Queensland man fails on TPD insurance claim due to non-disclosure of medical condition

Published 26 Jul 2017

Edington v Board of Trustees of the State Public Sector Superannuation Scheme [2016] QCA 247

Background
An individual lodged a claim for a TPD benefit in 2003 after he sustained a number of physical and psychological injuries as a result of being chased by two Rottweilers.

In 2004 the claim was rejected by the Board because they found that the disablement was related to schizophrenia, a pre-existing medical condition that was not disclosed. A series of appeals occurred but the eventual material result was the upholding of the Board’s original decision.

On Appeal to the Queensland Supreme Court in 2015
Issue 1

The appellant alleged that the Board erred in evaluating competing medical opinions. However, on appeal no error was found because despite discrepancies in dates of the appellant’s history found in medical reports written by Dr Reddan, a reasonable person in the Board’s position could have accepted the reliability of the reports’ analysis.

The appellant alleged that the Board failed to make further enquiries of the psychiatrists whose opinions were before it. The appellant judge referred to Aloca which expressed that while there was a duty to give properly informed consideration to applications for entitlements and make further enquires where necessary, this does not require the endless pursuit of perfect information.[1] Upon consideration of the present facts the appellant judge decided that the Board had properly informed itself.

Issue 2

The appellant alleged that the Board breached its duty to accord him natural justice by failing to notify and give him an opportunity to make submissions on material adverse to his claim. However, the appellant judge held that the material was not cast adversely to the appellant’s claim and it was not incumbent upon the Board to have referred it to him for comment in the circumstances.

Issue 3
The third issue questioned the primary judge’s finding that the appellant had failed to establish the requisite intention to create contractual relations. However, this finding was upheld on appeal. The question of the parties’ intent was required to be considered in the context of whether an intention to enter a contractual relationship which would co-exist with the trust relationship, ought to be implied. The appeal judge also noted that even if a contractual relationship was found, it would not assist the appellant in this case because if the appellant failed to prove any breach of trust, he would have also failed to prove any breach of contract.

Conclusion
The appeal was therefore dismissed given that the appellant had not succeeded on any of the three issues that encompassed the basis of his grounds of appeal.

For applicants, this case reaffirms the legal principle that individuals should disclose their pre-existing medical conditions when taking out total and permanent disability insurance since claims can be denied on the grounds of non-disclosure of same.

This case also shows applicants that in determining the reliability of expert medical reports, minor discrepancies in facts may not be a sufficient basis to prove the unreliability of an unfavourable report.

Call Gerard Malouf & Partners on 1800 004 878 for legal assistance on a TPD claim and you can speak to an experienced lawyer in relation to your own circumstances.


[1] Aloca of Australia Retirement Plan Pty Ltd v Frost (2010) 36 VR 618.

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