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 Claim Clarity Matters More Than Ever for Income Insurance

13 Aug 2026: Paige Estritori

Recent complaints reporting from Australia's financial dispute resolution system has put a practical issue back in front of workers: the value of income insurance is not only in the monthly benefit promised, but in how clearly a policy works when a claim is made. - read more

What Genetic Testing Reform Could Mean for Income Protection Applicants

05 Aug 2026: Paige Estritori

Australia’s move to restrict the use of adverse genetic test results in life insurance underwriting is an important development for people who have been hesitant to explore personal cover. While the reform is usually discussed in relation to life insurance, it also matters for income insurance because many retail policies sit within the broader life insurance framework. - read more

What a More Stable Income Protection Market Means for Your Pay Packet

29 Jul 2026: Paige Estritori

Recent APRA life insurance performance data has given the income protection sector a cautiously positive signal: the market appears to be moving through a more stable phase after several years of product redesign, pricing pressure and closer regulatory attention. For consumers, the important point is not that cover has suddenly become simple, but that insurer sustainability and claim reliability remain central to the value of any policy. - read more

Why the Simple Advice Push Matters for Your Cover

22 Jul 2026: Paige Estritori

Australia’s life insurance sector has renewed its push for consumers to receive simpler help with the cover they already hold, particularly through superannuation. The Council of Australian Life Insurers has again argued that many people need clearer, more accessible guidance about insurance inside super, including death, disability and, where available, income protection insurance. - read more

Chronic Illness Risk Puts Fresh Focus on Income Insurance

15 Jul 2026: Paige Estritori

New research highlighted by Zurich has put a timely spotlight on a major challenge for Australian workers: people are living longer, but many are also spending more of those years managing chronic health conditions. For households that rely on a regular wage, salary, business income or contract work, this trend reinforces why income insurance is not just a product for sudden accidents. - read more

Click for more Insurance News