Horse Accident Claim Rejected: A Deeper Look into Trauma Insurance

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

Share this news item:

Insurance News

Western Australia's Transport Sector Pushes for Enhanced Truck Licensing Standards 29 Mar 2026: Paige Estritori Western Australia's transport industry is urging the state government to implement more stringent heavy vehicle licensing requirements, aiming to bolster road safety and address concerns over inexperienced drivers operating large trucks. This initiative follows South Australia's recent reforms, which introduced tougher conditions for obtaining multi-combination (MC) licenses. - read more

Australian Road Transport Industry Grapples with Escalating Fuel Prices 29 Mar 2026: Paige Estritori The Australian road transport industry is currently facing significant financial pressures due to escalating fuel prices, which have substantially increased operational costs for trucking businesses nationwide. This surge in fuel expenses is compounding existing challenges, including rising maintenance costs, land taxes, and insurance premiums, thereby squeezing profit margins and threatening the viability of many operators. - read more

Navigating Seasonal Risks in Australian Trucking: Insurance Considerations 29 Mar 2026: Paige Estritori Seasonal variations in Australia present unique challenges for the trucking industry, influencing safety, operational efficiency, and insurance considerations. Wet weather conditions, increased holiday traffic, and heightened freight demand during peak seasons can all impact the risk profile of trucking operations, necessitating a thorough understanding of these factors to ensure adequate insurance coverage and business resilience. - read more

Australian Insurers Grapple with AI Disruption Fears 29 Mar 2026: Paige Estritori In recent weeks, major Australian insurers such as Insurance Australia Group (IAG), Suncorp (SUN), and QBE Insurance (QBE) have experienced notable declines in their stock prices. This downturn is largely attributed to growing investor concerns about the potential disruption posed by artificial intelligence (AI) within the insurance sector. - read more