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

CHU Introduces Cyber Coverage in Strata Insurance Policies

22 May 2026: Paige Estritori

In a significant move to address the evolving risks faced by strata communities, CHU Underwriting Agencies has incorporated cyber protection into its residential strata insurance policies. This enhancement provides coverage of up to $50,000 for losses resulting from social engineering fraud, a type of cybercrime where perpetrators impersonate trusted contacts to manipulate payment instructions. - read more

QBE Introduces Comprehensive Add-Ons to Landlord Insurance Policies

22 May 2026: Paige Estritori

QBE Insurance has unveiled significant enhancements to its commercial landlord insurance offerings, introducing a suite of optional add-ons designed to provide more comprehensive protection for property owners. These strategic enhancements aim to equip brokers with additional tools to better serve their clients in a competitive market. - read more

Blue Zebra Partners with New Underwriters for Home and SME Insurance

22 May 2026: Paige Estritori

Blue Zebra, a prominent underwriting agency, has announced a new capacity arrangement for its home building and contents, landlord, and SME package products. The agency has partnered with a co-insurance panel comprising Chubb, AIG, and HDI Global Specialty, marking a significant shift in its underwriting partnerships. - read more

The Rise of Autonomous Machinery in Australian Agriculture

21 May 2026: Paige Estritori

In recent years, Australian agriculture has witnessed a notable shift towards the adoption of autonomous machinery. This trend reflects a broader global movement aimed at enhancing efficiency and productivity in farming operations. However, despite the growing interest, several challenges continue to impede widespread implementation across the sector. - read more

Analyzing the 2026-27 Federal Budget's Impact on Agriculture

21 May 2026: Paige Estritori

The recently announced 2026-27 Federal Budget has introduced several measures with significant implications for the Australian agricultural sector. These initiatives aim to bolster the industry's resilience and address pressing challenges faced by farmers nationwide. - read more

Click for more Insurance News