Home / Daily / AFCA says injury definition 'must prevail' in dispute over hearing loss
28 April 2021
A man who experienced a large “pop” in his right ear after a shower, followed by loud continuous tinnitus and total loss of hearing in the affected ear, has lost a claim dispute with AIG.
The man lodged a claim under a policy providing benefits in cases where a person suffers permanent or total loss of various body parts. AIG declined the claim, saying the policy only responded if hearing loss resulted from an injury and in his case, there had been no injury.
The Australian Financial Complaints Authority (AFCA) agreed AIG was not liable.
“The policy only responds if the loss of hearing is from an ‘injury’ as defined,” AFCA said. “It is this term which must prevail as it is agreed to between the parties.”
The policy defined injury as “a physical injury caused by a violent, external, sudden and visible means”.
Notes from a doctor the AIG customer saw the same day the hearing loss occurred stated “sudden deafness in right ear, denies any trauma, no exposure to loud sound”. An Ear, Nose & Throat Head & Neck Surgeon diagnosed the condition as “profound idiopathic sudden sensorineural hearing loss with vertigo”.
AFCA ruled that the available information did not show the loss of hearing resulted from an insured event.
“I am not satisfied the complainant’s loss of hearing occurred from an injury as defined by the policy,” the AFCA ombudsman said. “The available information does not show it occurred from any external means.”
The man said the loss of hearing may have occurred when using a ride-on mower the day before but AFCA said the records of the doctor and surgeon made no reference to this as being a possible cause and the man’s arguments did “not assist him”.
“I agree the cause of the injury is unknown. However, I am not satisfied this provides sufficient basis to infer it must be from an injury,” the ombudsman said.
“No medical report has been provided to confirm this is plausible. The contemporaneous medical records do not support the loss of hearing was from a traumatic event or any external means.
“The insurer is entitled to deny the complainant’s claim.”
See the full ruling here.