Horse Accident Claim Rejected: A Deeper Look into Trauma Insurance

The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.

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
Author: Paige Estritori

Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.

Share this news item:

Insurance News

Clear

APRA Data Highlights Rising Public Liability Insurance Costs

14 Jun 2026: Paige Estritori

The Australian Prudential Regulation Authority (APRA) has released its latest National Claims and Policies Database (NCPD) statistics, revealing a substantial increase in public liability insurance premiums over recent years. Since 2015, premiums have risen by 40%, outpacing general inflation and placing additional financial strain on businesses across the country. - read more

Melbourne's Pride of our Footscray Nightclub Confronts Insurance Challenges

14 Jun 2026: Paige Estritori

Melbourne's vibrant nightlife is under threat as venues like Pride of our Footscray grapple with escalating public liability insurance premiums. The popular nightclub has been deemed 'uninsurable' for two years, reflecting a broader crisis affecting small businesses across Australia. - read more

ICA Advocates for Overhaul of Civil Liability Laws to Ease Insurance Burden

07 Jun 2026: Paige Estritori

The Insurance Council of Australia (ICA) has recently called for urgent reforms to outdated state and territory civil liability laws, highlighting their significant contribution to the rising insurance costs faced by small businesses and community organisations. These laws, many of which have not been reviewed in nearly 25 years, are increasingly seen as inadequate in addressing the complexities of modern liability claims. - read more

ACCC Approves Uniting Church's National Insurance Purchasing Program

07 Jun 2026: Paige Estritori

The Australian Competition and Consumer Commission (ACCC) has granted a six-year authorisation for the Uniting Church's national insurance purchasing program, a move anticipated to reduce premiums and deliver better outcomes for the organisation's diverse operations. - read more

NSW Court Decision Escalates Liability Risks for Construction Sector

07 Jun 2026: Paige Estritori

A recent landmark ruling in New South Wales has significantly altered the liability landscape for the construction industry. The court's decision removes the ability for developers and builders to rely on proportionate liability defences under the Design and Building Practitioners Act 2020 (DBP Act), thereby increasing their exposure to claims related to building defects. - read more

Click for more Insurance News