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A man who suffered 89% blindness in his right eye in an accident during a taxi driving shift has won a claim dispute and a $250,000 payout.

The worker was a beneficiary of his employers Taxi Personal Accident policy, held with Lloyds Australia, for drivers of insured vehicles.

It covered accidents causing death, partial or total disablement of limbs or eyesight sustained during working hours while you are driving a taxi that is listed in the policy schedule.

It included time limitations that provided a claim would only be paid if you suffer Temporary Total Disablement within twelve months of the date of the accident occurring, and such Temporary Total Disablement lasts for twelve months.

The driver lodged a claim after sustaining serious damage to his eye during a work shift in August 2018 when he was struck in the face by a rock thrown through his car window.

Medical experts in Australia and overseas all found the damage was permanent. No treatment options were recommended and the medical evidence indicated his eye sight was likely to deteriorate further in time.

Lloyds settled weekly temporary disablement benefits until he regained employment but denied a claim for lump sum benefit for total loss of sight in one eye, saying his impairment - at 89% loss of sight - did not constitute a total loss of sight.

Lloyds said other policies on the market offered a percentage of benefits for partial loss of sight and provided examples, whereas the taxi drivers policy had no such scope. Lloyds said the only way the lump sum benefit was payable is if the loss of sight was 100% in or around August 2019 being within 12 months of the injury. As the loss of sight was not 100% in August 2019, then it was not liable.

The man took the matter to the Australian Financial Complaints Authority (AFCA), arguing he had effectively lost all eyesight in his right eye.

AFCA determined Lloyds was liable to pay $234,434 - the lump sum benefit of $250,000 less the $15,566 temporary disablement benefits already paid.

The available medical evidence demonstrates that, due to the accident, he no longer has any effective eyesight in his right eye, AFCA said. It is fair in the circumstances to determine the complainant has suffered a total loss of sight in his right eye.

AFCA said the policy did not define total loss and the Certificate of Insurance provides that should any ambiguity exist in the clauses they will be interpreted in favour of the insured.

In November 2018, the taxi driver was examined by an ophthalmology registrar in hospital who determined he had permanent and irreversible central macular damage and his visual acuity due to the accident was 6/60, which is legally blind.

Neither pinhole or corrective lenses improved his sight.

The taxi driver then travelled overseas where he obtained the opinion of another ophthalmologist to try and find some treatment options. A December 2018 report from that consultation stated the damage to the right eye was permanent, irreversible and likely to deteriorate.

Lloyds later engaged a consultant ophthalmologist who said that while the driver had a severe visual defect in his right eye, the injury did not constitute a total loss of vision.

The man obtained a further medical opinion because he believed his sight was worsening but Lloyds said it could not consider that as total loss of sight must be within 12 months of the loss.

The panel disagrees with the insurers interpretation of the limitation periods in the policy, AFCA said.

The man was unsuccessful in his attempt to recoup around $20,000 spent travelling overseas to obtain the second medical opinion for possible treatment options.

See the full ruling here.

See the article here:
Taxi driver struck in the eye by a rock wins insurance payout - Daily - Insurance News

This entry was posted on November 25, 2020 at 10:52 pm and is filed under Eye Sight & Vision. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed. |