Horse Accident Claim Rejected: A Deeper Look into Trauma Insurance

3

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
Source: Paige Estritori

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

Share this news item:

Insurance News

Clear

Australian Life Insurance Premiums Set for 1.7% Growth in 2025

18 Dec 2025: Paige Estritori

According to a recent report by Swiss Re, Australia's life insurance market is projected to experience a 1.7% real growth in premiums in 2025. This anticipated increase is attributed to easing cost-of-living pressures and the repricing of disability income policies. - read more

TAL's Health Sense Plus Now Covers Income Protection Policies

18 Dec 2025: Paige Estritori

In a significant development for policyholders, TAL has expanded its Health Sense Plus program to encompass income protection (IP) policies. This initiative, effective from August 8, 2025, aims to incentivize proactive health management by offering premium discounts to clients who engage in preventive health checks. - read more

Pelagic Risk Services Strengthens Commitment to Marinas with Gold Sponsorship

18 Dec 2025: Paige Estritori

In a significant move to bolster support for the marina industry, Pelagic Risk Services has elevated its sponsorship status from Silver to Gold with the Marina Industries Association (MIA). This advancement underscores Pelagic's dedication to enhancing the operational capabilities and risk management strategies of marina operators across Australia. - read more

Australian Insurers Falling Behind in Cyber and AI Risk Readiness

18 Dec 2025: Paige Estritori

In an era where digital threats are escalating, Australian insurers are reportedly less prepared to manage risks associated with cyber threats and artificial intelligence (AI) compared to their global counterparts. This insight emerges from the latest PwC Insurance Banana Skins Survey, which assesses the industry's readiness to tackle emerging challenges. - read more

Australian Insurance Market Set for Significant Growth by 2029

18 Dec 2025: Paige Estritori

Australia's general insurance market is on a trajectory of steady expansion, with projections indicating that total direct written premiums (DWP) will reach $144.5 billion by 2029. This growth reflects a compound annual growth rate (CAGR) of 8.8%, as analysed by data and analytics firm GlobalData. - read more

Click for more Insurance News