A complainant who suffered serious injuries after falling from a horse will not receive a trauma payout after a complaints authority accepted that there was not enough evidence to prove the damage was irreversible. 

The claimant fell from the horse on October 16 last year and underwent surgery a few days afterwards to address a significant pelvic fracture. She said her ability to live her day-to-day life was significantly impacted.  

The woman has been undergoing physiotherapy and taking medication to regain her mobility, with her treating orthopaedic surgeon, referred to as Dr NJ, reporting that she has “debilitating symptoms affecting her left leg and foot”.  

Dr NJ said the claimant would continue to have such symptoms for 18 to 24 months but says a permanent diagnosis is “difficult to predict”.  

Clearview Life Assurance denied the claim on the basis that its policy’s “loss of independent existence” condition required a permanent inability for the insured to complete at least two daily tasks.  

In June, the complainant’s GP observed that the complainant required crutches to be mobile and could not complete duties such as shopping, laundry, preparing food, or cleaning the home.  

The woman also says she suffers from a loss of cognitive function and has shown no nerve recovery since the fall. She argues it would be unfair to take the view that she would improve in the future.  

The Australian Financial Complaints Authority acknowledged that the claimant had been seriously disabled but said the current medical advice indicated that she would make an eventual recovery.  

“Dr NJ is best placed to give an opinion on whether the disability is permanent, because he is a specialist and because he has been treating the complainant,” AFCA said. “He says it is ‘too early to state whether [the disability] is permanent’ and explains the further testing and treatment which is underway and planned.”  

However, the decision accepts that the insured’s condition might not improve and agrees that she would be entitled to a payment if she remained disabled.  

“It may be that she can establish, with later medical evidence, that her disability is permanent,” AFCA said. “But on the current evidence, I am not satisfied her disability is permanent or irreversible.”  

Click here for the ruling.