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

Why rural heavy vehicle safety matters for insurance

22 Jul 2026: Paige Estritori

The National Heavy Vehicle Regulator’s latest focus on agricultural heavy vehicle safety is a timely reminder for farm, livestock, grain and regional freight operators: safety standards are not just a compliance issue. They can also shape claims outcomes, business interruption, liability exposure and future access to affordable truck insurance. - read more

What Allianz’s Farm Cover Revamp Means for Farmers

21 Jul 2026: Paige Estritori

Allianz Australia has refreshed its farm pack insurance, with the updated product announced on 20 July 2026. For farmers and rural property owners, the significance is less about one insurer changing a product and more about what it signals across the broader farm insurance market: insurers are trying to make cover easier to understand while adjusting policy features to better match modern farming operations. - read more

New APRA Data Highlights a Split Professional Indemnity Market

21 Jul 2026: Paige Estritori

Fresh analysis of APRA’s latest National Claims and Policies Database has added useful detail to the current professional indemnity insurance conversation. The database, released in early July 2026, covers professional indemnity, public liability and product liability policy and claims information, giving insurers, brokers and business owners a clearer view of how different parts of the liability market are moving. - read more

Broker Remuneration Debate Puts Disclosure on the Agenda

21 Jul 2026: Paige Estritori

The debate over Australia’s draft Insurance Brokers Code of Practice has intensified, with industry and consumer voices questioning whether the proposed changes go far enough on remuneration disclosure and conflict management. For real estate agencies, the issue is not abstract. Many agencies rely on intermediated advice when arranging professional indemnity, public liability, management liability, cyber cover, office insurance and commercial motor policies. - read more

Overseas Medical Emergency Puts Travel Insurance Back in Focus

21 Jul 2026: Paige Estritori

A recent Australian travel insurance case has offered a sharp reminder that the most expensive travel risk is often the one no traveller expects. According to Finder, an Australian woman who became seriously ill while 19 weeks pregnant in Mallorca faced medical costs of more than $40,000 after being taken to hospital by ambulance. The ambulance component alone reportedly reached $12,000, with the remaining costs linked to hospital admission, testing and treatment. - read more

Click for more Insurance News