Horse Accident Claim Rejected: A Deeper Look into Trauma Insurance

The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.

The incident occurred on October 16 of the previous year, leading to a significant pelvic fracture for the claimant, followed by surgery a few days later. The woman has stated that her day-to-day activities have been severely affected as a result.

Currently, she is undergoing physiotherapy and taking medication to improve her mobility. Her orthopaedic surgeon, identified as Dr NJ, has reported that she exhibits "debilitating symptoms affecting her left leg and foot."

Despite these symptoms, Dr NJ remarked that it might take 18 to 24 months to see improvement, and confirmed that predicting a permanent condition is complex at this stage.

Clearview Life Assurance refused the claim, citing that their policy's "loss of independent existence" clause necessitates a permanent inability to perform at least two daily activities independently.

In June, the complainant's general physician noted that she requires crutches for mobility and is incapable of handling tasks such as shopping, laundry, food preparation, or housecleaning.

The claimant also stated she suffers from cognitive impairment and has not shown any nerve recovery since the incident. She contends it would be unreasonable to assume her condition will improve over time.

The Australian Financial Complaints Authority (AFCA) acknowledged the severity of her disability but indicated that the current medical advice suggests she could eventually recover.

"Dr NJ is in the best position to opine on the permanence of the disability, given his specialty and ongoing treatment of the complainant," AFCA noted. "He has said it's 'too early to declare a permanent condition' and has outlined the further testing and treatments that are in progress and planned."

Nonetheless, AFCA's decision leaves the door open for the claimant to present new medical evidence at a future point that might confirm the permanence of her disability.

"It may be possible for her to demonstrate with subsequent medical evidence that her disability is permanent," AFCA said. "However, based on the current evidence, I am not convinced her disability is permanent or irreversible."

This case offers a critical view into the complexities and challenges associated with trauma insurance claims and highlights the necessity for clear and definite medical proof in establishing the permanence of a condition.

Published:Tuesday, 1st Oct 2024
Author: Paige Estritori
Sources

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Clear

Understanding the 4.41% Increase in Health Insurance Premiums

18 Mar 2026: Paige Estritori

Australian health insurance policyholders are set to experience a significant increase in their premiums, with an average rise of 4.41% scheduled to take effect from April 1, 2026. This adjustment marks the most substantial hike since 2017, when premiums rose by 4.84%. - read more

Rising Insurance Premiums in Australia: What Policyholders Need to Know

18 Mar 2026: Paige Estritori

Recent industry reports indicate that Australian insurers are grappling with escalating claims costs and broader economic pressures, leading to adjustments in premium rates across various sectors. This trend is particularly significant for consultants and professionals who rely on comprehensive insurance coverage to mitigate risks associated with their services. - read more

Western Australia's Transport Sector Pushes for Enhanced Truck Licensing Standards

17 Mar 2026: Paige Estritori

Western Australia's transport industry is urging the state government to implement more stringent heavy vehicle licensing requirements, aiming to bolster road safety and ensure drivers possess adequate experience. This initiative follows South Australia's recent reforms, which introduced tougher conditions for truck drivers after a tragic triple fatality in 2024. - read more

Aon's 2026 Report Highlights Escalating Climate Risks for Australian Businesses

17 Mar 2026: Paige Estritori

Aon plc, a leading global professional services firm, has released its 2026 Climate and Catastrophe Insight report, shedding light on the escalating climate-related risks facing Australian businesses. The report indicates that insured catastrophe losses in Australia totaled an estimated US$2.9 billion in 2025, underscoring the growing financial impact of climate events on the insurance sector. - read more

Navigating Rising Premiums and Cybersecurity Risks in Australia's Insurance Sector

16 Mar 2026: Paige Estritori

As we progress through 2026, Australia's insurance industry is grappling with significant challenges that are reshaping the landscape for both insurers and policyholders. Two primary concerns have emerged at the forefront: the affordability of premiums and the escalating threat of cyber incidents. - read more

Click for more Insurance News