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

Medical Emergencies Lead Australian Travel Insurance Claims in 2024

28 Nov 2025: Paige Estritori

In 2024, medical incidents emerged as the leading cause of travel insurance claims among Australian travellers, accounting for more than 40% of all claims handled by nib Travel. This trend underscores the critical importance of securing comprehensive travel insurance to mitigate the financial risks associated with medical emergencies abroad. - read more

QBE Insurance Faces Market Challenges with Slower Premium Growth

28 Nov 2025: Paige Estritori

QBE Insurance Group, Australia's largest insurer by market value, recently reported a slowdown in premium rate growth, leading to a significant decline in its share price. The company's global average premium rate increased by only 1.5% in the nine months leading up to September 30, 2025, a decrease from the first-half pace. This deceleration is primarily attributed to slower growth in business property insurance prices. - read more

EQT's Bid to Acquire AUB Group: Implications for the Insurance Sector

28 Nov 2025: Paige Estritori

In a significant move within the Australian insurance industry, Swedish private equity firm EQT has extended a takeover offer for AUB Group, valuing the company at A$5.25 billion. This proposal includes a price of A$45 per share, representing a 25.1% premium over AUB's last closing price. Following the announcement, AUB shares surged up to 11% to A$39.95, though they remained below the offer price. - read more

Australian Insurers Report Record Profits Amid Market Dynamics

28 Nov 2025: Paige Estritori

Australia's general insurance industry has reported a return on equity (ROE) of 19% for the 2025 financial year, marking the highest in a decade. This impressive performance is attributed to a combination of factors, including benign weather conditions, strong investment gains, and the continued flow-through of premium increases. - read more

Seafood Distributor Prevails in Insurance Claim for Stock Losses Due to Power Outage

28 Nov 2025: Paige Estritori

In a recent ruling by the Australian Financial Complaints Authority (AFCA), a seafood distribution business has successfully claimed insurance for stock losses incurred during a week-long power outage. This case underscores the complexities surrounding insurance claims related to power failures and the importance of understanding policy exclusions. - read more

Click for more Insurance News