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Insurance Disputes





Page 519

18.1 Personal accident policies involve the payment of benefit, which is usually a specified money amount, in the event of accidental injury. The question “what is an accident?” can cause some difficulty although there will be many cases where it is obvious. There may be a clause describing the circumstances giving rise to a claim, such as “bodily injury by external, visible and violent means”. That description may not particularly restrict cover. The judicial decisions on the meaning of “accidental injury” amount to much the same as the more expansive definition. There are also usually many exclusions and attempts to make it clear that disablement resulting from disease is not covered. Some of those clauses attempt to restrict cover by covering only any disablement that “results solely and independently of all other causes”. All of these issues can give rise to difficulties of interpretation in some cases. The obvious cases cause no difficulty but it is sensible to be wary of what is apparently an obvious case when the clues point at something out of the ordinary. By their very nature personal accident policies are consumer policies and therefore subject to the Ombudsman’s jurisdiction. In the circumstances the reported decisions of the Ombudsman are of some significance in determining the effect of the wording of the policy.1

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