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

NSW Court Decision Escalates Liability Risks for Construction Sector

23 May 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

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

23 May 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

Australia's Rising Litigation Rates Prompt Calls for Legal Reforms

23 May 2026: Paige Estritori

Recent insights from the Insurance Council of Australia (ICA) reveal a concerning trend: Australia is now perceived as the most litigious market globally, surpassing even the United States. This development has significant implications for the insurance industry, particularly concerning the affordability and availability of public liability insurance for small businesses. - read more

ACCC Halts IAG's Bid to Acquire RAC WA's Insurance Operations

15 May 2026: Paige Estritori

The Australian Competition and Consumer Commission (ACCC) has recently opposed the proposed acquisition of RAC WA's insurance division by Insurance Australia Group (IAG). This decision stems from concerns that the merger could significantly reduce competition within Western Australia's insurance market, potentially leading to higher premiums for consumers. - read more

Declining Risk Readiness Among Australian Insurers Amid Escalating Cyber Threats

15 May 2026: Paige Estritori

Recent findings from PwC's Insurance Banana Skins survey reveal a concerning decline in risk preparedness among Australian insurers, marking the lowest levels in four years. The survey highlights that Australian insurers are now 6.6% behind their global counterparts on PwC's Preparedness Index, underscoring a significant readiness gap. - read more

Click for more Insurance News