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:
| NSW Productivity Commissioner Calls for Immediate Ban on Strata Manager Commissions 21 Apr 2026: Paige Estritori In a significant development for New South Wales' strata sector, Productivity Commissioner Peter Achterstraat has recommended the prompt prohibition of commissions received by strata managers. This move aims to safeguard the interests of apartment owners, especially as strata living becomes increasingly prevalent in Sydney. - read more |
| CHU's 2025 Report Shows Stability in Strata Insurance Premiums 21 Apr 2026: Paige Estritori CHU, Australia's leading strata insurance underwriting agency, has released its 2025 State of the Strata Market report, providing a comprehensive analysis of the current state of the industry. The report indicates that strata insurance premiums have experienced a modest increase of 2.8%, rising from an average of $954 to $981 per lot annually in the year leading up to June 2025. This increment is notably lower than the 14% surge observed in house insurance premiums during the same period. - read more |
| Insurance Council of Australia Advocates for Strata Law Reforms to Mitigate Rising Premiums 21 Apr 2026: Paige Estritori The Insurance Council of Australia (ICA) has called for significant reforms to Victoria's strata legislation, highlighting that inadequate governance and deferred maintenance are leading to increased insurance premiums for residents. With approximately one in five Victorians living in strata-titled properties, the impact of these issues is widespread and pressing. - read more |
| Surge in Insurance Complaints Highlights Processing Delays 21 Apr 2026: Paige Estritori Recent data from the Australian Financial Complaints Authority (AFCA) reveals a significant increase in consumer complaints against insurance companies, reaching an unprecedented average of 100 complaints per day. This surge is primarily attributed to delays in processing routine claims, rather than issues stemming from natural disasters. - read more |
| From Illness to Injury: Understanding the Scope of Income Protection Insurance In the uncertain times we face today, where both health and economic climates are unpredictable, safeguarding your financial stability becomes paramount. This is where income protection insurance steps in as an essential safety net. For many Australian families, it's the buffer that ensures life's financial commitments are met, even when ability to work is compromised. - read more
|
| Busting the Myth That Income Protection is Only for Physical Injuries To all the self-employed Australians! You're the backbone of our economy, recognized for your entrepreneurial spirit and abilities to navigate the unique challenges of managing your own business. Yet, with great freedom comes great responsibility, particularly when it comes to securing your financial well-being. - read more
|
| Unexpected Illness & Injury: Navigating Financial Security for Your Family Life is an unpredictable journey filled with twists and turns that can challenge even the most prepared among us. Sudden illnesses and unexpected injuries are just some of the uncertainties that can disrupt the harmony of family life. The emotional turmoil brought on by these circumstances is often compounded by the financial strain they can cause. It's during these trying times that the true value of peace of mind becomes clear. - read more
|
| Strategies to Use Life Insurance in Funding Shareholder Agreements Shareholder agreements lay the cornerstone for stable business relationships and continuity in Australia. Acting as a contract among business owners, these agreements set forth the expectations, rights, and obligations of all parties involved. They are particularly vital in delineating clear paths for dispute resolution, succession planning, and the transfer of ownership shares under varied circumstances, including the untimely death or departure of a shareholder. - read more
|
A formal request made by the policyholder to the insurance company for payment of a loss covered by the insurance policy.