Question 4: The proper construction of the words 'not related to' in cl 6.2(b)
34 There is no doubt that prior to becoming a member of QSuper Mr Edser suffered from a number of episodes of depression. There was extensive medical evidence before the panel about these episodes. As I have said, the battlelines were drawn over the issue of whether these events were evidence of a single underlying condition or instead unrelated events which had resolved. The panel preferred the former view. Following a review of the medical evidence it therefore said this:
The panel was satisfied the complainant had previously suffered and been diagnosed with major depression evidenced by symptoms of depression and anxiety at various times prior to the commencement of insurance coverage.
35 However, it was not enough for the panel merely to identify that Mr Edser had some pre-existing medical condition. The language of cl 6.2(b)(ii) cast upon it the burden of a answering a further question. For Mr Edser to be eligible for the TPD benefit the panel had to be satisfied that the TPD was 'not related to' the pre-existing medical condition. This required the panel to reach a view on the meaning of 'related to'. It did so, and concluded that 'if the complainant's identified pre-existing medical condition was causally or clearly connected to the complainant's TPD, clause 6.2 operated to exclude payment of his TPD benefit'.
36 Mr Edser submitted that this required him to negative the existence of any causal link between his pre-existing medical condition and his TPD. This was, he submitted, an unsound interpretation of cl 6.2(b). It was unsound because if one accepted that 'related to' implied a clear causal connection between the pre-existing condition and the TPD, the complement of that - 'not related to' - implied no clear causal connection. The key here was that the concept of no clear causal connection did not entail no causal connection at all. There remained a logical residue in the expression constituted by that class of causal connections falling short of being clear ones. In effect, Mr Edser submitted that the requirement that the TPD be 'not related to' the pre-existing medical condition did not mean that there could be no causal connection at all between the two conditions, but rather that any such connection could not be one to which the description 'clear' could appositely be applied.
37 At this point one may be tempted to ask rhetorically: why does this exercise in fine grain semantics matter? Certainly, that question occurred to me. Before turning to Mr Kelsey-Sugg's actual answer to this question on the specific facts of this case, it is convenient to begin with an example which may throw the problem at hand into clearer relief. Imagine a person with a pre-existing medical condition consisting of having only one arm. The person habitually drives their car by alternating the remaining arm between the steering wheel and the gear stick of their manual car. Whilst changing gears the person loses control of the vehicle and crashes the vehicle. A range of injuries are suffered which result in the person being TPD. In this example there is undoubtedly a causal connection between the TPD and the pre-existing medical condition. Reasonable minds may differ, however, on whether it can be said that the connection is clear one. Why precisely minds do differ on the question is itself to an extent obscure. Perhaps it is an intuitive sense that the kind of causal connection contemplated by cl 6.2(b) is one in which the causality should lie in the medical domain. Or maybe a closer examination of the facts would suggest a more exiguous connection than first appears. Here the thinking might be that although the underlying medical condition - the absence of an arm - caused the person to drive with one arm, it was not the direct cause of the accident. A further interceding event was necessary - the use of the remaining arm in a way which resulted in the loss of control of the vehicle and a set of final steps consisting of the crashing of the vehicle in such a manner as to result in injuries leading to TPD. Viewed in this way, that is as a chain of events with each link in the chain being causally indispensable, the pre-existing medical condition remains a cause of the TPD in the sense that it is a necessary although insufficient cause. Its role as a clear cause, however, is more contestable.
38 It is not necessary to resolve this conundrum. What the illustration serves to demonstrate is the nature of Mr Edser's argument. Accepting for the sake of argument that the panel's conclusion that Mr Edser had a pre-existing medical condition of depressive illness is correct, he submits that in the causal space between it and his TPD lie a series of events whose causal potency must be assayed. These events are the bullying and threats he suffered. As the panel noted, the TPD was variously diagnosed as an adjustment disorder with mixed anxiety and depressed mood, major depressive disorder and PTSD. It was impossible, so Mr Edser submits, to determine whether his pre-existing condition was a clear cause of his TPD without having some understanding of the extent of the role that the bullying and threats had played in the TPD.
39 To take an example, the bullying and threats might have been so extreme that any person, no matter how well-adjusted, would have suffered an adjustment disorder, a major depressive disorder and PTSD if exposed to them. Mr Edser's submission did not, however, depend on a thought experiment of this kind. Instead, he submitted that the evidence of one of the doctors who gave evidence to the panel made this very point. This doctor was Professor Alexander McFarlane, a Professor of Psychiatry in the School of Medicine at the University of Adelaide, who is an acknowledged expert in the field. He was retained by AFCA and asked a number of questions. One of the matters upon which he was asked to advise was:
…whether there was a relationship between the complainant's medical condition prior to the 2011 cover date and his condition in 2014 or whether they were unrelated.
40 In his report, Professor McFarlane reached the conclusion that:
…having considered the body of information provided, the episodes of depression that the complainant had experienced prior to 2011 are related to the condition that he developed and experienced in 2014. Those prior episodes influenced both the severity of his symptoms and the probability of their reoccurrence.
41 In reaching that conclusion he made this observation along the way:
The question then arises as to what the relationship is between Mr Edser's prior episodes of depression and the episode of depression he developed subsequent to this employment in November 2011. It is important to not dismiss the significance of the stressors that Mr Edser was exposed to in his employment or their capacity, independent of his prior history or vulnerability, to cause a psychiatric disorder. In this context, the word vulnerability indicates that an individual has a greater probability of developing an episode of depression due to the fact of his experiencing previous episodes of depression. In my opinion, there was a significant risk to his mental health as a consequence of the exposures that are the subject of the compensation claim arising from this period of employment beginning in 2011. In this setting risk refers to the probability that an asymptomatic individual will develop an episode of a psychiatric disorder. However, that is not the question that I have been asked to express an opinion about. The question is as to the nature of the relationship between his prior episodes or psychiatric symptomatology and his subsequent symptoms.
(Emphasis added)
42 Mr Kelsey-Sugg placed particular reliance upon the emphasised passage for two purposes. First, to demonstrate that the bullying and threats would have presented a significant risk to Mr Edser's mental health even if he had been an asymptomatic individual (I return later to the ambiguity in Professor McFarlane's use of the expression 'asymptomatic individual'). Secondly, to show that the panel had been informed of this by Professor McFarlane who nevertheless proceeded to answer the question the panel had asked him
43 The final form of Mr Edser's submission was that if the bullying and threats had themselves been sufficient to cause the TPD then this would entail that the TPD was 'not related to' his pre-existing depression. So far as the construction of cl 6.2(b) was concerned, this would be because whilst the pre-existing depression might be seen as causally connected to the TPD (as Professor McFarlane accepted) the connection was not one which was, in the requisite sense, clear. On this view, AFCA could not answer the question posed by cl 6.2(b) without also asking Professor McFarlane about the role that the threats and bullying played in the TPD because it was only by doing so that the size of the role played by the pre-existing condition could be determined.
44 Mr Kelsey-Sugg submitted that this argument was supported by the decision of Sackville J in Preston v AIA Australia Ltd [2014] NSWCA 165 at [81], where it was said that:
Without attempting an exhaustive classification, there is a third kind of case which was the subject of discussion in oral argument. An insured might suffer an accidental physical injury which is sufficient in itself to cause permanent disablement. The accident might also aggravate or activate a pre-existing condition which, independently of the direct consequences of the physical injury, is also sufficient in itself to cause total disablement. An example is an accident in which the insured suffers a serious hand injury and also a back injury which aggravates an existing back condition. Let it be assumed that each of the hand injury and the aggravated back condition is sufficient to prevent the insured working at his or her usual occupation and thus renders the insured totally disabled. In this situation, the better view is that the injury to the hand results solely and directly in total disablement and does so independently of the aggravation of the pre-existing back condition.
45 It was submitted that this was an example of a similar style of reasoning, that is to say, an example of a court having approached pre-existing medical conditions in a way which seeks to gauge their causal significance.
46 In assessing this submission it is important to keep one's eye focussed on the precise nature of the debate. That nature is framed by the question of law which has been posed. That question is Question 4 of the Amended Notice of Appeal, which is in the following terms:
4. Whether the Authority erred in law by misconstruing and/or misapplying the words 'not related to' in sub-clause 6.2(b)(ii) of the Insurance Terms, as requiring in effect that there be no 'causal nexus' between the pre-existing medical condition and the total and permanent disablement, when that was not what sub-clause 6.2(b)(ii) required.
47 So expressed, there are two contentions. The first is that the panel in fact applied a test to Mr Edser's case which required, in order for the TPD benefit to be payable under cl 6.2(b)(ii), that there should be no causal nexus between the pre-existing medical condition and the TPD. The second is that in doing so it misapplied cl 6.2(b)(ii) because the words 'not related to' did not authorise such an approach.
48 With respect to the panel, there is a degree of ambiguity in the approach that it took to the question of the requisite connection. Early in its reasons it gave some attention to the meaning of the words 'related to' in cl 6.2(b) and reached this conclusion:
In this context the panel was satisfied this intention was met if the words 'related to' were given the construction of a 'clear connection' being a 'causal nexus', rather than the wider ambit of 'any connection'.
49 It then said:
The panel therefore considered if the complainant's identified pre-existing medical condition was causally or clearly connected to the complainant's TPD, clause 6.2 operated to exclude payment of his TPD benefit.
50 These two paragraphs are inconsistent. In the first, the panel suggests that 'related to' should connote the presence of a clear connection and that the nature of the connection is a causal one. In the second paragraph, however, it says that it will be sufficient if there is a causal connection or a clear connection. The difference between the two paragraphs is that the causal connection in the second does not appear to have to be a clear one and the clear connection does not appear to have to be causal. A more generous reading of these two paragraphs is that they should be read together and as involving the application of a clear causal connection test. Doing so would avoid the apparent inconsistency between the eschewing of an 'any connection' test in the first paragraph and the imposition of a connection test in the second paragraph not tethered to notions of causation.
51 There is of course authority which counsels against reading the reasons given by administrative decision makers with an overly pedantic outlook, particularly where they comprise non-professional lawyers: Minister for Immigration and Ethnic Affairs v Wu Shan Liang (1996) 185 CLR 259 ('Wu Shan Liang') at 272 per Brennan CJ, Toohey, McHugh and Gummow JJ. If matters rested there, I would apply Wu Shan Liang and afford the panel's reasons this more generous interpretation.
52 That, however, is not the end of the matter. Subsequently in its reasons the panel made this statement:
The panel therefore accepts the complainant's TPD is clearly connected to both his vulnerabilities to and his recurrent presentations for, and diagnoses of depression and anxiety and find that 'but for' the existence of the pre-existing medical conditions, the 2012 workplace stressor may not have resulted in him becoming TPD.
53 (The reference to 'vulnerabilities' is not presently relevant and may be safely disregarded.) This passage would appear to be more consistent with the second paragraph set out above in the sense that it proceeds on the assumption that the clear connection question is not a causal one. I say that because if the panel had been applying the clear connection standard as a part of a test for causation then it would have had no need to go on to refer to the but-for standard. Put another way, if 'clear connection' connoted causation it would necessarily include a but-for element. Read that way, it would appear that the panel applied a clear connection test (not involving causation) and a separate causation standard (the but-for test) and that it found that both were satisfied. Again, however, this may be said to involve over-analysis in the Wu Shan Liang sense.
54 The last word on the topic was the panel's eventual conclusion which was couched in these terms:
Accordingly, the panel found the complainant's pre-existing medical condition and his TPD were causally or clearly connected with the meaning of clause 6.2 of the insurance terms.
55 This too utilises the language set out in the second paragraph of its introductory discussion. What test then did the panel apply? This is, at the end of the day, a question of fact. Although I am conscious of the warning in Wu Shan Liang, I do not think that in this case it would be appropriate to take the panel other than at its word. In part, this is because a construction of the panel's earlier discussion of the meaning of 'related to' as involving the postulation of a clear connection test does not gel with the later paragraphs which are not expressed that way. If I went down that path, I would not only need to construe differently the discussion of the meaning of 'related to' I would also then need to read the panel's later discussion of the facts other than in their own terms. Doing so would result in the panel's reference to the but-for test for causation being inexplicable.
56 In part my disinclination to give the panel's reasons the benefit of the doubt under Wu Shan Liang also springs from the fact that the panel was very much alive to the significance of the meaning of 'related to' and adopted an approach to it revealing considerable sophistication. So much is shown by the fact that its construction was aided by reference to case law. For example, immediately before it stated its views on the meaning of 'related to' it had said this:
While it is accepted by case law that the words' related to' can operate under a wide ambit to mean 'any connection' it has also been held by courts the words should be considered in the 'context in why they are used'. [Toohey's Ltd v Commissioner of Stamp Duties (NSW) (1961) 105 CLR 603 and Hatfield v Health Insurance Commission [1987] FCAR 462].
57 The panel accepted that cl 6.2 operated as an 'exclusionary provision'. That is, that its intention was to preclude the payment of TPD benefits where TPD was connected to a previous medical condition, the signs and symptoms of which existed prior to cover being issued. In the panel's opinion the clause operated as a 'risk management measure' given that the complainant was not required prior to the insurance commencing to make disclosures about his health or undergo any underwriting assessment.
58 One may infer, therefore, that the panel was conscious of the significance of the case law and - from a constructional point of view - the status of cl 6.2 as an exclusionary clause. This is not the handiwork of a legal ingénue. Consequently, I am not prepared to read the panel's reasons other than on their own terms. To read the reasons as if they actually said that the panel was applying a clear connection test would be an exercise in wishful thinking on my part.
59 I therefore conclude that the better reading of the panel's reasons is that it applied a two-limbed test to determine whether the words 'related to' were satisfied. This test entailed a consideration of whether: (a) there was a causal connection between Mr Edser's pre-existing medical condition and his TPD; or (b) there was a clear connection (that being one which was not causal) between the two.
60 The panel then proceeded to apply both limbs of this test to Mr Edser's case. Insofar as the first limb was applied, the panel's treatment of it is set out above and involved the application of a but-for test for causation. It appears to me that Mr Edser is essentially correct to submit that in effect this put the panel in a position where it needed to satisfy itself that there was no causal relationship between his pre-existing medical condition and the TPD. Perhaps a more precise way of putting the matter is that the panel appears to have proceeded on the basis that if the TPD would not have occurred but for the existence of his pre-existing medical condition, then it could be said that the two were related within the meaning of cl 6.2(b)(ii).
61 The next question is whether this involved a misapplication of cl 6.2(b)(ii). In my view, it did. I accept QSuper's submission that cll 6.2(b) and 6.2(c) travel together. Both require the positing of a single question: whether the TPD is related to a pre-existing medical condition. If the answer is no, then subject to its other requirements, the claim may proceed under cl 6.2(b). If the answer is yes, then subject to its other requirements, the claim may proceed under cl 6.2(c). The question in both cases is, however, the same. I do not accept Mr Edser's submission that one should attempt to interpret 'not related to' in cl 6.2(b)(ii) in isolation. There is a single question about the meaning of the term 'related to'. The answers which are received to that question then direct the decision maker down the complementary lines of inquiry in either cl 6.2(b) or cl 6.2(c).
62 The question which then arises is when is TPD 'related to' a pre-existing medical condition. This is question of construction of cl 6.2(b)(ii). The words 'related to' are elastic and, depending on context, connote a wide range of relationships of connection. As Beaumont and Lehane JJ observed in Joye v Beach Petroleum NL (1996) 67 FCR 275 at 285 of the relationship required by the words 'relates to':
..it will depend upon context whether it is necessary that the relationship be direct or substantial, or whether an indirect or less than substantial connection will suffice.
63 I pressed both parties on what they thought the standard required by 'relates to' was. For Mr Edser, Mr Kelsey-Sugg submitted that what was required was that the pre-existing medical condition be a dominant, proximate or effective cause of the TPD (T71.27-31). For QSuper, Mr Holyoak submitted that it required that there should be a clear causal relationship with the pre-existing medical condition (T43.14-15).
64 There is no evidence of what the authors of the insurance scheme intended by cl 6.2(b). However, QSuper submitted that its purpose was tolerably clear. Where members became insured without having to make an application for that insurance, the insurer (i.e. QSuper) needed for prudential reasons to reduce its exposure to pre-existing claims. Put another way, in any TPD insurance arrangement, the question of whether there are any pre-existing conditions needs to be addressed. It may be addressed, as it often is, at the inception of a contract of insurance by the putative insured disclosing to the putative insurer their medical history and the putative insurer then imposing an exclusion or adjusting the premium in some way. Alternatively, cover may be granted without any disclosure of prior conditions but on terms which limit the availability of a benefit when claims are made on the policy that arise from or are related to pre-existing medical conditions.
65 I accept that this appears most likely to be the philosophy underpinning cl 6.2. It seems tolerably clear that a relationship of mere causation in the but-for sense cannot suffice for the purposes of cl 6.2(b) and (c). For example, it would seem eccentric that an insured member who was severely injured in a car accident on the way to a consultation with a general practitioner about a pre-existing medical condition would be denied an entitlement to the TPD benefit. Yet, if 'relates to' connotes a but-for causation requirement, cl 6.2(b) would operate to deny the benefit on account of the fact that, but for the pre-existing medical condition, the TPD would not have ensued.
66 On the other hand, I do not accept Mr Kelsey-Sugg's proposal that the term 'relates to' requires the pre-existing medical condition to be the proximate, dominant or effective cause of the TPD either. This seems to be rather too much for the language of cl 6.2(b)(ii) to bear. In particular, I see nothing in its wording which indicates that cl 6.2(b)(ii) cannot operate where there are multiple non-trivial and sufficient causes of the TPD, including amongst them a pre-existing medical condition.
67 It seems to me that the most plausible interpretation of cl 6.2(b)(ii) is the one proposed by QSuper: that the connection required is one of clear causation. This standard will not be satisfied by the mere satisfaction of the but-for test. The decision maker will need to be satisfied that the pre-existing medical condition is causally connected to the TPD in a way which is clear.
68 Consequently, I accept that the panel did not correctly apply the correct causal standard. Instead, it asked itself two questions, neither of which was the correct one. It was not correct to ask whether the TPD was merely causally linked to the pre-existing medical condition because this was apt to encourage the application only of a but-for standard of causation. This risk appears, in fact, to have come to pass. Nor was it correct to ask - as the panel did - whether there was a clear connection without a causal element.
69 I would therefore allow Mr Edser's claim on the basis of Question 4 and would answer the question 'yes'. I reject QSuper's submission that the question did not involve a question of law. It involved the proper construction of the words 'relates to', which is a question of law.
70 For completeness, it will be seen that it has not been necessary to deal with Mr Edser's submission that Professor McFarlane's evidence required the conclusion that the bullying and other threats were themselves sufficient causal factors to have resulted in Mr Edser's TPD. The present appeal provides no means by which that contention could be assessed since it is not encompassed in the question posed.
71 In any event, there was other evidence before the panel on the issue cutting in both directions. Contrary to the submissions made on behalf of QSuper, I do not think that the argument advanced by Mr Kelsey-Sugg is in principle unavailable before the panel. Once a test of clear causation is applied I do not see the language of cl 6.2 as altogether ousting any contention that the effect of the bullying and threats was itself so substantial that it denied any clearly causative role to his pre-existing medical condition. It will depend on the facts. Certainly, if this argument is advanced to the panel on remitter it is a matter that it will need to address.
72 By the same token, and although I am not expressing a concluded view on the matter, there are some difficulties, surmountable perhaps, with the passage from Professor McFarlane's report upon which Mr Edser places reliance. In particular, there are two ambiguities in the report which would need to be resolved for any proper consideration of the issues which arise. The first is the Professor's reference to asymptomatic individuals. It is not clear whether by this Professor McFarlane meant persons devoid of any form of psychological disorder or whether he intended to refer to persons with an underlying condition not presently displaying symptoms. The second is that although he said that the stressors might produce psychiatric symptoms in such an individual, this does not necessarily equate to the symptoms which Mr Edser developed. Put another way, the stressors might have induced psychiatric symptoms in otherwise healthy individuals but it may not have made them TPD. In any event, the present litigation does not afford an opportunity to determine these issues.