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[1999] VSC 388
Supreme Court of Victoria
1999-10-15
Smith, J.
Original judgment source is linked above.
Workers Compensation - notice rejecting claim - validity of decision and notice - misstatement of evidence in reasons by insurer - capricious decision - error of fact - failure to consider relevant evidence.
"fails to comply with the provision of section 109 in that the circumstances relied upon failed to make out the grounds for rejection of the claim, and the provisions of the Act generally. . ."
"to advise that your claim for weekly payments under this Act has been rejected."
"after careful consideration of all available information, your claim was rejected as: * you did not sustain an injury within the meaning of the Accident Compensation Act 1985. * your claimed injury did not arise out of or in the course of employment. * your employment was not a significant contributing factor to the claimed injury. * your claimed injury was caused by stress of a type which does not create an entitlement to compensation under the Accident Compensation Act 1985. * your claimed injury has not resulted in an incapacity for work. * the circumstances of your claimed injury are not covered by the Accident Compensation Act 1985."
"The attached statement is part of this notice. Together they set out the reasons for the decision. It is important that you read the two documents carefully."
The notice then set out the options available to Ms Brewster.
"It was his opinion that: "She gave a complex history. She and her husband ran the Anglers Tavern for eight and a half years and were declared bankrupt in 1996. She was depressed some time after this. She was offered a job at the Bundoora Hotel which was owned at one time by her father. During this time she had an operation on her ribs. It was thought that she had a malignancy. Her ribs biopsy showed osteo-sclerotic change of unknown cause. At the same time her husband was having cardiac problems and since had coronary artery bypass surgery. Meanwhile, the licensee who co-owned the hotel would not pay her nephew who also works there. Her father died in 1995. Following the bankruptcy in 1996, she lost the family home. It is therefore considered that your employment was not a significant contributing factor. "
The last sentence was included as set out above in the paragraph which purported to be a quote from a report of Dr Grainger-Smith. In the text of the statement of the reasons of FAI it was not given its own concluding quotation mark.
"On 8 January, 1997, we requested that you provide a medical report to be taken into consideration when making this decision. You have not responded to this request. All available information, including medical evidence relating to your claim support the view that you do not have an entitlement to compensation."
"I believe that her work at the Bundoora Hotel was a significant contributing factor in the causation of her present illness."
"It is therefore considered that your employment was not a significant contributor."
in its own terms, was not the opinion of the doctor but the opinion of the author of the document. Counsel submitted that it may have been misleading but it was not intended as deception. In discussion with the learned Magistrate, however, counsel, conceded that the statement was grossly misleading.
". . . a travesty, it being such a gross misrepresentation of the truth. I am not saying there is fraud; of course I am not saying that. It is a big step to go that far, but it is a gross misrepresentation of the medical report, and if such was allowed to constitute a valid notice within the meaning of 109 (2), it would open all sorts of watersheds and gates really you would have a gradual drifting away from the values of the notice."
". . . I am going to hold that there is a deemed acceptance - there is no notice and there is a deemed acceptance of the claim. In other words the matter will proceed as if no notice was given within the time limit of 28 days."
Thus, his Worship found that the notice of objection was not a proper notice within the meaning of the Statute because it was a gross misrepresentation of the medical evidence. In an earlier passage his Worship explained his thinking as follows -
"I would interpret sub-s. (2) myself, but the notice that must include a statement of the reasons must be an accurate statement of the reasons. Now, they're not an accurate statement of the reasons, and they're manifestly inaccurate, and therefore as presently minded, I would rule the way that Mr Blackburn has in a sense put it; not that there was fraud but the notice was not within the meaning of the statute of proper notice."
He held that the notice was invalid. He also held that section 109 of the Act operated to bring about a deemed acceptance of the claim because no valid notice of rejection had been given. He held that orders should, therefore, be made in favour of Ms Brewster. The orders he made reflected what he saw as the normal consequences that would flow from acceptance of the claim.
"109. Responsibilities of authorised insurers and the Authority
(1) If an authorised insurer, the Authority or a self insurer does not give written notice of a decision to accept or reject a claim for weekly payments within 28 days of receiving the claim -
(a) the claim is deemed to have been accepted;
and
(b) the authorised insurer, the Authority or a self insurer must pay weekly payments to the worker subject to and in accordance with this Part.
(ii) The written notice of a decision to accept or reject a claim for weekly payments must in the case of a decision to reject the claim include a statement of the reasons for the decision.
(iii) A decision or deemed decision under this section is binding on the employer in respect of the employer's liability under the employer's excess."
"(a) That the learned Magistrate erred in law in holding that the rejection of claim notice dated 8 January 1998 given pursuant to section 109 of the Accident Compensation Act 1985 was invalid, or otherwise ineffective.
(b) Whether the learned Magistrate erred in law in holding that because of an irregularity in the said notice (constituted by the typographic layout of the quote from the opinion of Dr Paul Grainger-Smith contained on the first page of the said notice), there was no written notice of rejection given in accordance with section 109 of the Accident Compensation Act 1985.
(c) Whether the learned Magistrate erred in law in holding that because of an irregularity in the said notice (constituted by the typographic layout of the quote from the opinion of Mr Paul Grainger-Smith contained in the first page of the said notice), the claim was deemed to be accepted in accordance with section 109 (1) (a) of the Accident Compensation Act 1985.
(d) Whether the learned Magistrate erred in law in holding that once there was a deemed acceptance in accordance with section 109 (1) (a), the worker was ipso facto, entitled to an immediate order for arrears or weekly payments of compensation up to the date of hearing and continuing, without any requirement to establish by evidence that she was otherwise entitled to such compensation in accordance with the Accident Compensation Act 1985."
* written notice of the decision to accept or reject within 28 days of receiving the claim (section 109 (1) ),
* written notice to include a statement of reasons for the decision (section 109 (2) ), and
* the written notice to include a statement of rights of conciliation and review (section 123A).
He submitted that all these requirements were met and that the Act did not contain any other statutory requirements either expressly or by implication. In particular, he submitted that there was no statutory obligation express or implied that the reasons as set out in the notice should be capable of being objectively substantiated or, still less, that any factual assertion in the reasons must not be misleading. He submitted that the requirements of the Act were satisfied even if the reasons given could not be objectively substantiated or were in fact misleading as to any matter of fact stated in them.
"misdirected and that inaccuracy in my view renders it defective and of no effect. Accordingly the defendant has not complied with the requirements of section 109."
His Honour ordered the defendant to pay weekly payments. Thus, while this decision supports an approach that would allow an order for weekly payments where there is a deemed acceptance of the claim, it differs from the present case where there is no doubt that the notice of rejection was directed to the claim. In Pintar, the notice was not directed to the claim and, therefore, there was no notice of rejection that was relevant.
"Whatever the position may be prior to a determination by the court, once the court determines that the plaintiff has no entitlement, the plaintiff is not entitled to receive unpaid weekly compensation pursuant to section 109(11)."
"(11) If the authorised insurer or a self-insurer does not accept or reject a claim within the relevant periods specified in this section, the claim shall be deemed to have been accepted and the authorised insurer or self-insurer must pay weekly payments to the worker subject to and in accordance with this Part."
The drafting of the sub-section lent itself to an argument that the deemed acceptance was also "subject to ... this Part." The present equivalent makes it clear that the phrase applies to the payment of weekly payments not the deemed acceptance.
"I am satisfied that the clear intention of the legislature was that persons such as the present plaintiff who have been in the receipt of weekly payments for a lengthy period would be served with an appropriate notice under s.112 (1,2,3, & 6) and s.123A. It was not the intention of the legislator that such a person would have payments simply stopped without notice. It was also the intention of the legislature that payments were not to be stopped unless the VWA or authorised insurer had followed appropriate procedures and made decisions based on proper material. It would for example be unthinkable that a notice could be given when no assessment on the issue of "a serious injury" had been made by a medical practitioner or when an assessment had in fact been made which resulted in a level of impairment of 30% or more."
I agree that such actions would be unthinkable and would be contrary to the intentions of the parliament under the present Act. His Honour, however, did not explore the legal consequences of circumstances where there was no assessment on the issue of "a serious injury" or where an assessment was made of no serious injury notwithstanding a level of impairment of 30% or more. That was the nature of the task that was before the learned Magistrate in the present case.
"What factors a decision-maker is bound to consider in making the decision is determined by construction of the statute conferring the discretion. If the statute expressly states the considerations to be taken into account, it will often be necessary for the Court to decide whether those enumerated factors are exhaustive or merely inclusive. If the relevant factors - and in this context I use this expression to refer to the factors which the decision-maker is bound to consider - are not expressly stated, they must be determined by implication from the subject matter, scope and purpose of the Act. In the context of judicial review on the ground of taking into account irrelevant considerations, this Court has held that, where a statute confers a discretion which in its terms is unconfined, the factors that may be taken into account in the exercise of the discretion are similarly unconfined, except in so far as there may be found in the subject-matter, scope and purpose of the statute some implied limitation on the factors to which the decision-maker may legitimately have regard: . . . "
"material defect, omission or irregularity, will be deemed not to have been made if the claim is returned within 14 days of being served to the claimant with a notice under sub-section (3) [specifying material defects]."
Section 105 deals with medical certificates required to accompany a claim for compensation. Sub-section (2) provides
"(2) A certificate issued or purporting to have been issued under sub-section (1) is of no effect if it contains a material defect, omission or irregularity."
FAI Workers' Compensation (Vic) Pty Ltd
Brewster [1999] VSC 388
(1994) 55 FCR 439