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

AustralianSuper Announces Substantial Insurance Premium Increases 25 Apr 2026: Paige Estritori AustralianSuper, the nation's largest superannuation fund, has informed its members of impending increases in insurance premiums, set to take effect from May 30, 2026. This development is particularly noteworthy for those holding life, total and permanent disability (TPD), and income protection insurance through their superannuation accounts. - read more

Insurers Push to Extend Rebate for Low-Income Seniors 25 Apr 2026: Paige Estritori Health insurers are calling on the Australian government to exempt low-income seniors, including those on the Age Pension, from the proposed changes to the Private Health Insurance Rebate. The concern is that requiring these individuals to pay hundreds of dollars more each year to maintain their private health insurance could lead some to downgrade their coverage or abandon it altogether. - read more

Marine Insurers Maintain Support Amid Middle East Conflicts 25 Apr 2026: Paige Estritori The International Union of Marine Insurance (IUMI) has recently highlighted the resilience of marine insurers in the face of escalating conflicts in the Middle East. Despite the challenging geopolitical landscape, insurers continue to provide essential coverage for cargo, hull, liability, and offshore energy sectors, ensuring that global trade flows remain protected. - read more

Rising Insurance Premiums and Declining Profits in Australia 25 Apr 2026: Paige Estritori Recent findings from KPMG's annual review of the general insurance industry reveal a concerning trend for Australian businesses: insurance premiums are on the rise, while industry profits are experiencing a downturn. This development is largely attributed to the escalating costs associated with natural disasters. - read more