The incident arose after the player suffered an injury to her left ankle, prompting an investigation that revealed an "anomalous bony structure" in her right ankle, necessitating surgery. She subsequently filed a claim for the recovery expenses under a group personal accident and illness policy arranged by Football NSW.
AIG Australia contended that the claim could not be fulfilled as the condition did not satisfy their policy's injury definition. According to the insurer, an injury had to result from "violent, external and visible means" and "occur independently from any other cause." The player's GP described the condition as a bony deformity resulting from repetitive stress related to playing football, rather than a fracture.
The player argued that the rigorous nature of playing football constituted "violent, external and visible means" and that the injury was both unforeseen and accidental. However, the Australian Financial Complaints Authority (AFCA) clarified that the policy necessitated a single, standalone event influenced by a "strong visible force, external to the insured person."
In its official ruling, AFCA concluded that the repetitive strain stemming from the football activities, developing gradually over time, did not align with the policy's injury criteria. The ruling highlighted that the condition was not a consequence of a single, isolated event nor was it caused by an external force.
The ombudsman further noted, "Given the nature of the condition, the claim could not be established within the policy's injury requirements, thereby nullifying any claimable loss by the complainant."
The resolution from AFCA underscores the importance of policyholders understanding the specific terms and definitions embedded within insurance policies to determine coverage eligibility effectively.
