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:
| Inattention and Speed: Key Factors in Major Truck Crashes 28 Jan 2026: Paige Estritori The National Truck Accident Research Centre (NTARC) has released its latest Major Incident Investigation Report, shedding light on the predominant causes of significant truck crashes across Australia. The findings reveal that human factors, particularly inattention, distraction, and inappropriate speed, continue to be the leading contributors to these incidents. - read more |
| TAL's Health Sense Plus Now Covers Income Protection Policies 27 Jan 2026: Paige Estritori In a strategic move to enhance the value of its offerings, TAL has announced the expansion of its Health Sense Plus program to encompass income protection insurance. This initiative, effective from 8 August 2025, aims to incentivise proactive health management among policyholders by providing premium discounts. - read more |
| Rising Mental Health Claims Reshape Australia's Insurance Landscape 27 Jan 2026: Paige Estritori Australia's insurance sector is experiencing a significant shift as mental health conditions become the predominant cause of total and permanent disability (TPD) claims. Recent data from the Council of Australian Life Insurers (CALI) indicates that mental health issues now account for nearly one-third of all TPD claims, marking a substantial change in the industry's claim patterns. - read more |
| APRA Calls for Reforms in Income Protection Insurance Sector 27 Jan 2026: Paige Estritori The Australian Prudential Regulation Authority (APRA) has raised concerns about the sustainability of income protection insurance, following industry losses amounting to $2.5 billion over five years. APRA has urged life insurers to implement reforms to enhance the viability of these products and ensure they continue to meet policyholders' needs. - read more |
| Top Insurance Policies Every Working Adult Should Consider Insurance is an essential component of achieving financial stability. In life, unexpected events such as illnesses or accidents can pose serious financial challenges. Without adequate preparation, these can disrupt your finances significantly, making recovery even more complicated. This is where the crucial role of insurance becomes apparent. - read more
|
| How to Prepare for a Hassle-Free Life Insurance Claim Being prepared when it comes to life insurance claims can make a world of difference. Proper preparation helps you prevent delays and denials, ensuring that your loved ones receive the financial support promised by your policy without unnecessary hold-ups. By paying attention to the details, you can streamline the claims process, giving you and your family peace of mind during what is already a stressful time. - read more
|
| Disability Income Protection: What Every Hotel Operator Needs to Know Running a café is a rewarding yet challenging endeavor. With the hospitality industry being fast-paced and ever-changing, café owners often face unique financial challenges. Operating in an industry that is both physically demanding and unpredictable can sometimes lead to unforeseen circumstances that affect the stability and success of your business. - read more
|
| Navigating Pre-existing Conditions in Income Protection Insurance Income protection insurance is a safety net that many Australians rely on to secure their financial future in the event of illness or injury preventing them from working. It's a type of policy that provides a replacement income if you are unable to earn your regular income due to a health-related absence from the workplace. - read more
|
The periodic amount paid for the purchase of insurance.