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

Australian Insurers Brace for Profitability Decline After Record Highs 17 Dec 2025: Paige Estritori The Australian insurance industry is preparing for a downturn in profitability after achieving a decade-high return on equity (ROE) of 19% in the 2024-25 financial year. This peak performance was driven by robust underwriting results, substantial investment returns, and a period of relatively low natural disaster claims. However, industry analysts predict a six-point decline in ROE to 13% for the current financial year, bringing it back within the typical target range of 10% to 15%. - read more

Australian Insurtech Startups Experience Growth and Market Expansion 17 Dec 2025: Paige Estritori The Australian insurtech sector is demonstrating remarkable resilience and adaptability, with many startups reporting significant growth and successful market expansion. A recent survey of Insurtech Australia members reveals that companies generating annual revenues between $1 million and $10 million have experienced a 30% increase in revenue. Additionally, there has been a 10% rise in investment from private backers, indicating strong confidence in the sector's potential. - read more

Australian SMEs Advocate for National Reforms to Combat Rising Insurance Costs 17 Dec 2025: Paige Estritori Small and medium-sized enterprises (SMEs) across Australia are facing mounting challenges due to escalating insurance premiums. A recent report by the Australian Chamber of Commerce and Industry, in collaboration with the Insurance Council of Australia, highlights the urgent need for coordinated national reforms to address this pressing issue. - read more

WFI Insurance Joins Forces with Farmsafe Australia to Boost Farm Safety Standards 16 Dec 2025: Paige Estritori In a significant move to enhance safety within the Australian agricultural sector, WFI Insurance has announced a partnership with Farmsafe Australia. This collaboration is designed to raise awareness about farming hazards and advocate for the adoption of safer work practices among farmers. - read more