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
Source: Paige Estritori

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Clear

Human Factors Identified as Leading Causes in Major Truck Accidents

14 Mar 2026: Paige Estritori

Recent findings from the National Truck Accident Research Centre's (NTARC) 2025 Major Incident Investigation Report have brought to light the significant role human error plays in major truck accidents across Australia. The report, supported by National Transport Insurance (NTI), indicates that human factors such as inattention, distraction, and inappropriate speed are the predominant causes of these incidents. - read more

AFCA Sides with Freight Company in Dangerous Goods Disclosure Dispute

14 Mar 2026: Paige Estritori

The Australian Financial Complaints Authority (AFCA) has recently ruled in favour of a freight company in a dispute over the disclosure of transporting dangerous goods. This decision provides valuable insights into the obligations of transport companies regarding insurance disclosures. - read more

Navigating Rising Premiums: Challenges for Australian Insurers in 2026

14 Mar 2026: Paige Estritori

In 2026, Australian insurers are confronting a trio of significant challenges: escalating premium costs, persistent cyber threats, and a tightening labour market. These issues are reshaping the industry's priorities and strategies. - read more

The Future of Insurance: Australia's Insurtech Market Set for Explosive Growth

14 Mar 2026: Paige Estritori

Australia's insurtech sector is on the brink of a significant transformation, with projections indicating a surge from $377 million in 2025 to an impressive $4.2 billion by 2034. This anticipated growth, at a compound annual growth rate (CAGR) of 30.68%, reflects the increasing integration of digital technologies within the insurance industry. - read more

Addressing the Evolving Cyber Threat Landscape in the Insurance Industry

14 Mar 2026: Paige Estritori

The upcoming Insurance News conference, scheduled for March 19 in Sydney, is set to tackle the rapidly evolving landscape of cyber risks and the strategies insurers can employ to mitigate them. This timely event will feature a panel of experts, including QBE's Global Head of Cyber Services, Dominic Keller; WTW's Director of Cyber and Technology for the Pacific, Michael Parrant; and MGA's Broking Operations Manager, Trent Woodward. - read more

Click for more Insurance News