance companies to cover their expenses and gain a reasonable margin of profit (Woodhouse et al., 1967, p. 89). In addition, because the prevailing act of that time, the Workers Compensation Act, contained a fault clause where no compensation was paid out if the injury was attributed to the worker’s own misconduct (WCA 1956 sec 34), this produced an adversarial relationship between workers and employers. The benefits under WCA were also criticised to be meagre in value with a limited duration of six years (Woodhouse et al., 1967). ACC was designed to address those issues, and the scheme’s origin can be directly traced to a 1967 Royal Commission of Inquiry Report (more commonly referred to as the Woodhouse report, after its chairman, Sir Arthur Owen Woodhouse) that was formed in response to the growing discontent with the worker compensation system of that time (Todd, 2011). Woodhouse et al. (1967 p. 39-41, p.177-178) recommended a scheme that was founded on these five principles: • Community responsibility – because society benefits from the productive work of its members, then it also becomes society’s responsibility to help in the recovery of its injured members; • Comprehensive entitlement – the entitlements due to those injured members should be assessed uniformly, regardless of the cause of their injury; • Complete rehabilitation – rehabilitation not just in terms of financial restitution but also restoration to the maximum degree possible of bodily health and vocational utility; 17 • Real compensation – adequate recompense means addressing not only the income loss, but also any physical impairment that may affect the person’s ability to earn in the future, and • Administrative efficiency – the distribution of benefits should be hampered by “delays in compensation, inconsistencies in assessment, or waste in administration” (p.178). An independent review of ACC in 2008 conducted by PricewaterhouseCoopers Australia (PwC) seems to indicate that the ACC system has partially succeeded in its goals: “New Zealand has lower claims management expenses… than all Australian schemes, and lower total administration expenses… than the schemes providing comparable benefits... It is clear that ACC is paying a relatively high portion of total premiums directly to claimant benefits.” (Tess, Walsh, & Feyer, 2008, p. xiii). This overall favourable assessment of ACC, in comparison with other worker compensation systems was also echoed by (Lippel, 2012). However, the ACC scheme has also seen many amendments since its founding, and numerous authors have remarked that the amendments have led to a dilution of the Woodhouse principles by re-introducing some features of the pre-ACC system (Duffy, 2003; Gaskins, 2015; Kreber, 2007). Two prime examples of such features are the Experience Rating Programme (ERP) and the Accredited Employers Programme (AEP). 1.2.3 Accredited Employers and Third-party administrators The ERP and AEP1 were both introduced into the scheme by the 1992 Act. ACC considers the two programmes separate; however, the rationale for both programmes are similar and both provide ways for employers to obtain a discount on their Work levy. 1 AEP first appeared in the 1992 Act as ‘Self-insurance’ (Birch, 1991, p. 28); the programme name has changed in the subsequent laws (from ‘Exempt employers’ to ‘Accredited employers’) but the concept and overall structure has remained the same. 18 The Work levy is what employers and self-employed persons pay to fund the Work Account, which in turn funds the compensation for all work-related injuries. The Work levy is to ACC what an insurance premium is to a private insurer. One of the variables ACC uses to calculate2 a company’s levy is an industry-based risk; and because this is an industry-specific rate, all business within an industry will have the same flat rate, regardless of the individual company’s safety record. One criticism against this method for calculating levies is that, unlike insurance premiums, it does not take into account the status of the health and safety of the workplace (Lamm, McDonnell, & John, 2012, p. 25). This is where experience rating comes in; under the ERP, employers can obtain a discount on their Work Levy by leveraging their individual safety record. In theory, this incentivises employers to improve their business practices and make it safer. Experience or merit rating is a common feature in market-based insurance systems (Lamm et al., 2012). However, there are concerns that experience or merit rating, instead of encouraging employers to invest in safer workplace practices and environment, would instead incentivise employers to contest claims as non-work related (Lippel, 2012, p. 528). Merit rating was also considered by Woodhouse et al. in their 1967 report, but they ultimately concluded that it was an ineffective means of promoting safety (p. 140). The current ERP allows employers to get as much as 50% discount on their levy (ACC, 2019b). But for employers who wish to reduce their levies even more, they could join the AEP. Under the AEP, employers enter into an Accreditation Agreement (AC Act 2001 Section 184) with ACC, wherein they shoulder the administration and costs of providing compensation for the work-related injuries of their employees, in return for a much-reduced levy (as much as 90% reduction). Administration or management of the claims means determining cover and providing entitlements (AC Act 2001 Section 187). The AEP allows the Accredited Employer (AE) to “stand in ACC’s shoes” and make decisions about the claim (ACC, 2019a, p. 6). AEs can choose to either manage the claims on their own (i.e. self-insure) or 2 ACC calculates the levy based on three variables: • the individual liable earnings of the business, • the industry-based risk of work injuries, and • the cost to the scheme [ACC Paying Levies]. 19 contract it out to the third-party administrators (TPAs). In effect, the AEP allows employers to opt-out of having ACC as the default provider for work-related injuries and gives them back the freedom to choose their insurance provider. AEP is open to any employer who can meet and maintain the entry requirements, but ACC recommends that the savings potential particularly applies to employers with annual Work levies over $250,000 (ACC, 2019a, p. 4). Lamm et al. (2012, p. 26) notes that in 2007, around 25% of the country’s full-time workforce was under the AEP. AEs/TPAs are bound by the same legislation and regulations as ACC, and they are expected to manage claims in accordance with the standards and timeframes set in legislation; i.e. their management must not infringe upon the entitlements and the rights conferred by the Act (ACC, 2017). However, they are not bound by ACC policy and may have their own claims management policies and procedures. ACC conducts an annual audit of their procedures but does not specifically monitor claims managed by AEs/TPAs (Appendix 2 ACC OIA response). For this project, the ACC policies and procedures will serve as the default claim process. This is because each AEs/TPAs will have their own set of procedures, but they are expected to mirror or resemble the ACC template. When AEP was first introduced into the 1992 Act, it was called “the purest form of experience rating3” (Birch, 1991, p. 28). ACC still promotes AEP as a way of offering employers “real incentives to adopt effective injury prevention and rehabilitation initiatives” (ACC, 2019a, p. 6). However, there are apprehensions that the programme creates a danger where the employer will provide compensation at minimum cost, rather than in a manner which is consistent with the purpose of the scheme (Tennent, 2012). Indeed, Lamm et al. (2012) consider the AEP as less of a workplace improvement measure and more of a cost-savings measure for companies. A literature search found no study that specifically compared the compensation experience and outcome for workers under the ACC scheme versus AEP scheme, 3 If the possibility of a discounted levy under ERP is enough to incentivise employers to invest in workplace health and safety, then the possibility of having to shoulder all the costs for workplace injuries under AEP should serve as even bigger incentive for employers to prevent workplace injuries. 20 therefore these apprehensions remain tenuous. Still, it does not detract from the unsettling similarity that AEP bears with the pre-ACC system of worker compensation, whose very faults and deficiencies the ACC scheme was designed to address. 1.3 Compensation of occupational leptospirosis As noted above, the ACC scheme makes a distinction between injuries from an accident and injuries from a disease; the former is eligible for cover while the latter is not. The only exception is for occupational diseases. D. Duncan (2019, p. 55) termed this arrangement as an “accident plus exceptions” structure4, and this has been in place since the scheme’s inception. The implications for this structure will be discussed in more detail in later sections. 1.3.1 Cover versus Entitlement Before moving to further discussions of compensation for occupational diseases, it might be prudent to discuss the distinction between cover and entitlements, although both terms have been defined above. Cover and entitlements can be thought of as the two halves that make up a claim. Entitlements are usually what comes to mind when talking about compensation in general, e.g. receiving a reduced salary while off- work from an injury. However, entitlements are actually corollary to cover. Cover is the first hurdle a claim must pass; when a compensation claim is rejected, it is on the basis of cover. It is only after cover is granted that consideration of entitlements occurs. This delineation between cover decision and entitlement decision serves as the boundary line for the scope of this project. This study will only examine the compensation process up to the point of cover decision. This is because the criteria for deciding cover is universal whereas deciding on which entitlements are appropriate is on a case-by-case basis. 4 The reason for the inclusion of occupational diseases was because the pre-ACC worker compensation scheme, under the Worker Compensation Act, already granted compensation for anthrax and certain types of heavy metal poisoning. The 1972 ACC Act upheld the occupational diseases provisions from the Worker Compensation Act but recognised them as “extension of cover” (AC Act 1972 sec 65). 21 1.3.2 Cover for occupational diseases and the issue of causation Aside from the distinction between accidents and illness (discussed in sec 1.2.1), another way ACC categorises claims is by separating it into work-related (AC Act 2001 Section 28), non-work related (AC Act 2001 Section 26), and treatment injury- related (AC Act 2001 Section 32). Occupational diseases fall under the broad category of work-related injury claims, but because they are diseases rather than injuries, they belong to another sub category: Work-related gradual process, disease, or infection (WRGPDI) or just Gradual Process claims (AC Act 2001 Section 30). ACC provides a flowchart for deciding whether a claim falls under the WRGPDI cover (See Figure 1. ACC Gradual Process flowchart). To receive cover, a Gradual Process claim has to have the following: (1) That the injury was caused by a gradual process, disease, or infection (i.e. a confirmed diagnosis); and (2) That the injury was caused by a work-related causative property or characteristics that satisfy the three-tier test (i.e. an appropriate work-related exposure). The three-tier test to ascertain appropriate exposure asks the following: a) Does the causative property exist in the person’s employment tasks or work environment? b) Is the same property not found in the person’s non-work tasks or environment? c) Is there a significantly greater risk of disease for persons who perform those tasks or works in that environment than for those who don’t? As mentioned above, the abolition of the fault principle5 from the ACC scheme meant that causation becomes the sole element for deciding cover (Duffy, 2003; Tennent, 2009). Numerous authors have pointed out how proving causation for occupational diseases can be very challenging (Hook, 2008; Kreber, 2007; Tennent, 5 An alternative argument can be made here that the original intention of Woodhouse et al. (1967) for removing the fault principle was to actually put the emphasis of compensation on addressing the consequences of injuries, and not so much on the causes of injuries. However, the implementation of the scheme throughout the years has seen causation become the pre-requisite for compensation. 22 2012). Going back to the “accident plus exceptions” (D. Duncan, 2019, p. 55) description, it was argued that the accident-focused nature of the scheme has meant that ACC’s policies and procedures are more geared towards compensating for accidental injuries than they are for non-accidental injuries, thus making obtaining cover for the latter harder. Some of the difficulty is because, for the most part, it is easier to establish a causal link between an injury and a traumatic event than it is between an injury and a gradual process (Tennent, 2009). Leigh, 1999 in Lippel (2012, p. 522) observed that “those suffering occupational diseases… will have a more difficult experience with the compensation system than those suffering from traumatic injury”. Another factor making causation more difficult for occupational diseases is having to prove the work-relatedness of the exposure; in contrast, any injury that has been proven to be caused by an accident would automatically get compensation. Occupational diseases will only be compensated if they pass the work-related causation criteria as laid out in the three-tier test. The three-tier test requires not only that the exposure has to come from work but also that non-work exposures are excluded. Dew (2002, p. 164) observed that it is much easier to attribute symptoms to a non-work reason than it is to attribute it to workplace events. There have been criticisms that ACC’s interpretation of the causation requirements can be too narrow (D. Duncan, 2019; Hook, 2008). Forster, Barraclough, and Mijatov (2017) commented that “the way ACC applies causation makes injured people feel like the system is unfair” (p.1) and that this has recreated the same problems the ACC scheme was meant to prevent or overcome (p.2). ACC acknowledges that investigating whether a claim meets the stringent causation criteria can be costly in both time and resources, and that there are some occupational exposures that have a recognised heightened risk for certain diseases or conditions (Driscoll et al., 2005). These “notoriously work-related” disorders are listed in Schedule 2 of the Act (Tennent, 2012, p. 88). Disorders listed in Schedule 2 are accepted as arising from work, and thus no longer need to be subjected to the three- tier test (Kreber, 2007, p. 109). For this reason, it is believed that the cover decision process for diseases in Schedule 2 is more straightforward and streamlined compared 23 to conditions that are assessed against the three-tier test (Driscoll et al., 2005; Keenan, 2007). Figure 1 ACC Gradual Process flowchart. From https://www.acc.co.nz/assets/im- injured/6e764cb71f/work-gradual-injury-cover-decisions.pdf. Accessed 1 July 2019 24 1.3.3 Leptospirosis as a Schedule 2 injury Occupationally-acquired leptospirosis was added to Schedule 2 by the 2001 Act. It is listed in the Schedule as “Leptospirosis diagnosed as caused by working with animals or their carcasses”. The definition in Schedule 2 can be broken down into: (1) the disorder, i.e. “Leptospirosis”; (2) the exposure, which specifies not only that it has to be work acquired, i.e. “working” but also which activity, i.e. “with animals or their carcasses”; and (3) the need for a medical diagnosis, i.e. “diagnosed as”. In other words, in order for a leptospirosis claim to be granted cover under Schedule 2, it must have a medical confirmation of the disorder and an exposure as described in the Schedule. Once all that is established, there is a presumption of immediate cover [Tennant 2012]. The implication of a claim falling under a Schedule 2 condition is that the only way the insurer can decline cover is if they can prove that (a) the injury is not the kind described under the Schedule, or (b) the cause of the injury was not work- related (AC Act 2001 Section 60). In other words, the legislation is presumptive, and the onus is on the insurer to disprove causation. Leptospirosis claims that do not meet the conditions of a Schedule 2 injury will need to pass the three-tier test to get cover as a Gradual Process claim. It should be noted that the three-tier test is related to the assessment of the exposure, and not with the medical criteria. Any leptospirosis claim, whether it be a Gradual Process or Schedule 2 claim, must satisfy the diagnosis or case definition for leptospirosis. 1.3.4 Case definitions from MoH and ACC The Ministry of Health’s (MoH) Communicable Disease Manual [2017] defines confirmed and probable as: • Confirmed – a clinically compatible illness with least one of the following definitive laboratory evidences: 25 o Isolation of leptospires from a clinical specimen. o Detection of leptospiral nucleic acid from a clinical specimen. o A fourfold or greater rise in leptospiral MAT between acute and convalescent sera. o A single raised titre of ≥ 400 on MAT. • Probable – a clinically compatible illness with a suggestive laboratory evidence of a single raised titre of < 400 on MAT. A clinically compatible illness means that it is an acute illness characterised by fever, chills, headache, myalgia, nausea, diarrhoea, abdominal pain, meningitis, cough and conjunctival suffusion. Severe manifestations may include jaundice, renal failure, haemorrhage, pneumonitis, and haemodynamic collapse (MoH, 2017). Despite requiring at least only one of the laboratory results, the MoH recommends that both nucleic acid testing and MAT be undertaken to improve diagnostic accuracy. The MoH recommends IgM assays as a screening test but not a confirmatory test because of its potential for cross-reactivity with other diseases. MAT is the current gold standard serological test and MoH recommends paired samples with a minimum of two weeks in between samples (MoH, 2017). As of 1 April 2019, the ACC case definition for leptospirosis is not currently published anywhere in their website, but a 2014 ACC Review document entitled Leptospirosis in New Zealand (see Appendix 2 ACC OIA response) lists the case definition for confirmed and probable cases. The ACC review document states that both confirmed and probable cases may be eligible for compensation. The ACC case definition resembles that of the MoH, but differs on two accounts, namely, • the single titre level for a confirmed case for ACC is ≥ 800 on MAT (compared to ≥ 400 for MoH), and • the titre level for a probable case for ACC is ≥ 200 on MAT (compared to < 400 for MoH). 26 The inconsistent case definitions are concerning, especially because a medical diagnosis of the condition is a pre-requisite for leptospirosis claims. 1.3.5 Need for medical assessment A physician’s role in worker compensation has been described as that of a gatekeeper (G. Duncan, 2003), with medical practitioners often involved in the areas of access to cover, benefit determination, and the return-to-work process (Lippel, 2012, p. 524). Indeed, ACC requires Gradual Process claims to be lodged by a medical practitioner on behalf of the patient (ACC, 2019c, p. 6), and also seeks medical opinion regarding the appropriateness of cover and entitlements for Gradual Process claims (Tennent, 2012, p. 115). The effect of medical opinion on the compensation outcomes for certain occupationally-acquired conditions like chemical poisoning (Dew, 2002; Kreber, 2007) and degenerative conditions linked to workplace stress (D. Duncan, 2017; Tennent, 2009) have been examined; unfortunately, no such examination has been done for occupationally-acquired leptospirosis. Still, observations from said studies may be relevant to the issue at hand. Dew (2002, p. 175) notes that when uncertainty about causation exists, medical science can be co-opted by insurers to serve their interests of keeping the cost of insurance down. Kreber (2007, p. 114) also found that disagreements among medical experts regarding causation may result in delays in the decision process. In the case of leptospirosis, the long history of the condition as an occupational disease means that on the general level, there is a consensus regarding the typical symptoms and causes of the disease. However, on the specific level, some differences still exist; case in point would be the inconsistent titre levels discussed above. 1.3.6 Legislative time frame The law requires that ACC act on a Gradual Process claim within two months from the lodgement date (AC Act 2001 Section 57). If ACC requires further time for investigation, they can extend up to nine months, provided the claimant agrees to the extension. However, ACC is legally required to decide on a claim within nine months 27 of the claim being lodged. AEs/TPAs must also adhere to the same time limits for making a decision on a claim. 1.3.7 Leptospirosis claims statistics ACC provided leptospirosis claims statistics from years 2006/07 to 2017/186 (see Appendix 2 ACC OIA response). A summary is presented in Table 1. Table 1 Summary of leptospirosis claims statistics from 2006/07 to 2017/18. Total claims registered Total claims accepted Percent accepted ACC 346 198 57.2% AEs/TPAs 218 151 69.3% The claims data from AEs/TPAs represent claims managed by the AEs as well as those contracted out to TPAs. Although AEs are required to send claim information to ACC on a regular basis, ACC could not guarantee the accuracy of the data provided by the AEs (Appendix 2 ACC OIA response). The higher acceptance percentage from AEs/TPAs is an interesting finding, given the apprehensions earlier stated about AEP. As mentioned above, leptospirosis was included in Schedule 2 by the 2001 Act. However, the 2001 Act only came into force on the succeeding year, on 1 April 2002 [AC Act 2001 Section 2]. That means that prior to that date, all leptospirosis claims were subjected to the three-tier test. ACC did not provide claims data before 2007, citing incompleteness of the data due to a change in their database system during that year. Luckily, the 2007 DoL report by Keenan included ACC leptospirosis claims records from 1991/92 to 2005/06. A summary of the combined claims data from the 2007 DoL report and the data obtained from ACC is presented in Table 2. 6 An ACC financial year is 1 July to 30 June. ACC provided claims data for the last 12 financial years from 2006/07 to 2017/18 only. Data was extracted on 25 March 2019 and may differ if re-run at a later date. 28 Table 2 Acceptance percentage of leptospirosis claims before and after inclusion into Schedule 2 Percent Accepted Prior to inclusion into Schedule 2 (1991/92 to 2001/02) 74.1% After inclusion into Schedule 2 (2002/03 to 2017/18) * 56.4% *Combined data from Keenan (2007) (for the years 2002/03 to 2005/06) and from data requested from ACC (for the years 2006/07 to 2017/18) Table 2 shows that that since leptospirosis’ inclusion into Schedule 2, the percentage of accepted claims actually dropped. This reduction in acceptance is puzzling, especially since inclusion into Schedule 2 is believed to produce a more streamlined claim assessment process. 1.4 Chapter Summary In summary, this chapter shows the following points: • Leptospirosis is a recognised risk for certain occupations, and the disease causes considerable suffering in some patients. • Workers in New Zealand who develop leptospirosis during the course of their work are eligible for compensation. • The requirements of a leptospirosis claim can be complicated and the medical nature of the claim requires assessment from medical professionals before (by treatment providers like general practitioners or hospital doctors) and after lodgement (by medical advisors). • Much of the key decisions affecting a leptospirosis claim are made by medical professionals outside the claimant’s purview; this contributes to the patient’s feeling of “powerlessness” and adds to the overall stress caused by the illness. The goal of this study is to make the compensation process for occupationally- acquired leptospirosis better understood, by first documenting what happens to a claim before and after it is lodged, and second, by finding out how it is assessed for cover. 29 Chapter 2 Methods, Results, and Discussion This chapter is split into three sections: the first discusses the study aim and objectives as well as the methods used to answer them, the second contains the results from the inquiry, while the third section discusses the implication of said results. 30 2.1 Methods 2.1.1 Study genesis and development of the research question The supervisors for this project are all involved in another larger, on-going study that seeks to investigate the experiences of people with leptospirosis, with compensation making up a part of that experience (Benschop, n.d.). That larger study looks at compensation from the view point of the patient; however, while the patient perspective offers valuable insight about the consequences of the process, it is less able to provide insight on the internal factors that drive the process since many of the crucial decisions affecting the claim are made by treatment providers and insurance claim assessors largely outside of the patient’s purview. Moreover, some of the issues with compensation raised in that study stem from the decisions made by these key persons. That study brought up questions of how a leptospirosis claim is assessed and why it is assessed in that way. This project was therefore conceived as a way to round out the understanding of the whole compensation system for leptospirosis, focusing on the steps of claim initiation and cover assessment. This study seeks to achieve that aim by first establishing what are the bases of a claim, and second, investigating how treatment providers and medical advisors assess a case or claim. The research objectives are the following: • Clarify what are the requirements for a claim. • Find out what happens to a claim after its lodgement and up to when cover decision is made. • Discover factors that influences the assessment of a case or claim. This study focuses on the treatment providers and medical advisors, for two reasons: (1) the patient perspective is already being investigated by that larger ongoing study, and (2) speaking with patients would necessitate a full ethics application, which is not feasible within the one-semester project time frame. Refinement of the research question was greatly helped by discussions with a project consultant. The consultant is an experienced occupational health physician as well as an ACC health advisor. The consultant does not personally handle leptospirosis 31 claims for ACC but is familiar with ACC procedures and policies. The discussions with the consultant helped define the project scope and frame the interview questions. 2.1.2 Study design. The study goal informed the choice of a qualitative mode of inquiry. As (Maykut & Morehouse, 1994, p. 16) state, “qualitative research places emphasis on understanding through looking closely at people’s words, actions and records”. In this study, the qualitative approach was used to find out how the key actors make the decisions they make, enabling discovery and exploration of the factors affecting the process. The study design is that of a qualitative descriptive study described by (Sandelowski, 2000, 2010). A qualitative descriptive study is a distinct method from other types of qualitative study (e.g. phenomenology, ethnography, grounded theory) which require interpretation of findings through a specific paradigm. In qualitative description, the emphasis is on obtaining a comprehensive description of the phenomenon or topic under study, using the everyday language of the phenomenon (Sandelowski, 2000, p. 336). It is said to possess a factist position on data, i.e. it assumes that the accounts from the participants are truthful and is more or less an accurate portrayal of reality (Sandelowski, 2010, p. 80). Seixas, Smith, and Mitton (2018, p. 779) likened the researcher role in such a study as that of a “composite sketch artist”, whose goal is to depict the reality witnessed by a person, using reports from the person. Both Milne and Oberle (2005) and Neergaard, Olesen, Andersen, and Sondergaard (2009) note that although qualitative description tends to stick close to the surface of the data, it does not mean that no interpretation occurs. Sandelowski (2000, p. 335) posits that the researcher, in selecting what to describe will, “in the process of featuring certain aspects of it, begin to transform the experience or event”. The results of a qualitative descriptive study may be low-level inference but having an accurate summary of events or phenomenon can help generate hypotheses or working concepts for future investigations. It is hoped that obtaining an accurate 32 description of the case or claim assessment process of these key actors will shed light on where the inconsistencies are and where areas for improvement can be made. 2.1.3 Data collection This study made use of data coming from publicly available documents and information requested from ACC as well as data from the results of the interviews. The data from the documents were used to determine the formal procedure and requirements of the process (see Section 3 in Chapter 1) and to establish the context for interpreting the interview results, which were used to discover and reconstruct how the actual process plays out in real life. The publicly available documents were all obtained online, from organisation websites or online archives. These were divided into documents that were about compensation in general (e.g. various legislations and ACC reports and publications), documents pertaining to leptospirosis as a disease (e.g. MoH guidelines), and documents pertaining to leptospirosis as an occupational hazard (e.g. WorkSafe guidelines and the 2007 DoL report). Information regarding leptospirosis claims and procedures was also requested from ACC via an Official Information Act request (see Appendix 2 ACC OIA Response). A semi-structured interview method was utilised in this study. This method was chosen because it provided a guide to the interviewer but also allowed the interviewer to seek clarification and probe beyond the initial answers. This is especially important as one of the objectives of the study was to discover how decisions are made. May (2011) writes that this method allows greater latitude to the interviewee to answer on their own terms while still providing the interviewer with a structure to follow. The flexibility of a semi-structured interview allows the interviewer to cover the same topics in each interview but also makes room for participants to add topics that they feel might be relevant into the discussion (Corbin & Strauss, 2015). The interview questions were developed with the supervisors and the consultant. One set was developed for the treatment providers (Appendix 3) and another for the medical advisors (Appendix 4). 33 2.1.4 Ethical considerations The ethical considerations were assessed using Massey University’s Risk Assessment checklist and was discussed with all the supervisors. A low-risk ethics application was deemed appropriate for the type of participants and for the project time frame. The low-risk ethics notification was obtained on 11 Feb 2019 (See Appendix 1 Low Risk Ethics Notification Letter). Confidentiality and informed consent were key concerns in the discussions about ethical considerations. Strategies to address confidentiality included using codes for the transcript and setting limits to who will have access to the transcripts. Informed consent was achieved by making it clear to the participants what the aim of the project was and how the data will be managed. A participant information sheet and consent form (Appendix 5) were sent with every invitation, and the researcher made sure to double check at the start of the interview if the participants had any questions about the research purpose. Their respective interview transcripts were also sent to each participant, to give them the chance to review and make amendments to the transcript. 2.1.5 Sampling strategy The study goals informed the sampling strategy and sample size. Purposive sampling was used to recruit participants. It is a technique wherein participants are deliberately selected on the basis of their knowledge and its relevance to the topic being investigated (Denscombe, 2014). Participant selection is based on the researchers’ judgement on which potential participants will produce the most valuable data. For this reason, participants were also referred to as key informants and were recruited precisely because of their experience and knowledge. Treatment providers who can serve as potential key informants were first identified by supervisors, drawing upon their contacts and connections established in other projects, and then referred to the researcher. The profile of treatment providers selected for this study was that of clinicians who commonly encounter leptospirosis and therefore more familiar with the disease and its impact on workers than the overall population of physicians. 34 The sample pool for medical advisors was similarly populated by referrals from the supervisors and from the consultant, who is himself a medical advisor. Referrals were also sought from the participants. Concern about project size in relation to the time frame and resources also factored into the sample size consideration. A target size of 3-4 key informants for each group was deemed appropriate, with the first group composed of treatment providers and the second of medical advisers. However, obtaining the targeted number was a secondary concern; the main consideration was to obtain participants that will provide quality insight. The emphasis in purposive sampling is to select “information-rich” cases (Patton, 2015 in Liamputtong, 2019). 2.1.6 Recruitment of treatment providers Four treatment providers were referred to the researcher. They were approached through email and invited into the study. All agreed to be interviewed. Three were primary care or community care physicians (“TP 1”, “TP 2”, “TP 3”) while one was a secondary care or hospital-based physician (“TP 4”). The initial intention was for the treatment providers to be represented wholly by primary care physicians. However, a meeting with the consultant led to the realisation that a portion of claims come from hospitals, and therefore the perspective from a hospital- based physician would give a more complete view of the situation. Experience of the physicians ranged from 20 to 35 years in practice. All work in areas where the meat processing industry makes up a significant portion of the industrialised sector. TP 1 and 2 also work as company doctors for meat plants while TP 3’s practice is in an area with three neighbouring meat plants and therefore sees plenty of meat workers, along with dairy and beef farmers. TP 4 is located in a region that had some of the highest number of leptospirosis cases in the country between 2010-15 (El-Tras et al., 2018). A particular feature in the secondary-care setting is that clinical and administrative duties are more distinctly delineated than in a primary-care setting and this meant that TP 4 could not answer some of the more procedural questions about compensation. The researcher was instead referred to the hospital’s ACC liaison 35 officer for those administrative-related questions. The answers from the liaison officer were used to supplement the interview results from TP 4. 2.1.7 Recruitment of medical advisors Five medical advisors, three from ACC and two from TPAs, were contacted via email and sent invitations. One advisor from ACC declined on the grounds that they did not have experience with regards to leptospirosis claims, while two (one from ACC and the other affiliated with a TPA) did not reply to both initial and follow-up invitations. Of the two medical advisers who agreed to participate, one works as a consultant for a TPA (“MA 1”) while the other works for ACC (“MA 2”). Both are occupational medicine physicians and have worked as medical advisors for many years. The ‘quality’ of the participants in this group made up for the lack of quantity, e.g. MA 2 serves as the lead advisor for Schedule 2 claims for ACC and the procedural practices of ACC meant that leptospirosis claims would almost always be referred to MA 2. In terms of advisor experience with leptospirosis claims for ACC, MA 2 is on the top of the list. Failure to obtain another TPA-affiliated advisor was also not a cause for concern since the study does not seek to compare TPA practices, and the interview from MA 1 indicates that the advisor is separate from the procedures of a TPA. The interview with MA 2 lead to an opportunity to interview the Team Manager (“TM”) for the Gradual Process Team of ACC. The Gradual Process Team are the case coordinators handing all Gradual Process claims, including Schedule 2 claims, for ACC. The role of case coordinators will be discussed in more detail in the Results section. Case coordinators were initially not included as potential key informants, mainly because their role was thought to be purely administrative. However, the interview with MA 2 revealed how closely the two roles were intertwined and it was decided that an interview with a case coordinator would lend more accuracy to understanding the process. 36 2.1.8 Preparation and conduct of interviews One interview per participant was conducted. Consent to be audio-recorded was obtained prior to the interview session and confirmed again at the start of the interview. The student researcher conducted all but one of the interviews (TP 1), which was done by the supervisor. Both interviewers used the same question set. An in-person interview, at a time and place of their choosing, was the first option offered to the key informants. In-person was preferred because the naturalness in a face-to-face setting was said to stimulate more thoughtful and accurate responses (Shuy, 2011). However, it was also foreseen in the interview preparation stage that some of the informants may choose to be interviewed via phone or video call. Groves, 1978 in Shuy (2011) found that telephone interviews tended to have a faster pace and that this inspired less introspection, while Aquilino, 1994 in Shuy (2011) concluded that it was harder to gain the respondents’ trust in phone interviews. Shuy (2011) added that the absence of visual cues in a telephone interview may lead to shorter and less thoughtful responses. The following strategies were therefore employed to reduce the disadvantages of a telephone interview: (1) carefully crafting the interview questions in order to increase the chances of eliciting more open responses, and (2) using follow-up or probing questions to encourage participants to elaborate, clarify or amend their responses. The researcher also attended a workshop in order to practice and improve their interviewing skills and paid particular attention to rapport building during the conduct of the interviews. The table below lists the media and length of the interviews, in the order of the interview dates. 37 Table 3 Dates, duration, and medium of the interview with the key informants Interviewee Medium Interview Date Duration TP 4 Phone 27 Mar 2019 17:25 MA 1 Phone 28 Mar 2019 20:30 MA 2 In-person 2 Apr 2019 34:27 TP 1 In-person 2 Apr 2019 16:05 TP 2 In-person 4 Apr 2019 33:06 TP 3 Video call 17 Apr 2019 30:26 TM Phone 24 Apr 2019 26:33 The interviews began with a general question asking the participants to relate their role in occupational leptospirosis. This was not a specific question in the questionnaire but was used to establish rapport and also allowed the participants time and opportunity to get into the headspace of the interview topic. Rapport building was especially important as the interview session was, in most instances, the first verbal dialogue between the researcher and the key informant; communications prior to the interview were in the form of email or text messages. The interview followed the structure in the question sets, although in some instances, questions were paraphrased or went unprompted because the answers from the informants naturally flowed into the next question. The interviewer let the participant dictate the flow and pace of the conversation and built on the informant’s answers to pose follow up questions. 2.1.9 Interview transcription All interviews were transcribed by the researcher. A selective transcript was made. Denscombe (2014) writes that a selective transcript is appropriate if the aim is to acquire factual information from the interview contents. The initial transcription was sent to all the key informants, for them to add or delete information as well as confirm the written account of their answers. Whatever revisions they made were automatically accepted, and only the revised transcript was used in the study. This step not only gave greater autonomy and control to the participants, but also ensured the accuracy of the transcript. 38 Milne and Oberle (2005) note that an accurate transcription is necessary for ensuring authenticity, which is a key element in upholding the rigor of a study. Authenticity means making sure the participants had the freedom to speak, have their voices heard, and their perspectives accurately represented (Milne & Oberle, 2005, p. 415) 2.1.10 Data analysis The analysis of the data was guided by the thematic analysis method described by Braun, Clarke, Hayfield, and Terry (2019). The first phase of the analysis started with familiarisation with the data. In this study, the process of transcribing the interviews jumpstarted familiarisation. Braun et al. (2019, p. 853) note that familiarisation provides a crucial entry point into the data, allowing the researcher opportunity to closely read and thoroughly engage with data and make sense of ideas in the data that are new to them. The interview transcripts were read and reread, noting down which segments in the data were responsive to the research question, as well as the unexpected features in the data, and noticing patterns across the data. These observations contributed to the next phase of the analysis, which was the generation of codes. The coding phase was a more thorough and systematic way of engaging with the data; it entailed meticulous reading of the data and assigning codes for the noticed features. The codes functioned as labels or descriptions for broad concepts in the data and served as the individual unit of analysis. Braun et al. (2019) differentiated between semantic (i.e. description captures the surface-level or manifest meaning) and latent codes. (i.e. description captures the implied or implicit meaning). Vaismoradi, Turunen, and Bondas (2013, p. 403) notes that thematic analysis incorporates both manifest and latent aspects. This study was concerned with manifest meaning. Examples of initial codes for this study include doctor recognition, patient compliance, cover denial because of titres, consistency of symptoms with exposure, etc. Initially, the codes were generated inductively. However, as the coding phase progressed, and as the researcher sought to apply the same codes or labels for similar concepts, the coding shifted to a more deductive manner. Merriam and Tisdell (2016, p. 202) notes that data analysis is a recursive process that involves moving back and 39 forth “between inductive and deductive reasoning, between description and interpretation”. The next phase of the analysis was the construction of themes. It referred to the process of grouping the coded material based on shared concepts. Braun et al. (2019) differentiated between themes that are domain summaries (i.e. themes that are a summary of what participants said about a topic) and shared meaning-based pattern. (i.e. themes that capture an important element in the data and represent a patterned response or meaning (Braun & Clarke, 2006, p. 82)). Because this study undertook a semantic approach, the analytic process involved a progression from description to interpretation (Braun & Clarke, 2006). The description part of the analytic process was represented by the initial themes, which were mostly domain summaries that followed the narrative progression of the claims process, i.e. from treatment provider and onto claim assessors. However, as the themes were reviewed and re-defined in the next two phases of the analysis, interpretation of the data occurred in the form of theorising the “significance of the patterns and their broader meanings and implications” (Patton, 1990 in Braun & Clarke, 2006, p. 84). This meant that the initial themes were re-examined in relation to one another and in relation to the research question, and what was produced from this process of interpretation were themes based on shared meanings. The last step of the analysis method was that of writing up the report, and this meant another round of examining the themes while at the same time connecting to existing literature. With regards to literature, unlike other thematic analysis studies who chose to delay the literature review until after the analysis in order to reduce the impact of researcher preconceptions (Anderson & Clarke, 2017), this study engaged with literature during the conduct of the interviews, as well as in the initial stages of data analysis. Braun and Clarke (2006, p. 86) pointed out that engaging with literature before analysis may sensitise the researcher to subtle features of the data, although it may also narrow the field of vision at the expense of potentially crucial aspects. In this case, the unfamiliarity of the researcher to the topic beforehand, as well as concerns about the project time frame, meant that literature engagement before analysis was chosen. 40 2.1.11 Methods reflections The choices detailed above were selected as the best possible fit for the study objectives, time frame and resources, as well as for the novice status of the researcher. That said, this section discusses the possible weaknesses of the chosen methods as well as the strategies employed to offset the shortcomings. The small sample size increased the risk of anecdotalism, wherein one or few idiosyncratic instances of a phenomenon is mistakenly reified into a pattern or theme (Braun & Clarke, 2006, p. 95). One way to mitigate the risk for anecdotalism was by corroborating observations among the participants, but this was not always possible; it should also be noted that prevalence does not always equate to importance. For Braun and Clarke (2006), the way to avoid anecdotalism was for the researcher to practice criticality. Milne and Oberle (2005, p. 414) described criticality as taking a critical approach and being deliberate about every decision made in a study. Criticality not only addressed anecdotalism, it also helped avoid the problem of underdeveloped themes. Connelly and Peltzer (2016) defined underdeveloped themes as those that failed to convey anything of significance, and attributes insufficient interview preparation and lack of criticality during analysis as factors that lead to underdeveloped themes. Strategies used to prevent underdeveloped themes included avoiding one-word themes (Braun et al., 2019) paying attention to coherence and choosing compelling examples (Braun & Clarke, 2006), and explaining the rationale that underlies a theme (Connelly & Peltzer, 2016). The use of documents also helped support the observation from the interviews, but their use also came with some considerations. The documents used in the study were government publications and reports, but Milne and Oberle (2005) note that this does not always mean that they are objective and accurate. Another consideration is that the documents were not produced for research purposes, and the original intention, including inherent biases, may remain embedded in the information. Criticality was once again the answer to these potential pitfalls. Criticality of the document meant actively engaging with the data and being cognizant of the contextual factors that come with the information (McLennan & Prinsen, 2014). 41 Active engagement required both criticality and reflexivity; reflexivity meant acknowledging one’s own “biases, dispositions, and assumptions” regarding the research (Merriam & Tisdell, 2016, p. 249). For this study, the researcher’s status as an outsider to the whole system of compensation in New Zealand meant there was probably less initial bias in approaching the topic, but it also meant that the researcher relied heavily on the information provided by the participants and from documents and literature. It could be said that the knowledge imbalance between the interviewer and participant was in the favor of the latter, and this meant again that criticality had to be a conscious, ongoing effort by the researcher. 2.2 Results The following section contains the results from the document analysis and interviews. It is split into three parts. The first recreates the whole process and identifies the key actors involved in each step and the decision-making criteria they employ. The second and third parts summarise the key findings from the interviews with the treatment providers and the claim assessors, respectively. 2.2.1 Leptospirosis claims process – from claim initiation to cover decision The steps in the compensation process, as determined from the document analysis and interview results, are shown in Figure 2. The diagram starts with the patient deciding to see a treatment provider and ends when cover is decided. The diagram also includes the major decision each key actor needs to make, as well as examples of the questions that go into their decision-making. 42 Figure 2 Process map and decision criteria of the ACC leptospirosis claims process, starting from when the patient decides to visit a treatment provider and up to when cover is decided 43 The explanations for the steps are found below: • Patient decides to see a treatment provider (Arrow 1). This is the first step and thus an integral part of the process and was therefore included in the diagram; however, this step is outside the scope of this project. The factors that drive or deter patients to seek medical attention may be investigated in future studies. • When the treatment provider sees the patient, they must make the following critical action points: Ø Suspect leptospirosis, basing their suspicion on the patient’s symptoms and exposure history. Ø Come up with a treatment plan. Ø Decide which laboratory tests are appropriate to help them confirm diagnosis. Ø Recognise the occupational link of the condition and initiate a claim. The last action point is the next step in the compensation process. The treatment provider lodges a leptospirosis claim on behalf of the patient, using an ACC 45 Injury Claim form (Arrow 2). • Because of leptospirosis’ inclusion into the Schedule 2 list of occupational diseases, the administrative process for dealing with those claims is streamlined. That means ACC has a set procedure for dealing with leptospirosis claims; when a leptospirosis claim is registered in the ACC system, it is automatically assigned to the Gradual Process Team and assigned a case coordinator. The case coordinator’s first task will be to obtain further information about the exposure (information mostly comes from the patient and the employer, although the latter is not applicable for self- employed individuals) and the condition (from the treatment provider/s7, e.g. 7 For patients or claimants who see more than one treatment provider, the case coordinator will request information from all the treatment providers. 44 patient notes and laboratory results) (Arrows 3). This is a very important step because insufficient information can cause a denial of cover. • The patient, treatment provider/s, and employer (if applicable) will send the requested information back to the case coordinator (Arrows 4). • Once the case-coordinator has obtained the necessary information, they send the claim to the medical advisor for comment (Arrow 5). If the case coordinator has a specific question about the claim, e.g. if the timeline of symptoms matches with the exposure timing, they will ask the medical advisor to for comment. The medical advisor will use the information coming from the treatment provider to check the diagnosis and the information from the patient and the employer to assess the appropriateness of the exposure. Note: The procedural tasks of the case coordinator discussed above pertain more to ACC; an AE/TPA might have similar practices but the specifics may vary for each AE/TPA. One difference could be that, for AE/TPA, the medical advisor might be distinctly separate from the case coordinator; external medical advisors may just be consulted by an AE/TPA on a case-to- case basis. Whereas in ACC, consulting with a medical advisor is a procedural requirement and medical advisors are part of the internal organisational structure. Still, it can be assumed that the general steps of gathering and assessing information are applicable to all. • The medical advisor then sends back their recommendation on whether the information supports the diagnosis and the work-related exposure (Arrow 6). It must be stressed here that the cover decision is the job of