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

PSC Move Signals Stronger Competition in Transport Insurance Broking

07 Jul 2026: Paige Estritori

PSC Insurance Brokers’ investment in MA Insurance Brokers is a timely reminder that specialist transport insurance advice is becoming increasingly valuable in a tighter, more complex market. The deal, announced in late June 2026, sees MA begin operating as PSC Transport Insurance Brokers, while founders Barry Mathison and Mariann Illyes retain an equity stake and continue leading the business as managing principals. - read more

New Heavy Vehicle Law Puts Safety Systems Under the Insurance Spotlight

23 Jun 2026: Paige Estritori

Australia’s updated Heavy Vehicle National Law is moving from policy discussion to operational reality, with the new framework scheduled to commence on 1 August 2026 in HVNL-participating states and territories. For transport operators, this is more than a compliance calendar item. It is a signal that safety systems, driver fitness, fatigue controls and record-keeping will carry greater weight when insurers assess risk, price cover and review claims. - read more

ACCC Halts IAG's Acquisition of RAC WA's Insurance Division

16 Jun 2026: Paige Estritori

The Australian Competition and Consumer Commission (ACCC) has intervened to prevent Insurance Australia Group (IAG) from acquiring the insurance operations of the Royal Automobile Club of Western Australia (RAC WA). The proposed $1.35 billion transaction raised significant competition concerns, prompting the ACCC to act in the interest of consumers and the broader insurance market. - read more

Broker Held Accountable for Denied Truck Damage Insurance Claim

16 Jun 2026: Paige Estritori

The Australian Financial Complaints Authority (AFCA) has determined that a broker breached its duty of care, resulting in the denial of a truck damage claim due to the driver's inexperience. This case underscores the critical importance of brokers thoroughly understanding and communicating policy exclusions to their clients. - read more

Daimler Truck and Geico Introduce Telematics-Based Insurance for Freightliner and Western Star

16 Jun 2026: Paige Estritori

Daimler Truck Financial Services and Geico Insurance have partnered to launch 'Connected Insurance,' a data-driven, telematics-based program designed to assist Freightliner and Western Star owner-operators and small fleets in reducing their commercial vehicle insurance costs while promoting safer driving practices. - read more

Click for more Insurance News