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

IAG and Ag Guard Forge Partnership to Elevate Crop Insurance for Australian Farmers

14 Nov 2025: Paige Estritori

In a significant development for Australia's agricultural sector, Insurance Australia Group (IAG) has announced a strategic partnership with Ag Guard, a specialist rural underwriting agency. This collaboration will see Ag Guard managing the underwriting for IAG-owned CGU and WFI's crop insurance portfolios starting June next year. - read more

WFI Insurance and AgCarE Collaborate to Incentivize Sustainable Farming Practices

14 Nov 2025: Paige Estritori

In a move to promote sustainable agriculture, WFI Insurance has partnered with AgCarE, a certification program developed by AgForce, to offer premium reductions to farmers who achieve AgCarE certification. This collaboration aims to enhance financial, environmental, and social outcomes for Australian farmers and rural communities. - read more

Diversification in Small Farms Creates New Avenues for Insurance Brokers

14 Nov 2025: Paige Estritori

The landscape of Australian agriculture is undergoing a significant transformation as small commercial farms increasingly diversify their operations to enhance income and sustainability. This shift presents both challenges and opportunities for insurance brokers, as new ventures introduce complex risk management needs. - read more

ICA's Strategic Plan to Combat Escalating Motor Insurance Costs

14 Nov 2025: Paige Estritori

The Insurance Council of Australia (ICA) has unveiled a comprehensive report titled 'Motor Insurance Policy Paper - A Roadmap for Reducing Rising Premiums,' addressing the significant 42% increase in comprehensive motor insurance premiums since 2019. This surge has brought the average annual premium to $1,052 in 2024, prompting the need for coordinated action to alleviate the financial burden on consumers. - read more

Inattention and Speed: Key Contributors to Major Truck Accidents in Australia

14 Nov 2025: Paige Estritori

The National Truck Accident Research Centre (NTARC) has released its 2025 Major Incident Investigation Report, shedding light on the primary human factors contributing to significant truck crashes across Australia. The findings emphasise the critical roles of inattention, distraction, and inappropriate speed in these incidents, underscoring the necessity for targeted safety interventions within the transport industry. - read more

Click for more Insurance News