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

Addressing Human Factors in Rising Australian Truck Insurance Claims

04 Jun 2026: Paige Estritori

Gallagher's recent guidance for Australia's heavy vehicle sector identifies fatigue, inattention, distraction, and inappropriate speed as major contributors to truck incidents and related insurance claims. This analysis is based on recent crash data and regulatory expectations, highlighting the need for comprehensive risk management strategies within the transport industry. - read more

Hostplus and MetLife Extend Partnership to Strengthen Member Insurance Offerings

03 Jun 2026: Paige Estritori

Hostplus, a leading Australian superannuation fund, has announced the extension of its group insurance partnership with MetLife Australia until June 2028. This strategic move aims to enhance the insurance benefits available to Hostplus members, reflecting the fund's commitment to providing comprehensive and cost-effective coverage. - read more

Nautilus Marine Insurance Celebrates 21 Years with New Brand Identity and Team Expansion

03 Jun 2026: Paige Estritori

Nautilus Marine Insurance, a leading provider in Australia's marine insurance sector, has marked its 21st anniversary by unveiling a refreshed brand identity and expanding its team with strategic appointments. This evolution underscores the company's commitment to growth and its dedication to serving the marine community. - read more

Zurich Introduces AI-Powered Cyber Insurance Solution for Australian Businesses

03 Jun 2026: Paige Estritori

Zurich Financial Services Australia has unveiled 'Prime One', a cutting-edge cyber insurance product designed to bolster the digital resilience of Australian businesses. Developed in partnership with Cowbell, a specialist in adaptive cyber and specialty insurance solutions, 'Prime One' leverages artificial intelligence to streamline the underwriting process, offering rapid and tailored coverage. - read more

Government Unveils Major NDIS Reforms Targeting Over $36 Billion in Savings

03 Jun 2026: Paige Estritori

The Australian government has announced substantial reforms to the National Disability Insurance Scheme (NDIS) as part of the 2026 federal budget, aiming to save more than $36 billion over the next four years. These changes are intended to curb the scheme's rapid growth and ensure its sustainability, while refocusing support on individuals with significant and permanent disabilities. - read more

Click for more Insurance News