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

Brisbane Hailstorm Sees Over 16,000 Insurance Claims

03 Nov 2025: Paige Estritori

The recent hailstorm in Brisbane has triggered more than 16,000 insurance claims, marking it as a significant event as declared by the Insurance Council of Australia. Both Suncorp and IAG have experienced a substantial influx of claims following the severe weather conditions that affected parts of Queensland and Victoria over the weekend. - read more

Strata Futures Report Proposes National Task Force for Industry Overhaul

03 Nov 2025: Paige Estritori

The recently released Strata Futures Report has put forth a comprehensive set of 64 recommendations aimed at transforming Australia's strata industry. Central to these proposals is the establishment of a national task force, co-funded by the government, to spearhead reforms and foster a high-performing, transparent, and sustainable model of property ownership and governance. - read more

Surge in Mental Health Claims Reshapes Australia's Insurance Landscape

31 Oct 2025: Paige Estritori

Australia's insurance industry is experiencing a significant shift as mental health conditions have become the leading cause of total and permanent disability (TPD) claims. Recent data from the Council of Australian Life Insurers (CALI) indicates that mental health issues now account for nearly one-third of all TPD claims, marking a substantial change in the industry's claim patterns. - read more

Australian Super's Claim Delays Raise Concerns Among Members

31 Oct 2025: Paige Estritori

Australian Super, one of the nation's largest superannuation funds, is facing criticism over significant delays in processing insurance claims, particularly those related to income protection and total and permanent disability (TPD). Members have reported prolonged waiting periods, leading to financial hardships and uncertainty. - read more

New Legislation Prohibits Life Insurers from Using Genetic Test Results

31 Oct 2025: Paige Estritori

The Australian government has enacted legislation prohibiting life insurers from using the results of genetic tests to refuse coverage or increase premiums. This landmark decision aims to eliminate genetic discrimination and encourage individuals to undergo potentially life-saving genetic testing without fear of financial repercussions. - read more

Click for more Insurance News