57 He noted that the appellant did have the capacity to issue a policy which excluded pre-existing conditions, or which may have been issued at a special additional premium. The appellant did not explore those options. It refused to grant any policy to the respondent by reason of her pre-existing condition. It is the discrimination which is reflected in that decision which is to be reasonable having regard to any relevant factors.
58 The appellant adduced evidence about 'claims causation risks' and anecdotal evidence of catastrophic large claims. It also adduced evidence about the progressive incidents of metastatic cancer. The Magistrate accepted all that evidence.
59 The evidence of the appellant (as identified in the written submission referring to evidence) included evidence from Michael John Garrard, Shirley Ann Thompson, Professor Fox and Dr Charles Corke. Mr Garrard is the former deputy manager of the appellant. He did not play a role in its decision to refuse the respondent travel insurance. His affidavit is more by way of argument, asserting the reasonableness of the appellant's discriminatory conduct. It is largely based upon information provided to him by Ms Thompson and by Dr Corke. He described the difficulty confronting the appellant as that it:
'would be impossible to prove that any complication is as a result of the disease process and that no other person could have suffered this outcome if they did not have the underlying condition.'
60 He confirmed, as the Magistrate found, that the destination was very much a secondary consideration. He said the respondent's medical condition meant she would not have been treated by the appellant as an acceptable risk for any form of overseas travel insurance.
61 Mr Garrard's evidence provided some anecdotal statistical evidence. He said the appellant issued numerous policies of travel insurance each year. He did not say how many policies were issued in which some form of pre-existing medical condition was excluded. There were about 30,000 to 35,000 claims on issued policies each year. Over a period of 20 years, he had seen only about 50 claims in which there had arisen the difficulty of deciding whether there was some causal link between the condition that was the subject of the claim and the reported pre-existing medical condition. As a matter of arithmetic (assuming the number of claims each year over the 20 year period was 30,000), that would mean that the difficult claims represent about 0.008% of all claims. No information was given about the number of policies issued, but it would be very many more than the number of claims. He did not explain whether all, or any, of the 50 difficult claims concerned a claimant with a pre-existing condition similar to the respondent's medical condition, or whether they had arisen when there was in place some policy or protocol or guideline specifically to consider proposals for travel insurance where a particular pre-existing medical condition had been tabbed as potentially of significance.
62 In fact, the decision not to offer any travel insurance to the respondent was made by Ms Thompson based upon her knowledge and experience. The appellant did not have a formulated policy either to refuse any travel insurance in respect of persons suffering from a pre-existing condition such as that of the respondent, although it may have had such a policy in respect of other pre-existing medical conditions. Nor did it have a formulated protocol to require particular medical information and an individual assessment (including perhaps a premium loading) before making a decision whether to issue a policy of travel insurance in the case of persons with the respondent's particular pre-existing medical condition.
63 Ms Thompson is an experienced nurse. She prepared for the appellant 'medical appraisal department guidelines' for consideration of applications for travel insurance. They are periodically updated. The guidelines include a list of 'challenging conditions'. The 'challenging conditions' at the time (and still) include the following:
'Conditions that are even more challenging and should be considered for "NO POLICY" are as follows:
Terminal cancer - prohibited to cover under policy
Metastatic cancer.'
64 She had regard to the respondent having been diagnosed with breast cancer in May 1997 and with metastatic breast cancer in December 2002. She had regard to the fact that the treatment included biophosphonates, indicating bony metastases and so the possibility of fractures or compression of the spinal chord 'if that is where the metastases were located'. She considered the condition gave rise to 'possible medical complications such as increased risk of infections and blood clotting disorders', and it suppressed the immune system so there was a real risk of infection. She regarded it as 'almost impossible' to decide with any certainty whether certain medical conditions are associated with a pre-existing condition, due to the large number of possible medical complications suffered by a person with metastatic cancer.
65 She concluded:
'In my opinion, and from the cases I have been involved in, whatever medical event befell the applicant, be it accidental injury or illness, it would be more complicated, the prognosis poorer and the medical event may have precipitated the final stages of her underlying disease. On site medical care and any repatriation costs would be higher than for any client without similar underlying disease. This made it too great a risk for QBE to agree to offer the Applicant a policy.'
66 She gave evidence of two cases, involving 'cancer' where in one instance pneumonia and in the other a stroke led to expensive claims because the pre-existing medical condition was either the real cause or a significant aggravating cause of the severity of the condition, but the insurer nevertheless accepted the full claim.
67 Dr Corke, the consulting doctor to the appellant, was asked only in October 2002 to advise the appellant about the influence of 'metastatic cancer' upon general susceptibility of a patient to other illness and injury. His report is as follows:
'With reference to the influence which metastatic cancer might have on the general susceptibility of a patient to other illnesses and injuries I would submit the following observations:
Cancer, particularly metastatic cancer, is well recognised to significantly predispose to deep venous thrombosis and thromboembolism. These conditions are also associated with long distance travel.
Cancer is associated with depression of the immune system which predisposes to infectious disease and results in a more severe course when infection occurs.
Any accidental traumatic injury occurring in a patient with metastatic cancer would be expected to be more complicated (as healing is delayed in these patients).
Where the disease involved bone then the chance of fracture, even from a minor injury, would be more likely.
Unfortunately patients with metastatic cancer are at substantially more risk of developing other illnesses not directly due to the cancer and are likely to have a more prolonged period of recovery from illness and injuries they sustain.'
Dr Corke is on occasion asked by the appellant to adjudicate in cases where a person with an underlying medical condition is involved in an accident or develops another condition to 'dissect' what is causing the current complaint. He professes the medical experience enabling him to do so. Even accepting, as he says, that it is often very difficult to determine whether an underlying condition has caused or contributed to the illness suffered whilst travelling, or has made recovery more prolonged, the appellant clearly has qualified medical resources to enable such judgments to be made. For example, given the second paragraph of his report, one could understand a decision to refuse to indemnify in respect of deep venous thrombosis suffered whilst travelling.
68 Professor Fox provided reports to the appellant only during 2003. They are dated 25 February 2003 and 25 July 2003. His views were not the foundation or part of the foundation for the appellant's discriminatory conduct. They may provide evidence to support the correctness of Ms Thompson's understanding of the significance of the respondent's pre-existing condition.
69 The first report of Professor Fox dealt with 'the issues of recurrence of metastatic cancer and whether or not recurrence can be predicted' in certain individuals. There is a significant incidence of cancer in Australia. In the case of metastatic (i.e. spread) breast cancer, there is generally a period of about six months from commencing hormonal treatment to relapse or progressive disease. Relapse then may be, but need not be, acute and may require hospitalisation and evacuation to Australia. Professor Fox described eight relapse emergencies. There is nothing to indicate in his report that, in the event of one of those relapse emergencies occurring, there is particular difficulty in identifying the condition as related to the pre-existing condition. He also referred to the risk of venous thrombosis or pulmonary embolism, which he describes as syndromes of metastatic cancer. Again, there is no particular difficulty identified in ascribing the onset of such an illness to the pre-existing condition, if it be the case.
70 Professor Fox also described 'prognostic factors' which indicate individuals with a greater or lesser risk of developing tumour recurrence and its complications. The mobility of the respondent put her in the lower risk category. He noted however that there is a significant potential for such persons to deteriorate over a period two to three months. That is not suggested to be a real concern in the respondent's circumstances. She planned to travel to Japan within a few days, and for a short time. If she were in clinical remission (as she was), she was not especially vulnerable to recurrence in that time frame. Professor Fox also identified the sites of metastatic disease as a prognostic determinant. There is no evidence that the appellant could not have sought, and learned of, those sites through the respondent's medical advisers.
71 Accordingly, his first report of 25 February 2003 does not really much advance any claim by the appellant that its discriminatory conduct was reasonable. It dealt with the risks of recurrence of metastatic cancer and whether recurrence can be predicted in certain individuals. It described how recurrence might appear. As the respondent expected any illness arising from or related to her pre-existing condition to be excluded, any recurrence in the way he described (even if, on his analysis, quite unlikely to occur during her trip to Japan) would not be covered by the proposed policy.
72 The subsequent report of Professor Fox of 29 July 2003 was provided upon the basis of information partly available to the appellant at the time of its decision, and partly on information from the respondent's treating doctors which (presumably) the appellant could have procured at short notice had it been sought. As a result of that information, Professor Fox identified several of the eight relapse emergencies which might have applied to the respondent. He confirmed, based upon the reports from the respondent's doctor, that she was young and active, and at the lowest end of the scale of vulnerability to recurrences.
73 In response to the question about the diagnostic problems which might arise in 'attempting to isolate the pre-existing condition' should the respondent suffer some other accidental injury whilst travelling, Professor Fox said:
'It can be difficult to sort out various medical events as subsequently related or not related to her metastatic cancer. Clearly should she fracture her femur at the site of the bone metastasis that would be obvious. Sometimes with cerebral events that can be difficult to determine whether there is another underlying cause, and similarly with intercurrent illnesses, e.g. infections in lungs or urinary tract, etc.'
74 On the other hand, accidental injury at an identified metastatic site would 'almost certainly' be due to the pre-existing condition. He indicated that a fracture at another site (presumably without serious external trauma) may be due to a general thinning of the bones as a result of malignancy, and the cause 'could be difficult to determine'. He also said it would be difficult to 'sort out' the management of an unrelated medical condition as her underlying disease may pre-dispose her to a number of different events such as venous thrombosis and a greater propensity for infection.
75 In his oral evidence, Professor Fox explained that sometimes it may be hard to determine whether a disease or illness is caused by the pre-existing condition. He gave the example of a stroke, which may be due (for example) to high blood pressure or to tumour metastases.
76 Professor Fox told the learned Magistrate that it would not be too difficult to say whether a recognised common danger of metastatic cancer was related to that condition. He referred to the examples of deep vein thrombosis, or a fracture at a lesion site or from generally weakened bones. He also said that in the event of treatment for a totally unrelated event, if problems occurred then because of metastasis, generally the treating doctor would be able to recognise that. He did, however, refer to 'grey areas', although 'a lot of the major matters' could be recognised and explained to the proposed insured in advance.
77 He also said:
'The risks are related to the cancer, but then - yes, sure. It's just that these events, medical events, either due to the cancer or due to the treatments are sometimes difficult to dissect out, generally often difficult to dissect out. It's a common problem but you're right. The risk of anything happening in six days is quite low, just simply on a time basis.'
78 Earlier cases on the meaning of reasonableness under discrimination legislation have focussed on whether discrimination has been made out. The expression has been given its ordinary meaning, albeit that it appears in legislation reflecting positive social policy. In Commonwealth Bank of Australia v Human Rights and Equal Opportunity Commission (1997) 150 ALR 1 (Commonwealth Bank), the Full Court addressed whether the bank had engaged in discriminatory conduct contrary to the Sex Discrimination Act 1984 (Cth). The issue turned, in part, upon whether the bank imposed a condition on female employees which was 'not reasonable having regard to the circumstances of the case'. See also Waters; Commonwealth v Human Rights and Equal Opportunity Commission (1995) 63 FCR 74; and Styles.
79 The meaning of 'reasonable' in s 46(1)(g) must depend upon its context in the DD Act (see e.g. per Dawson and Toohey JJ in Waters at 395). But I do not think the expression in s 46(1)(g) requiring the discrimination to be 'reasonable having regard to any other relevant factors' should be given other than its ordinary meaning. There is no cause to give them some refined meaning by reason of their expression in the exemptions part of the DD Act. They are words of ordinary parlance. There is no legislative indication that they should be given some more refined meaning. The objects of the DD Act, as expressed in s 3, do not in my view require the Court to give the expression other than its ordinary meaning. The fact that those words may apply only after discriminatory conduct otherwise in contravention of the DD Act has been established does not provide a context for some more refined or onerous meaning. The content, and context, of s 46(1)(g) directs attention to the reasonableness of established discrimination. Whether the discrimination is shown to be reasonable is a question of fact in all the relevant circumstances. See the discussion by Sackville J in Commonwealth Bank at 33-34.
80 The learned Magistrate concluded that the discrimination of the appellant was not shown to have been reasonable. In my judgment, that conclusion was readily available. Indeed, having regard to the fact that the conclusion was based upon essentially uncontested evidence, upon which I could form my own view, I agree with the conclusion.
81 The discrimination occurred upon the basis of the decision-making system described above. The causation issues of concern to the appellant involved knowledge of the condition of metastatic breast cancer generally, and an unrefined and anecdotal knowledge of previous large claims. As to the latter, the appellant did not apply that anecdotal knowledge in any coherent way to its decision-making. It did not address whether its premiums for travel insurance were fixed having regard to the fact that over a 20 year period it had experienced about 50 difficult causation claims. Apart from describing anecdotally two of those claims, it did not address how many of those 50 or so claims had been accepted. It did not address whether all or any (if any) of those 50 or so claims which had been accepted were ultimately considered as claims it should not have accepted or at what cost. It did not indicate whether, with the greater medical knowledge now available, or the capacity to seek further medical information about the proposed insured before deciding to issue a policy of travel insurance, those claims would not now present the same causation difficulties. It did not address how many of those 50 or so claims involved policies of travel insurance issued only shortly before the proposed overseas travel, and for a short period of travel only.
82 Its evidence is that less than one in 10,000 claims result in decisions which the appellant regards as difficult claims. It has not explained whether the 50 or so difficult claims involve one or a few particular pre-existing conditions. It has not explained whether it has had any difficulty with claims in the past in respect of metastatic breast cancer, or whether any such difficulties have arisen in respect of that condition where the claimant has been treated by particular forms of medication or in particular ways, or whether the stage of progress of the disease has been relevant to the difficulty. The labelling of a condition as 'cancer' or more precisely as 'metastatic cancer' does not of itself mean that it is a reasonable decision to refuse to insure all persons with that condition.
83 As the evidence of Professor Fox shows, there are events which may arise in the progress of metastatic breast cancer which can reasonably readily be identified as caused by that illness. In the respondent's circumstances, they were quite unlikely to arise. There are medical conditions which may also arise which are well known as potentially related to such an illness, such as venous thrombosis, fracture upon or minor trauma at a metastatic site, so that the appellant should reasonably readily identify whether they may be related to that illness. There are also incidents which may occur on overseas travel which, although apparently unrelated to the illness, may be more prolonged or complex or difficult to treat by reason of the illness. But the appellant's evidence did not go near to showing the extent to which such problems might arise, or at what cost, or how they might be addressed, in the case of the respondent. Instead, by virtue of the anecdotal claims experience which did not relate specifically to the respondent's pre-existing medical condition, the appellant discriminated against the respondent. It declined her any travel insurance. Its decision excluded her from insurance property loss. It excluded her from insurance for any family emergency (for example, she was concerned to be able to return promptly to Australia if one of her children in the care of relatives needed urgent care whilst she was away, or if her husband travelling with her, fell seriously ill or was injured). It excluded her from insurance for any personal illness or accident, even minor illness or accident, occurring whilst she was overseas for a short period, even if the illness or injury was unrelated to her pre-existing medical condition.
84 The appellant made no attempt to seek further medical information from the respondent or from her medical advisers. As the Magistrate found, the view was taken that any such information could only re-affirm the appellant's decision. In my judgment, the decision of the learned Magistrate that the discrimination was not reasonable having regard to the relevant factors should not be disturbed.
85 For the reasons given, I consider the appellant applied a decision-making process which was too formulaic or which tended to stereotype the respondent by reference to her disability. Such grouping of individuals, whether by race or disability, without proper regard to an individual's circumstances or to the characteristics that they possess, may cause distress or hurt. This case provides an illustration. Legislation such as the DD Act is aimed to reduce or prevent such harm. Section 46 of the DD Act recognises that there are circumstances in which discrimination by reason of disability may be justified (or, at least, not be unlawful). It requires that the particular circumstances of an individual who is discriminated against be addressed, but not in a formulaic way. Even if the exemption pathway provided by s 46(1)(f) is utilised, the reference to 'any other relevant factors' confirms that legislative intention.
86 Lest it be thought that the point has been overlooked, I note that the appellant's notification of its refusal to insure invited the respondent, if she had any questions, to contact the appellant. The Magistrate found the notification did not reasonably give the impression that there was any point communicating further with the appellant. I did not understand senior counsel for the appellant to contend that finding was wrong. I agree with the finding. The invitation was not one which, in context, conveyed any prospect of the appellant altering its decision in the light of further information or discussion. It is not a matter which I regard as adding to any measure of the reasonableness or otherwise of the appellant's discrimination.