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

Why Insurance Pricing Is Becoming More Client-Specific

05 Jul 2026: Paige Estritori

Australia’s commercial insurance market may be softening on the surface, but the latest industry commentary suggests small businesses should be cautious about assuming every policy will automatically become cheaper. The emerging message is that the old idea of a single hard or soft insurance market is giving way to a more targeted pricing environment, where insurers assess each line of cover, occupation, location and claims history in much greater detail. - read more

General Insurance Code Review Puts Service Standards in Focus

21 Jun 2026: Paige Estritori

Australia’s general insurance sector is edging closer to a significant reset of its customer service rulebook, with Financial Services Minister Daniel Mulino indicating he wants meaningful progress on the long-running review of the General Insurance Code of Practice. A draft of the revised code is expected to move towards consultation shortly, following a review process that began in November 2023 and produced more than 100 recommendations in late 2024. - read more

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

Click for more Insurance News