Horse Accident Claim Rejected: A Deeper Look into Trauma Insurance

3

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

Call for Enhanced Support for Indigenous Insurance Customers 09 Dec 2025: Paige Estritori The Life Code Compliance Committee has identified significant gaps in support for Indigenous customers within the insurance sector, following an audit of three major insurers representing two-thirds of the market. The analysis reveals that these insurers lack adequate procedures for safe self-identification, a critical step towards ensuring cultural inclusivity and accessibility. - read more

Australian Insurtech Startups: Pioneering the Future of Insurance 09 Dec 2025: Paige Estritori The Australian insurtech sector is experiencing significant growth, with startups introducing innovative solutions that enhance efficiency, security, and customer engagement within the insurance industry. A recent report titled 'Insurtech Down Under: Trends, Tech and Triumphs' highlights the pivotal role these companies play in reshaping the market. - read more

Australian Insurers Address Surge in Mental Health Claims 09 Dec 2025: Paige Estritori The Australian insurance industry is facing unprecedented challenges due to a significant rise in mental health-related claims. The Council of Australian Life Insurers reports that mental health has become the leading cause of total and permanent disability claims, accounting for nearly one in three payouts. - read more

Calls for Overhaul in Australian Insurance Claims Handling Processes 09 Dec 2025: Paige Estritori Australian consumer advocacy groups are intensifying their calls for substantial reforms in the insurance industry's claims handling processes. The Australian Consumers Insurance Lobby (ACIL) has criticised the current system, highlighting ongoing issues that compromise consumer outcomes. - read more