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

AFCA Upholds Policyholder's Income Protection Benefits Against Zurich

12 Feb 2026: Paige Estritori

The Australian Financial Complaints Authority (AFCA) has recently ruled against Zurich Insurance, instructing the insurer to maintain the current income protection benefits for a policyholder after an 11-year delay in proposing a reduction. This decision underscores the critical importance of timely and transparent communication between insurers and their clients. - read more

Neos Recognized as Leading Income Protection Insurer in 2025

12 Feb 2026: Paige Estritori

In the 2025 Life Insurance Awards presented by Money Magazine, Neos has been honored as the top provider in the Income Protection Insurance category. This accolade reflects Neos's commitment to delivering comprehensive and reliable income protection solutions to Australians. - read more

Northern Australian Marinas Struggle with Rising Insurance Costs

12 Feb 2026: Paige Estritori

Marina operators in Northern Australia are confronting a significant crisis as insurance premiums escalate dramatically, with some experiencing increases exceeding 300% over recent years. This surge in costs is placing immense financial strain on the industry, prompting urgent calls for government intervention. - read more

GT Insurance Provides Flexible Solutions Amid Global Trade Shifts

12 Feb 2026: Paige Estritori

As global trade dynamics undergo significant shifts, GT Insurance is reaffirming its commitment to supporting marine clients navigating these challenges. The recent imposition of US tariffs-25% on Australian steel and aluminium, and 10% on other exported goods-has introduced new uncertainties for local exporters, particularly in sectors like beef and bulk freight. These tariffs, effective from April 5, 2025, have prompted concerns about declining export volumes and reduced freight margins. - read more

Business NSW Advocates for Urgent Insurance Reforms to Alleviate Rising Premiums

12 Feb 2026: Paige Estritori

Business NSW, the leading business advocacy group in New South Wales, has raised alarms over the escalating insurance premiums that are placing significant financial strain on businesses across the state. Recent findings from their Business Conditions Survey reveal that nearly 80% of businesses have encountered double-digit increases in insurance costs over the past year, with one in three reporting hikes of 30% or more. These surges starkly contrast with the annual inflation rate of 2. - read more

Click for more Insurance News