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

Australian Insurers Navigate AI Disruption Fears 05 Apr 2026: Paige Estritori In recent weeks, Australia's leading insurance companies, including Insurance Australia Group (IAG), Suncorp (SUN), and QBE Insurance (QBE), have experienced notable declines in their share prices. This downturn is largely attributed to growing investor concerns about the potential disruptive impact of artificial intelligence (AI) on the traditional insurance business model. - read more

Rising Premiums Challenge Australian Insurers in 2026 05 Apr 2026: Paige Estritori In 2026, Australian insurers are grappling with significant challenges as premium affordability becomes a pressing concern. A recent survey by Gallagher Bassett highlights that 70% of insurers have reported increased claim costs and frequencies over the past year. This surge is largely attributed to escalating climate-related losses and inflationary pressures affecting materials and labour costs. - read more

AI-Driven Cyber Insurance Now Available for Australian SMEs 05 Apr 2026: Paige Estritori In a significant development for Australian small and medium-sized enterprises (SMEs), Zurich has partnered with US-based cyber insurance specialist Cowbell to introduce an AI-driven cyber insurance product tailored for businesses with annual turnovers up to $100 million. This collaboration marks a pivotal step in enhancing cyber resilience among Australian SMEs. - read more

AFCA Rules in Favor of Restaurant in Arson Insurance Dispute 05 Apr 2026: Paige Estritori In a landmark decision, the Australian Financial Complaints Authority (AFCA) has directed an insurer to honor an arson-related claim for a restaurant, despite the non-disclosure of the director's criminal history during the policy's inception. This ruling underscores the complexities surrounding disclosure obligations and the interpretation of policy terms. - read more