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

Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.

Share this news item:

Insurance News

Clear

Second NSW H5 Bird Flu Detection Puts Biosecurity Back on the Farm Risk Agenda

17 Jul 2026: Paige Estritori

A second H5 bird flu detection in New South Wales has moved avian disease risk from a distant global concern to a practical on-farm planning issue for Australian producers. The latest case involved a petrel found at Hawks Nest on the NSW Mid North Coast, following an earlier detection at the same beach. Authorities have indicated the human health risk remains low, and there has been no reported H5 detection in NSW commercial poultry flocks at this stage. - read more

What the Partnered Health Breach Means for Clinic Risk

17 Jul 2026: Paige Estritori

The latest reporting on the Partnered Health cyber attack may be a wake-up call for allied health practices that store patient information, uses shared booking systems or relies on cloud-based clinical software. The healthcare group, which operates more than 60 clinics nationally, became aware on 23 June 2026 that a malicious actor had accessed data from some clinics. Potentially affected patients were not notified publicly until more than three weeks later. - read more

What the Partnered Health Cyber Attack Means for Fitness Operators

17 Jul 2026: Paige Estritori

A cyber attack disclosed by Partnered Health Group on 15 July 2026 has put health-related data security back on the agenda for Australian service businesses. The incident reportedly affected patient information across 21 clinics in multiple states and territories, including contact details, Medicare information, private health insurance details and medical records. While this was a healthcare provider incident, the lessons are highly relevant for fitness professionals who collect health screening forms, injury histories, progress notes, emergency contacts and payment details. - read more

AI Agent Risks Put Consultant Cover Under the Microscope

17 Jul 2026: Paige Estritori

A new industry report on AI agents has sharpened an issue that many Australian consultants can no longer treat as theoretical: when automated tools make decisions, access client data or carry out tasks, which insurance policy responds if something goes wrong? - read more

Taree Flood Lessons Renew Pressure on Insurance Affordability

17 Jul 2026: Paige Estritori

A fresh roundtable in Taree has put flood insurance affordability back under the spotlight, more than a year after the May 2025 floods devastated parts of the Manning Valley and Mid North Coast. The discussion, co-hosted by Insurance Council of Australia CEO Andrew Hall and federal MP Alison Penfold, brought together business and council leaders to examine why recovery alone is not enough when the underlying flood risk remains. - read more

Click for more Insurance News