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.

An individual who sustained serious injuries from a horse riding accident has been denied a trauma insurance payout, as authorities concluded that there is insufficient proof that her condition is irreversible.

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

Regulatory Review of Life Insurance Premium Practices in Australia

01 Apr 2026: Paige Estritori

In June 2025, the Australian Securities and Investments Commission (ASIC) and the Australian Prudential Regulation Authority (APRA) provided an update on their joint review of life insurance premium practices. This initiative was prompted by concerns over frequent and substantial premium increases that may not align with policy terms or policyholder expectations. - read more

Ongoing Deficiencies in Direct Life Insurance Sales Practices Identified by ASIC

01 Apr 2026: Paige Estritori

In August 2025, the Australian Securities and Investments Commission (ASIC) released findings from a review of direct life insurance sales practices, uncovering persistent deficiencies despite previous regulatory interventions. - read more

Swiss Re Suspends New Life Insurance Operations in Australia

01 Apr 2026: Paige Estritori

Swiss Re Life & Health Australia has announced a suspension of new life insurance business activities in the country, effective October 2025. This decision stems from concerns over the sustainability of Total Permanent Disability (TPD) insurance products, which have seen a significant rise in claims, particularly related to mental health. - read more

AIA Australia Highlights Need for Structural Reform in Life Insurance

01 Apr 2026: Paige Estritori

Damien Mu, CEO of AIA Australia, has raised concerns about the sustainability of the current life insurance model, citing a significant increase in mental health claims and economic volatility. Speaking at the company's recent Thrive for Life presentation, Mu emphasised that the industry is facing structural changes driven by these factors. - read more

Click for more Insurance News

Business Insurance Articles

Understanding Liability Insurance: A Must-Read for Australian Small Business Owners

Liability insurance is a form of insurance designed to offer protection against claims resulting from injuries and damage to people or property. It covers legal costs and any payouts for which the insured party would be responsible if found legally liable. Intended to protect against claims resulting from injuries and damage to other people or property, liability insurance is critical for small businesses as it shields them from potentially crippling legal expenses. - read more

Liability Risks: What Small Businesses in Australia Should Know

Welcome to our comprehensive guide on liability risks for small businesses in Australia. The world of business is fraught with challenges, and one often overlooked aspect is the array of potential liabilities that can stifle growth or even lead to catastrophic financial loss. It's crucial for small business owners to grasp the critical role that insurance plays in the protection and longevity of their ventures. - read more

The Cost of Public Liability Coverage: Is It Worth It?

Public liability insurance is a crucial safety net for both businesses and individuals, providing protection against the financial fallout from claims of injury or damage that your business operations might cause to third parties. This type of insurance is designed to cover legal and compensation costs, safeguarding you from unexpected financial burdens. - read more

Critical Risk Management Strategies for Every Australian Tradesman

Welcome to the crucial world of risk management for Australian tradesmen. Whether you're a seasoned professional or just starting, understanding and mitigating the inherent risks in the trades industry is paramount to both the safety and sustainability of your business. This article intends to guide you through the world of risk management, emphasizing the pivotal role of liability insurance. - read more

Start Here !

Knowledgebase

Term Life Insurance:
A life insurance that provides a cover for a specific period of time - usually one to five years or until the insured reaches age 65 or 70.

This website is owned and operated by Clark Family Pty Ltd (ACN 010 281 008) as Trustee for the Clark Family Trust (ABN 35 957 893 714), 43 Larch Street Tallebudgera QLD 4228. Clark Family Pty Ltd is an Authorised Representative (AR 1298860) of Unique Group Broker Services Pty Ltd (AFSL 509434) for financial product referrals and an Authorised Credit Representative (ACR 401491) of Saccasan Pty Ltd (ACL 386297). Check our licensing details on the ASIC registers: Clark Family Pty Ltd ACR, Clark Family Pty Ltd AR, Saccasan Pty Ltd, Unique Group Broker Services.

IMPORTANT: We act solely as an introducer and refer enquiries to licensed third-party brokers, insurers, and lenders. We do not provide financial product advice or credit assistance. We may receive a fee or commission from these third parties in consideration for the referral. Before any action is taken to obtain a product or service referred to by this website, advice should be obtained (from either the third party to whom we refer you or from another qualified intermediary) as to the appropriateness of obtaining those products having regard to your objectives, financial situation and needs. Whilst we have our own process for validating the legitimacy of our referral partners, you should independently verify the credentials and licensing of any adviser or provider you engage. Visit the ASIC website for further information.