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

TAL's Health Sense Plus Now Covers Income Protection Policies

27 Jan 2026: Paige Estritori

In a strategic move to enhance the value of its offerings, TAL has announced the expansion of its Health Sense Plus program to encompass income protection insurance. This initiative, effective from 8 August 2025, aims to incentivise proactive health management among policyholders by providing premium discounts. - read more

Rising Mental Health Claims Reshape Australia's Insurance Landscape

27 Jan 2026: Paige Estritori

Australia's insurance sector is experiencing a significant shift as mental health conditions become the predominant 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

APRA Calls for Reforms in Income Protection Insurance Sector

27 Jan 2026: Paige Estritori

The Australian Prudential Regulation Authority (APRA) has raised concerns about the sustainability of income protection insurance, following industry losses amounting to $2.5 billion over five years. APRA has urged life insurers to implement reforms to enhance the viability of these products and ensure they continue to meet policyholders' needs. - read more

Marinex Underwriting Sets Sail in Australian Marine Insurance Market

27 Jan 2026: Paige Estritori

In a significant development for Australia's marine insurance sector, Rhodian Group has announced the launch of Marinex Underwriting, a new agency dedicated to providing specialised marine insurance products tailored to the Australian market. This initiative marks Rhodian's third agency launch, following the establishment of Halo Underwriting and Batch Underwriting in previous years. - read more

Club Marine Marks 65 Years of Leadership in Australian Boating Insurance

27 Jan 2026: Paige Estritori

Club Marine, Australia's largest recreational boat insurer, is celebrating its 65th anniversary in 2024. Since its founding in 1959 as Marine Hull & Liability, the company has grown from a small operation in Victoria to a nationwide provider of insurance services for the country's boating community. - read more

Click for more Insurance News