Prima facie case
20 The applicant submitted that its amended statement of claim combined with the documents annexed to the Silva affidavits established a prima facie case. The principles for determining whether there is a prima facie case for the purposes of r 10.43(4)(c) were summarised by Edelman J in Kadam [2016] FCA 1343 at [53]-[54]:
Finally, as to r 10.43(4)(c), the test for a prima facie case is well established. It is satisfied if, on the material before the Court, inferences are open which, if translated into findings of fact, would support the relief claimed: Perdaman Chemicals and Fertilisers Pty Ltd v ICICI Bank Ltd [2013] FCA 175 [58] (McKerracher J); Western Australia v Vetter Trittler Pty Ltd (in liq) (1991) 30 FCR 102, 110 (French J); Ho v Akai Pty Ltd (in liquidation) [2006] FCAFC 159; (2006) 24 ACLC 1,526, 1,529 [10] (the Court).
The approach to whether there is a prima facie case "should not call for a substantial inquiry": Ho v Akai, 1,529 [10] (the Court); WSGAL Pty Ltd v Trade Practices Commission (1992) 39 FCR 472, 476 (Beaumont J); Sydbank Soenderjylland A/S v Bannerton Holdings Pty Ltd (1996) 68 FCR 539, 549 (the Court).
21 The causes of action pleaded against the respondent require the applicant to prove:
(1) that the applicant and respondent had entered into a contract of life insurance that included the "Disability Income Plan";
(2) that to obtain the benefits under the "Disability Income Plan" the respondent was required to be suffering from a "Total Disablement";
(3) that a "Total Disablement" was defined under the policy as meaning that the respondent was:
(a) unable to perform one of the important duties of his occupation (as an anaesthetic nurse) that he must be able to perform to earn an income; and
(b) was following the advice of a medical practitioner; and
(c) was not working.
(4) that the applicant lodged claims with the applicant seeking the monthly benefit under the "Disability Income Plan" over the period February 2016 to October 2016;
(5) that in those claims the respondent falsely and/or fraudulently represented to the applicant that he suffered from a "Total Disablement" within the meaning of the policy, had suffered from it since 2002, did not perform duties of any other occupation (paid or unpaid) during the claim period, did not have a return to work plan, that there were daily restrictions upon him that prevented him from performing the usual duties of his occupation and that the information on the claim form was true, correct and complete;
(6) at the time of making these claims, the respondent was, contrary to these representations, intending to perform or performing the duties of another occupation and was capable of performing the duties of his usual occupation; and
(7) that the applicant believed the respondent was thus suffering under a "Total Disablement" within the meaning of the policy.
22 The evidence filed in support of these allegations was as follows. Annexure O of the Silva affidavit of 30 January 2017 consists of the contract documents. These include a letter confirming the respondent's purchase of the policy and the policy terms. The "Priority Protection Policy Schedule" states that the insurance cover includes "Disability Income". In clause 2 of the "Policy Terms and Conditions" also contained within that annexure "Total Disablement" is defined as pleaded by the applicant. The terms of the "Disability Income Plan" are in clause 6 of the "Policy Terms and Conditions". Clause 6 states that a "Total Disablement Benefit" is included in the "Disability Income Plan".
23 Also annexed to that affidavit, as Annexure P, are the claim documents alleged to have been submitted by the respondent over the course of 2016. These provide support for the applicant's allegations in regard to the representations allegedly made by the applicant. In these claim documents, the respondent states that he does not have a return to work plan and is unable to perform his occupation, though might if his health improves. He also states that he is unable to perform "all" duties of his usual occupation due to "pain, stiffness and depression". He states "pain, stiffness and depression" to be daily restrictions upon his ability to work. He also ticked a box confirming that his "continued Total Disablement" was "due solely and directly to [his] injury/sickness". The period of total disablement was stated to be from 2002 to present. The respondent also declared at the bottom of each claim form that all information in the form was "true, correct and complete".
24 In order to demonstrate the respondent's representations to be false, the applicant annexed to the 30 January affidavit, as Annexure Q, surveillance reports obtained by its investigators in Riga and Stockholm. These reports included photographs, emails and text messages. They demonstrate a person, alleged to be the applicant, performing acupuncture and, importantly, appearing to operate an acupuncture business. Further, in Annexure I of the 30 January affidavit there is correspondence from the respondent where he states:
Yes the information is true. I am doing some acupuncture treatments. But not able to this as a full career but as a step back into the workplace.
25 The surveillance evidence and correspondence from the respondent appears to indicate that he was performing another job. An inference could then be drawn that he was capable of performing his original occupation and that he was working at the time of making the claims. If this evidence is not contradicted, these inferences could be translated into factual findings that the representations made by the respondent as to his alleged disablement were false and that the respondent was not suffering from a "Total Disablement" within the meaning of the policy at the time. Such findings would support the relief claimed. Accordingly, I am satisfied that the material before the Court establishes a prima facie case in respect of the matters alleged by the respondent in its amended statement of claim. The requirement in r 10.43(4)(c) is therefore satisfied.