Horse Accident Claim Rejected: A Deeper Look into Trauma Insurance
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:
| National Climate Risk Assessment Unveils Growing Insurance Challenges 17 Sep 2025: Paige Estritori The Australian government has unveiled its inaugural National Climate Risk Assessment alongside a comprehensive National Adaptation Plan, highlighting the heightened impact of natural disasters on insurance accessibility across the nation. With an urgent call to action, the government acknowledges the impending climate threats and commits to intensifying efforts towards emission reduction. - read more |
| ASIC Extends Relief on Distribution Rules for Insurance Providers 16 Sep 2025: Paige Estritori The Australian Securities and Investments Commission (ASIC) has announced an extension of the exemption allowing general insurance providers to forego appointing product distributors as authorised representatives. This decision comes with the introduction of a new legislative instrument, 2025/520, which renews the previous framework, originally established under instrument 2015/682. The relief will now continue until August 27, 2030. - read more |
| Cyber Insurance Becomes Essential Amid Rising Digital Threats 12 Sep 2025: Paige Estritori The recent cyberattack on Fortnum Private Wealth, accompanied by ASIC's legal action, has spotlighted the critical risks cyber threats pose to financial advice companies in Australia. With digital integration intensifying across the finance sector, the owner of Fortnum, Entireti, plans to defend the case, underscoring the necessity for ongoing vigilance in cybersecurity measures. - read more |
| Swiss Re Foresees Rising Premiums Amid Increasing Global Risks 10 Sep 2025: Paige Estritori In a comprehensive analysis, Swiss Re Institute predicts that global property and casualty insurance premiums will rise in tandem with GDP over the upcoming decade. This growth is driven by amplified natural catastrophe losses, asset accumulation, and heightened economic and litigation claims inflation. The institute's report outlines the evolving insurance landscape amid increasing global risks. - read more |
| The Role of Health Insurance in Supporting Preventive Care Preventive healthcare refers to measures taken to prevent diseases, rather than treating them after they occur. This includes actions like regular health screenings, vaccinations, and adopting healthy lifestyle practices. - read more
|
| Top 5 Reasons to Consider Life Insurance While You're Young When you’re young, life is all about new experiences and making plans for a promising future. While factors like travel, career, and relationships often take centre stage, one aspect often overlooked is life insurance. It might seem like something to consider later in life, but starting a policy while you're young can be a savvy financial move. - read more
|
| Everything You Need to Know About Waiting Periods and Income Protection Benefits Income protection insurance is a crucial financial product designed to secure a portion of your income if you're unable to work due to illness or injury. This type of insurance acts as a financial safety net, ensuring that you can maintain your lifestyle and meet essential expenses while recovering. - read more
|
| Smart Strategies to Lower Your Health Insurance Premiums In today's rapidly changing health insurance landscape in Australia, keeping track of costs and coverage can be daunting. Many Australians find themselves grappling with high premiums that seem to increase year after year. - read more
|
A provision in a life insurance policy that prevents the insurer from voiding coverage due to a misstatement by the insured after a certain period.