C. PARTICULARS
40Section 85 provides:
"85 Duty of claimant to co-operate with other party
(cf s 48 MAA)
(1) A claimant must co-operate fully in respect of the claim with the person against whom the claim is made and the person's insurer for the purpose of giving the person and the insurer sufficient information:
(a) to be satisfied as to the validity of the claim and, in particular, to assess whether the claim or any part of the claim may be fraudulent, and
(b) to be able to make an early assessment of liability, and
(c) to be able to make an informed offer of settlement.
(2) In particular, the claimant must comply with any reasonable request by the other party or the other party's insurer:
(a) to furnish specified information (in addition to the information furnished in the claim form) or to produce specified documents or records, or
(b) to provide a photograph of and evidence as to the identity of the claimant.
(3) The reasonableness of a request may be assessed having regard to criteria including the following:
(a) the amount of time the claimant needs to comply with the request,
(b) whether the information sought is cogent and relevant to a determination of liability or quantum of loss, having regard to the nature of the claim,
(c) the amount of information which has already been supplied to or is available to an insurer to enable liability and quantum of loss to be assessed and an offer of settlement made,
(d) how onerous it will be for the claimant to comply with the request,
(e) whether the information is privileged,
(f) whether the information sought is sufficiently specified,
(g) the time of the request and whether the claimant will be delayed in commencing proceedings by complying with the request.
(4) The duty under this section applies only until court proceedings are commenced in respect of the claim but if the claimant fails without reasonable excuse to comply with this section, court proceedings cannot be commenced in respect of the claim while the failure continues."
41Section 85(1) identifies three purposes for the information required. Only the third, though, has any significance in the present application. AAMI did not rely upon any inability to assess liability or any inability to determine whether the claim was fraudulent. In any event, the claim form itself appears to me to provide sufficient detail to enable the insurer to assess liability and the genuineness of the claim.
42It appears that little, if any, attention was paid by the insurer to the information supplied with the claim. It included the following material:
"25 What are your injuries from the accident? (List all injuries and affected areas of the body, e.g. fracture to left leg and neck strain)
[handwriting] Neck pain. Lower Back pain sometime extreme pain to lower back caused by disc protrusion of lower back at L2, L3, L4 and minor at L5. Post traumatic stress disorder causing insomnia, anger, anxiety, nervousness, etc.
26 How do the injuries affect you now? (The effect of your injuries may change over time, e.g. have to use crutches and wear neck brace)
[handwriting] I have constant lower back pain which prevents me from doing most activities and those that I can do, I can only do for a short time. This includes such simple activities such as sitting down for more than 5 minutes ... it makes it very difficult and painful to complete normal household duties such as cleaning, lawn mowing and playing with my children. At times the pain is so severe I cannot move at all. I suffer from insomnia that causes me to wake all through the night and it is difficult to actually get to sleep. I am on medication to try and assist my sleep. I am extremely nervous when my family travels in cars especially when I am not driving. I am also very anxious in a car when I am not driving. Being seated in a veh for any extended period leaves me with a sore back. I find that I break down a cry when I think about my difficulties and this is all the time. I am overprotective of my family now and this leads to household tension and I get extremely angry at the most minor thing. None of these injuries, pain or emotional issues were present prior to this incident." [sic]
43Notwithstanding this information, the first two requests by AAMI that it asserts were both reasonable and not adequately answered are:
"1. Nature and extent of all injuries sustained by the claimant in the accident.
2. What continuing or permanent disabilities are alleged?"
44This request was made within six months of the claim form being submitted. Plainly this is "information which has already been supplied" under s 85(3)(c), which is part of the statutory criteria for assessing whether the request is reasonable.
45In my view, it is not reasonable for an insurer to make a request for information already supplied by the claimant, at least in circumstances where the insurer does not identify the inadequacy of the provided information. That was not done here. Nor do I think that there was any inadequacy in that information supplied.
46AAMI read unpaginated affidavits comprising about 300 pages of material, all but five pages of which comprised annexed documentary material. About 280 pages of that material was not the subject of any reference in submissions. Yet those pages comprised information supplied to AAMI, in the possession of AAMI or available to AAMI. AAMI's answer to this material was to submit that it was for the claimant to disprove the reasonableness of the request and to complain when the claimant sought to address the relevant factors listed in s 85(3) by means of a schedule served during the application.
47Generally, a party who applies for an order must prove the entitlement to that relief: "He who asserts must prove" (Currie v Dempsey (1967) 69 SR (NSW) 116 at 125; 86 WN (Pt 2) (NSW) 460 at 468). To prove a failure to comply with a duty in s 85(1) and (2) the insurer must prove, first, a request, secondly, that the request is reasonable having regard to the s 85(3) factors, and, thirdly, that the claimant has failed to comply with the request. Only then does the question of reasonable excuse for the failure under s 85(4) arise. My inclination is that reasonable excuse is a matter for the claimant to prove. At least, the claimant would need to raise an excuse that can be assessed as reasonable or otherwise. But the applicant insurer needs to prove the three matters listed above: a request, that is reasonable, with which there was no compliance.
48In any event, I do not regard the onus of proof as being determinative in this matter.
49AAMI sought particulars in a letter dated 5 April 2012 and received a response dated 5 February 2013. On 8 February 2013, AAMI wrote as follows:
"We refer to your correspondence of 5 February 2013 and thank you for your response.
We confirm however that a number of Section 85A Particulars remain outstanding which we outline as follows:
1. Nature and extent of all injuries sustained by the claimant in the accident.
2. What continuing or permanent disabilities are alleged?
3. Please particularise all impairments.
4. Please also let us know if the claimant contends that he exceeds the s 131 threshold? If so, on what basis.
5. Please specify the specialities of all further experts that the claimant intends to qualify or rely upon.
6. Full itemised particulars of all out of pocket expenses claimed. (Please provide names of providers together with amounts). Please advise the total sum claimed.
7. Particularise any claim made by the claimant in relation to future out of pocket expenses advising the type of out of pocket expenses claimed into the future, the duration over which such out of pocket expenses are claimed and the cost of such out of pocket expenses. Please advise the total sum claimed.
8. Please quantify any claim for loss of earnings to date.
9. Please particularise any other claims for damages arising from the subject accident.
10. Please provide copies of the claimant's tax returns for the three financial years preceding the accident to date as well as notices of assessment issued by the Australian Taxation Office for those years.
11. Please let us have a copy of the most recent Medicare History Statement.
12. Please have your client execute and return the enclosed authorities to Collarenebri, Walgett and Maclean Hospitals.
13. With respect to your response at Point 14, please also provide the name and address of all medical practitioners, therapists and hospitals the claimant attended upon in relation to the work incident in around 2004 when he experienced back pain.
We refer you to Section 85(4) of the Act and look forward to receiving the requested particulars in the near future."
50This was the only outstanding request as at 18 February 2013 when proceedings were commenced and in my view, should be taken to record the matters that remained of concern to AAMI.
51Although AAMI refrained from considering each of these numbered questions individually against the s 85(3) factors, the claimant has sought to do so by the schedule to which I earlier referred. I invited AAMI to answer the schedule either orally, or in writing within two and a half days. That opportunity was declined.
52AAMI faces two initial difficulties. First, AAMI submitted that the claimant was not entitled to commence proceedings because s 85(4) provides that, "court proceedings cannot be commenced in respect of the claim while the failure continues". AAMI submitted that this failure has existed at all times since April 2012. Yet on 22 November 2012 AAMI served a s 110 notice. Section 110 provides:
"110 Insurer may require claimant to commence court proceedings
(cf s 52B)
(1) The insurer of a person against whom a claim is made may give the claimant notice requiring the claimant to commence court proceedings in respect of the claim if:
(a) the claimant has been entitled to commence the proceedings for a period of at least 6 months, and
(b) at least 18 months have elapsed since the date of the motor accident to which the claim relates.
(2) The claimant must comply with the notice within 3 months after its receipt.
(3) If the claimant does not comply with the notice as required by this section, the claimant is taken to have withdrawn the claim.
(4) A claimant whose claim is taken to have been withdrawn by the operation of this section may apply to a court of competent jurisdiction for reinstatement of the claim.
(5) The court may reinstate the claim if the court is satisfied that the claimant has a full and satisfactory explanation for the failure to comply with the notice."
53In my view, a notice under this section (at least if it is valid) unequivocally asserts an entitlement in the claimant to bring a claim. When asked about validity, AAMI by its counsel declined to regard the s 110 notice as invalid. But invalidity must follow from s 110(1)(a) if the claimant was not entitled to bring a claim because of the effect of s 85(4).
54The proper conclusion is that the s 110 notice operated to waive any outstanding particulars entitling AAMI to rely upon s 85(4). AAMI has elected to remove any disqualification on commencement by compelling the claimant to commence. Having told the claimant it was entitled to commence and compelling it to do so, it cannot be heard to say that the claimant was not entitled to commence.
55The claimant principally relied upon the s 110 notice as a "reasonable excuse" under s 85(4), if an excuse were needed. I accept that submission. But s 110 also operates to remove any inability in the claimant to commence proceedings by reason of the outstanding particulars.
56In circumstances where the claimant is compelled to commence proceedings by 22 February 2012 in accordance with the s 110 notice, I do not regard a request for particulars on 8 February 2013 attempting to preclude commencement of proceedings under s 85(4) as reasonable. This intent of AAMI is made reasonably plain by letter dated 29 January 2013, which states:
"Further to the s 110 notice dated 2 November 2012 served upon your office on 23 November 2012, we would also be grateful if you would ensure the particulars requested on 5 April and 12 June 2012 are provided in advance of the commencement of proceedings, as required by s 85, if the matter is to be pursued."
57If the s 110 notice did not waive any entitlement to outstanding particulars then the claimant would be left somewhere between Scylla and Charybdis: unable to commence because of s 85, but compelled to commence by s 110. This cannot be right. In my view, the service of the s 110 notice operated as an abandonment by AAMI of any entitlements it had under s 85. I note that once proceedings are commenced no duty under s 85 continues, by reason of s 85(4).
58The second initial difficulty faced by AAMI is that the request on 8 February 2013 did not purport to rely on s 85 but s 85A. Section 85A provides:
"85A Duty of claimant to provide relevant particulars of claim
(1) A claimant must provide the insurer of the person against whom the claim is made with all relevant particulars about the claim as expeditiously as possible after the claim is made.
(2) The Authority may approve a form to be completed by claimants in connection with the provision of particulars in compliance with this section.
(3) For the purposes of this section, relevant particulars about a claim are full details of:
(a) the injuries sustained by the claimant in the motor accident, and
(b) all disabilities and impairments arising from those injuries, and
(c) any economic losses and other losses that are being claimed as damages,
sufficient to enable the insurer, as far as practicable, to make a proper assessment of the claimant's full entitlement to damages."
59The purpose of this provision is to enable "proper assessment of the claimant's full entitlement to damages" and is different from the purposes for the information sought in s 85 as listed in ss 85(1)(a), (b) and (c). More importantly, a breach of s 85A does not expressly preclude commencement of the proceedings, unlike s 85(4).
60AAMI does not rely on any breach of s 85A as justifying the orders sought.
61I note that AAMI refers to s 85(4) at the conclusion of its letter dated 8 February 2013. To the extent that this reference indicates reliance on s 85(4) it manifests a misunderstanding of the impact of s 85A. Properly read the letter of 8 February 2013 does not seek to controvert the impact of the s 110 notice by precluding the commencement of proceedings because it is expressly confined to "Section 85A Particulars" rather than s 85. The reliance on s 85 in earlier letters does not overcome this difficulty given that the earlier letters all precede the claimant's response on 5 February 2013.
62Accordingly, I regard the request dated 8 February 2013 as the only outstanding request prior to the proceedings being commenced. I also regard it, as it states expressly, as a request under s 85A and not s 85. AAMI does not, as I said, rely on any breach of s 85A, but asks me to ignore the express reference to 85A. I do not think there is any basis for me to do so.
63Also, the terms of the letter dated 8 February 2013 indicate that it subsumes previous requests.
64For these reasons, I reject the application under s 85.
65However, in case I am wrong I propose to make some comments about the particular requests, quoted above, and ignore for this purpose both the reference to s 85A in the request and the election inherent in the s 110 notice.
66I have already dealt with, effectively, the first three requests, which I find to be unreasonable because they are already answered by the claim form. By the schedule attached to his submissions, the claimant also referred to further material in the evidence which was in the possession or available to AAMI which would add to the unreasonableness of those requests.
67Further, I reject any entitlement in AAMI to ask, as in question 5, for the specialities of all medico-legal experts. That is a matter of privilege, a relevant factor identified in s 85(1)(e). Nor can it be reasonable for AAMI prior to the proceedings being commenced to know of decisions to be made by the claimant shortly before or during the trial. The claimant in this case had identified all 11 of his treating doctors and their specialities in the claim form provided to AAMI.
68AAMI also relied on requests numbered 4 and 7 to which similar requests had been answered, "To be advised". The claimant submits that it could not answer the questions about the s 131 threshold until further expert assessment had taken place. As the claimant's letter of 5 February 2013 had stated, AAMI did not dispute this proposition and I am inclined to accept it. I am also not persuaded that a request about whether the claimant "contends" something about his injuries is properly information falling within s 85, but if it does I am persuaded that the claimant has established a reasonable excuse.
69The claimant was asked about future out-of-pocket expenses claimed. This seems to me to be onerous under s 85(3)(d) (see also (a) and (g)). Until such time as the claimant has completed all medical assessments, at least, and perhaps until he has actually incurred the expenses, he cannot provide details of expenses. How else can they properly be described as "out-of-pockets"? Further, the length of time needed to comply with this request becomes more significant when the s 110 notice was close to expiry. For these reasons, I do not regard this request as reasonable.
70In relation to the loss of earnings and other damages to date, the claimant responded on 5 February 2013:
"During the 2009/2010 financial year, the claimant earned the sum of $68,333.00 net or $1314.00 per week. He off work totally unfit [sic] until mid January 2011, at which time he resumed working in a variety of restricted hours and duties as dictated by his medical condition. During his periods of total and partial incapacity, the claimant received various payments of workers compensation from Employers Mutual Limited claim reference number 770519083607. A list of those payments has been requested (3 December 2012) and will be supplied upon receipt.
The claimant also claims the sum paid by way of weekly payments by Employers Mutual Limited from 11 November 2010 until trial. In addition the claimant also claims any tax deducted by Employers Mutual Limited pursuant to the principal [sic] of Fox v Wood. The claimant also claims loss of his superannuation entitlements at 9% of the net past loss pursuant to the Superannuation Guarantee Legislation.
9. Future Economic Loss - $1290.00 per week for 21 years - (5% multiplier 685.6 less 15% for vicissitudes) = $751,76100.
The claimant's future economic loss is calculated on the basis of the award rate for a Senior Constable Level 6 Step 1 which equates to an annual loaded gross salary of $89,553.00 pa."
71Without reference to this answer received on 6 February, AAMI repeated its request two days later. I do not regard this as a reasonable request bearing in mind the factors listed in paras (a), (c), (d) and (g) of s 85(3).
72AAMI also asked for the past three years' tax returns. The claimant supplied group certificates for the three years on 6 February 2013. Again, on 8 February 2013 AAMI reiterated the request without reference to the material supplied. It seems to me that in the absence of some identified reason (which was not suggested by AAMI), the group certificates show the relevant income of the police officer for the relevant years. The request thus offends the factors in s 85(a), (b), (c) and (g) in requiring the further information.
73The most recent Medicare statement was requested and said to be unavailable. AAMI did not challenge this matter and the request simply repeated. I do not think that I can conclude that the request was reasonable, cogent and that the information was otherwise unable to be obtained without some submission and evidence from AAMI to that effect.
74AAMI also sought authorities from the claimant, but AAMI had already obtained a relevant signed authority as part of the claim form. No submissions were made that the authority thereby provided was insufficient. In the absence of such submission, the further request for an authority is unreasonable.
75The final request, made for the first time one week before the claimant was obliged to commence proceedings, sought information about doctors, therapists and hospitals which were connected with "back pain" experienced by the claimant on one occasion eight years previously. Considering the matters in paragraphs (a), (b), (c), (d) and (g) in s 85(1), I regard this request as unreasonable.
76Accordingly, for all these reasons, I reject AAMI's notice of motion.
77The orders of the Court are:
(1)Defendant's notice of motion (filed 17 April 2013) dismissed.
(2)Defendant pay the plaintiff's costs of the motion.