A policyholder has lost a dispute over accident insurance due to a lack of medical evidence supporting his injury claim.

He did not meet his policy’s accident definition because there was no sudden, specific event that caused the injury, the financial services ombudsman has ruled.

In June 2024, the man bought accident-only cover with Lloyd’s. He said he injured his left shoulder in November of that year and had to stop working.

When Lloyd’s rejected his claim, he turned to the Australian Financial Complaints Authority, but the ombudsman accepts Lloyd’s argument that when an acute incident or trauma occurs, it is usually documented by treating practitioners.

In this case neither a GP nor a physiotherapist noted it.

AFCA finds the shoulder injury was not caused by an accident solely and independently of any other cause. 

The man said he was hurt while building a garden shed, but when the insurer saw his clinical records, they showed he did not report a shoulder injury. 

A physiotherapist’s notes showed treatment for symptoms in the insured’s left shoulder from July 2024, and a medico-legal consultant occupational physician concluded the injury was left shoulder impingement, a pre-existing condition related to the man’s work. 

Building the shed may have exacerbated the condition. 

The ombudsman notes the policy requires an accident that causes an injury to be “a sudden, unexpected, unusual, specific event”. 

The man worked on the shed for hours and his pain developed gradually rather than occurring in a distinct, identifiable incident. 

“This distinction is critical given the policy’s requirements.” 

AFCA says Lloyd’s did not fully manage the claim in line with its obligations and had conceded shortcomings in its claim handling, but these did not result in significant delay or cause the complainant any loss. 

Read the determination here.