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

CHU Introduces Cyber Coverage in Residential Strata Insurance

14 May 2026: Paige Estritori

In response to the escalating cyber threats targeting strata communities, CHU Underwriting Agencies has expanded its residential strata insurance policies to include cyber protection. This enhancement provides coverage of up to $50,000 for losses resulting from social engineering fraud, a prevalent form of cybercrime where perpetrators impersonate trusted contacts to manipulate payment instructions. - read more

CHU Expands Strata Insurance Capacity to Support Larger Developments

14 May 2026: Paige Estritori

CHU Underwriting Agencies has announced a significant increase in its single risk capacity, raising the limit to $690 million from the previous $300 million. This substantial enhancement enables CHU to better support larger residential and commercial strata developments across Australia. - read more

CHU's 2025 Report Shows Stability in Strata Insurance Premiums Amid Climate and Regulatory Shifts

14 May 2026: Paige Estritori

CHU, Australia's leading strata insurance underwriting agency, has released its 2025 State of the Strata Market report, providing a comprehensive analysis of the current state of the industry. The report offers valuable insights into premium movements, the impact of weather events, regulatory developments, and emerging risks affecting strata insurance. - read more

ACCC Deepens Investigation into IAG's Proposed RAC Insurance Acquisition

14 May 2026: Paige Estritori

The Australian Competition and Consumer Commission (ACCC) has intensified its examination of Insurance Australia Group's (IAG) proposed acquisition of RAC Insurance, moving the process into a Phase 2 review. This decision underscores the regulator's concerns about the potential impact on competition within Western Australia's insurance market. - read more

Click for more Insurance News