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

Australian Insurers Tackle Premium Affordability Challenges in 2026

31 Mar 2026: Paige Estritori

In 2026, Australian insurers are prioritizing premium affordability and insurability as they confront escalating claims costs, climate-related losses, and technology-enabled fraud. According to Gallagher Bassett's 2026 global claims study, these factors are significantly influencing pricing, underwriting, and capital allocation decisions. - read more

Australian Life Insurers Achieve Significant Underwriting Gains in Q4 2025

23 Mar 2026: Paige Estritori

The Australian life insurance sector has reported a substantial underwriting gain of $279 million for the December quarter of 2025, a significant improvement from the $36 million recorded in the same period the previous year. This data, released by the Australian Prudential Regulation Authority (APRA), highlights a notable turnaround in the industry's financial performance. - read more

Record Profits for Australian General Insurers in 2024

23 Mar 2026: Paige Estritori

Australia's general insurance industry has reported an unprecedented after-tax profit of $6.1 billion for the year 2024, marking a significant milestone in the sector's financial performance. This figure is three times higher than the five-year average of $2 billion, according to KPMG's General Insurance Insights report. - read more

IAG Achieves 33% Increase in Insurance Profit Amid Lower Claims

23 Mar 2026: Paige Estritori

Insurance Australia Group (IAG), the country's largest insurer, has reported a 33% increase in its full-year insurance profit, reaching A$606 million for the 12 months ending June 2025. This significant growth is attributed to a combination of reduced claims expenses and strategic premium adjustments. - read more

Introducing Backd: Affordable Insurance for Casual and Contract Workers

15 Mar 2026: Paige Estritori

In a significant move to address the insurance needs of Australia's growing casual and contract workforce, TAL has partnered with global insurtech company Cover Genius to launch Backd. This innovative digital-only insurance product aims to provide accessible and affordable life and income protection coverage to workers who have traditionally faced challenges in obtaining such protection. - read more

Click for more Insurance News