Horse Accident Claim Rejected: A Deeper Look into Trauma Insurance

3

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
Source: Paige Estritori

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Clear

AFCA Upholds Policyholder's Income Protection Benefits Against Zurich

12 Feb 2026: Paige Estritori

The Australian Financial Complaints Authority (AFCA) has recently ruled against Zurich Insurance, instructing the insurer to maintain the current income protection benefits for a policyholder after an 11-year delay in proposing a reduction. This decision underscores the critical importance of timely and transparent communication between insurers and their clients. - read more

Neos Recognized as Leading Income Protection Insurer in 2025

12 Feb 2026: Paige Estritori

In the 2025 Life Insurance Awards presented by Money Magazine, Neos has been honored as the top provider in the Income Protection Insurance category. This accolade reflects Neos's commitment to delivering comprehensive and reliable income protection solutions to Australians. - read more

TAL's Health Sense Plus Now Covers Income Protection Policies

04 Feb 2026: Paige Estritori

In a significant development for policyholders, TAL has expanded its Health Sense Plus program to encompass income protection (IP) policies. This initiative, effective from August 8, 2025, aims to incentivise proactive health management by offering premium discounts to clients who engage in preventative health checks. - read more

Surge in Mental Health Claims Puts Pressure on Australia's Insurance Industry

04 Feb 2026: Paige Estritori

Australia's insurance sector is facing unprecedented challenges as mental health conditions have become the leading cause of total and permanent disability (TPD) claims. Recent data from the Council of Australian Life Insurers (CALI) reveals that mental health issues now account for nearly one-third of all TPD claims paid out. - read more

Rest Super Faces Class Action Over Alleged Wrongful Deduction of Income Protection Premiums

04 Feb 2026: Paige Estritori

Shine Lawyers has initiated class action proceedings in the Federal Court against Rest Superannuation, alleging that the fund wrongfully deducted income protection premiums from members' accounts between December 2008 and June 2019. The lawsuit claims that up to 500,000 Rest members may have been affected by these deductions. - read more

TAL's Health Sense Plus Now Covers Income Protection Policies

27 Jan 2026: Paige Estritori

In a strategic move to enhance the value of its offerings, TAL has announced the expansion of its Health Sense Plus program to encompass income protection insurance. This initiative, effective from 8 August 2025, aims to incentivise proactive health management among policyholders by providing premium discounts. - read more

Click for more Insurance News