Sports Injury Claims Example

Below is a basic example of the benefits that can be claimed under the policy and the process in order to claim.

Kathryn was competing at a local show jumping event when her horse refused a fence, resulting in a fall and suspected leg injuries. An ambulance was called and she was transported to the local hospital where she was given something for her pain and sent home.  After being in extreme discomfort that night Kathryn visited her local GP the next morning who gave her some pain relief, a certificate stating she was not fit to work for one week and referred her to a specialist.  Kathryn made an appointment with the specialist for the following week, where an X-Ray was ordered, revealing a fractured tibia that would require surgery. As Kathryn was unable to work due to her injury she arranged for the surgery to be performed the following Thursday.  The specialist provided an unfit for work certificate for an additional 4 weeks.  Her operation was successful and she started on a course of physiotherapy and was able to return to work 12 weeks after the injury.  Kathryn was earning an average weekly wage of $600 per week.

Kathryn completed a ‘PA Claim Form – Member’ two days after her injury, had her employer complete the employer’s statement, and sent the claim form off to Gow-Gates who recorded the claim.  Gow-Gates acknowledged Kathryn’s claim and provided her with the contact details of the Insurer’s claims administrator.  At the time of visiting the specialist Kathryn had the ‘Medical Report’ section completed and this was sent off to the claims administrator, as per the contact details provided by Gow-Gates, together with ‘unfit for work’ certificates. Following payment of the medical expenses Kathryn sent the receipts and additional ‘unfit for work’ certificates to the claims administrator.

The claim was settled by the Insurer as follows –

Private Practitioner Visit Scheduled amount covered by Medicare
(*Gap not covered)
Specialist Surgeon Scheduled amount covered by Medicare
(*Gap not covered)
X-Ray Scheduled amount covered by Medicare
(*Gap not covered)
Anaesthetist Scheduled amount covered by Medicare
(*Gap not covered)
Private Hospital accommodation 3 days @ $420 $1,260.00
Theatre Costs $ 600.00
Ambulance Cost $ 300.00
Sub Total $2,160.00
Total Non-Medicare Expenses Benefit payable 85% $1,836.00
Plus Physiotherapy benefits
Physiotherapy – 5 visits @ $40 per visit @95% for each visit – $190.00
Less Excess $100.00
TOTAL MEDICAL EXPENSES PAID $1,926.00
Plus Weekly Benefit
Loss of income 12 weeks @$600 per week
(14 days excess applies, $500 per week maximum applies)
$5,000.00
TOTAL CLAIM PAYMENT $6,926.00

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