AAI Limited t/as GIO v Con
[2025] NSWPICMR 6
•27 February 2025
| CERTIFICATE OF DETERMINATION OF MERIT REVIEWER | |
CITATION: | AAI Limited t/as GIO v CON [2025] NSWPICMR 6 |
CLAIMANT: | CON |
INSURER: | AAI Limited t/as GIO |
MERIT REVIEWER: | Elizabeth Medland |
DATE OF DECISION: | 27 February 2025 |
CATCHWORDS: | MOTOR ACCIDENTS - Motor Accident Injuries Act 2017; merit review; dispute under section 6.24; whether a request for mobile service provider details is reasonable and whether the claimant has a reasonable excuse for failing to comply; insurer has denied liability on basis that injuries do not arise from a motor vehicle accident; inconsistencies in the evidence including a report to ambulance and hospital staff that injuries arose from a fall from stairs; Held – request for the claimant to provide the name of his mobile service provider is reasonable; will potentially assist in obtaining geolocation information to reconcile with claimant’s version of events. |
DETERMINATIONS MADE: | CERTIFICATE Issued under s 7.36(4) of the Motor Accident Injuries Act 2017 1. For the purposes of s 6.24 of the Motor Accident Injuries Act 2017, a request for the claimant to provide the name of his mobile service provider is reasonable. 2. For the purposes of Schedule 2(1)(x) of the Motor Accident Injuries Act 2017, claimant does not have a reasonable excuse for failing to comply with the request. |
STATEMENT OF REASONS
INTRODUCTION
CON, the claimant, suffered an injury on 28 April 2024. The circumstances that led to that injury is a matter of controversy between the parties.
The claimant has lodged a claim for statutory benefits with the compulsory third party insurer of his motorcycle, AAI Limited t/as GIO (the insurer). He alleges that his injury arose due to a single motor vehicle accident, when his front wheel “washed out” on the Cahill Express Way.
The insurer has denied liability for the claim, on the basis of their view that the injuries do not arise from a motor accident. The insurer points to a number of inconsistencies in the evidence that suggest that the injury arose from circumstances that do not involve a motor accident.
The subject dispute does not require me to make a determination as to whether the claimant was injured in a motor accident, rather the dispute relates to the claimant’s duty to cooperate.
Specifically, GIO seeks an assessment of a dispute pursuant to Schedule 2(1)(x) of the Motor Accident Injuries Act 2017 (MAI Act), which provides:
“whether (for the purposes of section 6.24 (Duty of claimant to co-operate with other party) a request made of the claimant is reasonable or whether the claimant has a reasonable excuse for failing to comply.”
The insurer has requested the claimant provide the name of his mobile phone service provider for the purposes of investigating the legitimacy of his claim. The claimant has declined to provide the information.
LEGISLATIVE FRAMEWORK
Section 6.24 of the MAI Act provides as follows:
“6.24 Duty of claimant to co-operate with other party
(cf s 85 MACA)
(1) A claimant must co-operate fully in respect of the claim with the other party to the claim (being the insurer on the claim or, if there is no insurer, the person against whom the claim is made) for the purpose of giving the other party 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 in the case of a claim for damages.
(2) In particular, the claimant must comply with any reasonable request by the other party—
(a) to furnish specified information (in addition to the information furnished in the claim) 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 for damages by complying with the request.
(4) A duty under this section in respect of a claim for damages 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.”
DOCUMENTATION
I have considered all material provided by the parties in their application and reply and any further documentation provided.
SUMMARY
Claim form
In the claimant’s application for personal injury benefits (claim form) signed on
18 June 2024 the claimant states he was involved in a motor accident on 28 April 2024 at approximately 5.00pm on the Cahill Express Way. He describes the accident as “Front wheel washed out as I was attempting to enter a [sic] emergency area/safety zone on the Cahill Express way – there is a 10cm gutter while entering the off ramp – my wheel was out. Unsafe.”
Statutory declaration of the claimant dated 28 August 2024
The claimant states he was injured in a motor vehicle accident on the Cahill Expressway on 28 April 2024. He describes a breakdown lane on the left-hand side heading north with a concrete lip of approximately 8cm high leading into the breakdown lane.
He was travelling South to North and reduced his speed to approximately 40kmph as he wanted to enter the breakdown lane. His motorbike could not travel over the lip and it caused a high-impact crash.
Specifically addressing a request for information from the insurer, the claimant states that the purpose of the journey was a recreational ride on his new bike. He states that he had not consumed any alcohol but had taken some medications prior to bed. In answer to a query as to whether he had any prior driving convictions, including any charges or convictions for drink driving he states that he has had “no convictions for drink driving.”
In answer to the insurer’s query as to why the claim form and police specifies a time of 5.00pm when the accident occurred, yet in correspondence from his then lawyers dated 9 August 2024 states the accident occurred at 8.00pm the claimant explains that he made that statement when on heavy doses of oxycodone. He states that he may have had concussion and was in extreme pain. He explains that he was suffering from acute anxiety and was feeling apprehensive about how he would care for his wife and daughter during the recovery period.
In answer to a question as to whether the claimant called an ambulance at the scene the claimant states: “after the collision, another motorist stopped and assisted me in getting on my motorcycle again and driving home. I wish to point out that I was in the Australian Army, previously, in the 6th battalion for 4 years as an infantry man. This training and background may have assisted me in my struggle to get home with my motorcycle when I was badly injured. I did not think about calkling [sic] an ambulance at the time and only wanted to get home.”
Further statutory declaration of the claimant dated 10 September 2024
This statement is in reply to the insurer’s request for further information. In answer to a question as to why there is a photograph with damage to gloves when the claimant had stated that his hands did not touch the ground. He states that his hands did not touch the ground when thrown off the bike and he hit the ground. He explains that the gloves became scratched after rolling off his bike.
In answer to a query about why an ambulance was not called at the scene the claimant states:
“I have been diagnosed a mental health condition with acute anxiety after the accident, I was in a highly anxious state and panic. Due to my military training kicked in. It was a fight-or-flight situation. I wanted to be home and back to base with my wife. All I can think about is getting home to my wife and family.” [sic]
Government Information (Public Access) Act 2009 (GIPA) outcome from Transport of NSW dated 10 September 2024.
The claimant requested information from the department specifically about the subject breakdown lane and any accidents that have occurred at the location. The request also asked for details of the construction.
Statutory declaration of the claimant’s wife dated 8 August 2024
The claimant’s wife states that around 8.40pm she and her daughter were in the dining room when she heard an approaching motorcycle indicating the claimant had returned home. The claimant came into the unit and he looked in shock and his face was pale.
She removed his motorcycle jacket which was damaged and had scratches from the shoulder down to his left arm and whilst helping him removing his shoes he advised that he had an accident on his motor bike and he needed to call an ambulance. The claimant then phoned the ambulance.
She states that she was told by the claimant to say that he fell down the stairs. She was confused but followed his instructions.
Provided are photographs of black and plastic gloves that include some scratches to the knuckle area.
A photograph of a white and red motorcycle helmet demonstrates some scratches to the back and side area of the helmet.
Photographs of a brown leather jacket seemingly demonstrate scratches down the left shoulder and arm area.
Photographs of a motorcycle appear to demonstrate some scratch marks to various areas on the left hand side of the bike.
Police
Before me is a police statement of the claimant dated 11 July 2024. The claimant states that around 5.00pm on 28 April 2024 he was travelling north on the Eastern Distributor toward the Cahill Expressway.
He describes the accident occurring after his motorbike did not make it over the “lip” on the Cahill Expressway.
Ambulance
The NSW Ambulance incident report documents a call being received at 8.54pm on
28 April 2024. During the call the claimant is reported to have said that he had “fallen down” and that the fall was down the stairs and accidental. He advised that he would be waiting and a request was made not to use lights and sirens. The claimant phoned again at 9.10pm enquiring about the expected arrival time of the ambulance crew.The crew attended the claimant’s place of residence in Wahroonga at 9.23pm. The report includes the following summary:
“CALLED TO – FALLS – SERIOUS. O/A Pt leaning on car, alert and responsive, obvious distress/grimacing. Pt States that at 2045 – pt was TAKING GARBAGE OUT when he started FELT LIGHTHEADED and fell, LANDED L side elbow into ribs, heard crack. Pt unsure if he suffered LOC. 10/10 pain in L rib Back L hand side thoracic region, PT states he heard ?crunching noise from ribs. Pt initially very rude to crew. Crew moved stretcher around to assist pt from leaning against car sitting or laying down. Pt very standoff-ish with crew and stated that he needed ‘pain relief fucking now’. Officer Lawther advised pt that they did not appreciate pt being rude or swearing. Pt became very defensive when told this, stating ‘I have not been rude or swore at you, I have my wife here as a third party witness’ Crew unable to get initial obs before methoxyflurane as pt was not being cooperative. O/E – GCS 15, PEARL, NIL SIGNS OF HEADSTRIKE, NIL ORAL DAMAGE, DENIES C-SPINE PAIN/TENDERNESS, NIL OBVIOUS DEFORMITY, NIL FLAIL SECTION, NIL SUBCUT EMPH NOTED, NIL BLEEDING, ALL NEUROVASC OBS IN TACT, CAPREFULL <3SECS, BI LATERAL AIR ENTRY, AFEBRILE, NIL BRUISING, NIL SWELLING, PAIN TO L CLAVICLE REGION AND L THORACIC POSTERIOR REGION, PAIN WORSE ON PALPATION, PAIN WORSE ON MOVEMENT, PAIN WORSE ON INSPIRACTION, ?ETOH SMELL ON BREATH. Officer Lawther and PT both apologised for potentially coming across as rude and agreed to start fresh. Crew delayed on scene due to pain management. Pt sitting on edge of stretcher and unable to move legs onto stretcher due to pain. Pt pain decreased and pt able to move his legs onto stretcher. 12 lead ecg shows sinus tach. Crew noticed pt sp02 dropping to approx. 88% on RA. pt denies sob. EN-ROUT – Pt remained GCS 15, PEARL, FAST-, PAIN INCREASING ON MOVEMENT WHILE DRIVING. Pt placed into ISO 10 AT HPH. CREW and hospital staff had very difficult time moving pt from stretcher to bed due to pain.”
Hospital
The ambulance transported the claimant to Hornsby Hospital. The records include a description of the injury mechanism as: “…taking out the bins – turned and lost balance – L sided impact onto 4-5 concrete steps/tiles – acute pain to ribs – mobilised on scene to call wife/partner for help – then walked to end of road to wait for ambulance ‘waited for 20minutes’”
The claimant was transported from Hornsby Hospital to Royal North Shore Hospital (RNSH) via ambulance at 2.04am on 29 April 2024. The relevant report also refers to a fall and the hospital records of RNSH includes a history of “fall from standing height then fell down 4 stairs.” The claimant stated that he was unable to recall the mechanism of injury.
Other medical evidence
The claimant consulted his general practitioner (GP) Dr Shin, at Heritage Medical Practice Wahroonga via telehealth on 6 May 2024 and he is recorded to have suffered injury due to a “serious MVA.”
The certificate of capacity attached to the claim form completed by Dr Shin dated
18 June 2024 records: “motor bike rider, while pulling into emergency lane on Cahill Expressway hit curb/gutter with unexpected raised edge roughly 10cm then fall into left side.”In a report of Dr Duckworth dated 26 June 2024 the claimant is reported to have suffered injury on 28 April when riding his motor bike on the Cahill Expressway.
A report of Dr Baba, shoulder elbow and hand surgeon, dated 25 June 2024 who reports the claimant having suffered a clavicle fracture due to a motor cycle accident.
Dr Shin in a letter of 2 August 2024 that in his professional opinion the injuries sustained are consistent with a motor vehicle accident and a result of high impact forces and are unlikely from a fall down some stairs.
Other evidence and correspondence
The insurer’s liability notice dated 22 July 2024 denies liability for the claim on the basis that the injuries do not arise from a motor accident. The insurer summarises the material and notes a number of inconsistencies. The letter notes the claimant bears the onus of proving that the injuries result from a motor accident.
The insurer states that “the inconsistencies raise issues of reliability and credit that can only be addressed by way of questioning during an oral assessment conference.”
The insurer states that the contemporaneous material is the most reliable evidence and therefore they are not satisfied that the injuries result from a motor accident.
In a letter to the claimant dated 16 July 2024, the insurer notes that the liability notice raises serious concerns around the evidence and version of events. The insurer states: “the overall impression created is that you may have engaged in fraudulent conduct for financial gain.” The insurer notes the MAI Act has significant fines for parties found to have engaged in such conduct and as such the insurer invites the claimant to review and reply to the evidence and the concerns raised.
The claimant has previously been legally represented. Taylor Rose for a period of time represented the claimant. In a letter to the insurer dated 9 August 2024, the lawyers set out a number of matters including the claimant’s personal circumstances. The letter notes that the claimant has worked at several large Wall Street banks and is a Justice of the Peace and is a respected member of society and his reputation is very important to him.
The letter notes the claimant was riding at approximately 8.00pm around Randwick. A note from the Toll Roads indicates that the claimant passed on the Woolloomooloo Road at 8.10pm.
Explaining as to why the claimant told to the ambulance crew a different version on the night of the accident the letter states the claimant was in intense pain and found the ambulance personnel to be aggressive and uncooperative. He believes that he bumped his head. He told the hospital staff the same story after the hospital staff were apparently also aggressive and unprofessional and “after proper reflection corrected the version provided to everyone when he submitted his claim to your company”.
In a letter dated 5 September 2024 the insurer makes a further request for information that includes a request for the name of the claimant’s mobile phone service provider. This request is repeated in a further letter 11 October 2024. That letter also attached an authority addressed to LINKT to enable the insurer to obtain all “relevant records”.
In an email response directly from the claimant dated 17 October 2024 the claimant states “I understand your demand for my telephone metadata for geolocation purposes”. The claimant declines to provide the information noting that the request for personal data is protected by legislation, including requirements for collection by consent. The claimant states that as an alternative to providing metadata, he would send photographs he took on the day of the accident which include photographs of his bike and helmet intact at the Gap on South Head before the accident. The photographs are attached including data to the side that suggest the photograph was taken at 3.19pm on 28 April 2024. Also attached is a letter from the claimant cardiothoracic surgeon dated 16 October 2024 that the injuries suffered are “completely consistent with a high impact motor vehicle accident seen in a lot of motorcyclists and even pushbike riders with similar injuries. In particular, when they hit a gutter with a raised edge and all the descriptions of [CON’s] accident are consistent with this.”
In a letter response dated 24 October 2024 the insurer maintains a number of inconsistencies in the evidence. The insurer also notes that on the claimant’s version he drove approximately 33km to his home with left and right clavicle fractures, rib fractures and a flail segment. The insurer states that a response that he was able to take the trip due to his training and background in the Army is not a reasonable explanation given the significant injuries alleged.
The insurer notes that the claimant indicated in his response to the insurer that he set off from home at around 4-4.30pm in the afternoon, yet the photographs from the Gap are taken at 3.19pm and 3.22pm and “you now allege the accident occurred at about 8:00pm and have provided no explanation as to your actions and whereabouts for the intervening period.”
The insurer also refers to history provided in the Linkt Toll account that reveals one result at 8.10pm at the Eastern Distributor at Woolloomooloo. This is inconsistent with your Statutory Declaration which suggests that you travelled on other Toll roads (i.e. the Harbour Bridge – South bound) during your journey from your residence.”
In respect of the request for the mobile phone details the insurer states:
“Considering the above, GIO maintains its request for you to provide details of your mobile phone service provider to enable provision of your telephone records. GIO remains of the view that the request is reasonable as those records will contain objective evidence of your actions and whereabouts on the day of the accident in circumstances where there are significant inconsistencies in your own version of events. GIO confirms that the request will be limited to the day of the accident and note that you have not explained how such a request will infringe on your privacy.”
In an email response dated 24 October 2024 the claimant asks why his letter from
Dr Nicholson was not referred to. The claimant suggests that the failure to consider the letter raises concerns as to the insurer’s adherence to procedural fairness.During the course of this dispute process a Direction for Production was issued, with my leave, to LINKT. The claimant included some of the documents returned in an Application to Admit Late Documents received by me on 2 February 2025. The document indicates the claimant’s motorcycle passing through a toll on 28 April 2024 on the Eastern Distributor at 8.10pm, travelling in a northerly direction. The insurer does not object to the documents. I have considered the documents in making my determination.
SUBMISSIONS
Insurer
In support of the application the insurer goes through the evidence and a chronology of events.
The insurer submits that by failing to provide the details of the mobile phone service provider the claimant is in breach of s 6.24 of the MAI Act. In making the submission, the insurer highlights the various inconsistencies in the evidence which are summarised above.
When indicating no objection to the claimant’s application to admit late documents in respect of his LINKT account, the insurer notes that the material does not alter their position. The insurer states that the material does not rectify the significant inconsistencies in the evidence, including the claimant’s own version of events.
Claimant
In his reply form the claimant refers to the decision of Obeid v Transport Accident Commission [2003] VCC 636, where a plaintiff was found to have been injured in a motor vehicle accident where they had initially informed hospital staff that they had fallen down stairs.
The claimant refers to the report of Dr Duckworth and the report of Dr Ian Nicholson which provide the opinion that the injuries are consistent with the mechanism of a motorbike accident.
The claimant refers to the case of Ebraham v AAI Limited t/as GIO Insurance [2018] VCC 18, where it was reinforced that the parties uphold good faith throughout the course of the claim under an insurance contract. He states that “any perceived inconsistency in my statement can be attributed to the highly agitated state I was in following the accident and medication.”
He goes onto submit that he has a well documented history of mental health issues that may have affected his initial response. He also notes that he was on opoids and was concussed from the accident and was attempting to manage his own documentation while recovering from multiple broken ribs and a broken collarbone. He submits that these factors impacted his clarity and coherence at the time and explains the “slight” variations in his statements to the police.
The reply also requests that he be able to meet privately with me before any public discussion. He notes that as a former member of the Australian Defence Force he has had the privilege of engaging with senor officials in the Defence Force, the Department of Foreign Affairs and a prominent hedge fund manager with dealings in sensitive international matters. He states that such dealings are inherently private under the “Privacy Act”. He submits that access to the information would not only infringe on his privacy without his consent but also compromise his confidential discussions with senior government officials.
It is to be noted that I indicated to Commission staff that I would not discuss this dispute with the claimant in the absence of the insurer, and declined a request for a private discussion.
The claimant notes that as a Justice of the Peace he upholds the highest standards of integrity and expect the same level of fairness and respect for due process in all dealings.
At the teleconference held with the parties on 6 December 2024 the claimant made oral submissions as to why the details of his mobile service provider should not be handed over by him.
The claimant noted that he is in contact with several high ranking officials in the defence forces, and officials of foreign nations, and matters of national security are discussed. He therefore submits that on that basis the details of his mobile service provider should not have to be provided as it would compromise those matters of national security and the relevant persons.
The claimant submitted that the photographic evidence provided and the toll information verifies his whereabouts and is sufficient evidence for the insurer’s purposes of verifying the accident.
The claimant submitted that the inconsistencies in the evidence can be put down to the fact he was involved in a high impact accident and the significant injuries sustained. He also stated that the inconsistencies can be put down to a concussion and the pain killing medication administered.
It was also reiterated that the claimant has military training and was an infantry man which explains his ability to ride home from the scene of the accident.
The claimant noted that he is offended by the notion that there is an assumption that he has lied and takes “sever umbrage” to a suggestion that he may have committed financial fraud. He noted that it is not an issue of money, that he is able to fund his treatment on his own, but the issue is one of integrity.
FINDINGS
As noted above, my task in assessing this dispute is not to make a determination as to whether the claimant was injured as a result of a motor accident.
The task is to assess whether the request for the claimant’s mobile service provider details to be provided is a reasonable request (s 6.24(2) of the MAI Act) having regard to the matters set out in s 6.24(3). The relevant criteria set out in s 6.24(3) is clearly relevant to my assessment, however, my view is that it is not an exhaustive list noting the word “including”.
The insurer is under an obligation to verify a motor accident. Pursuant to s 6.24 a claimant is under an obligation to “co-operate fully” with the insurer for such purpose.
There are a number of major inconsistencies in respect of the claimant’s version of events. In particular, the initial report of the mechanism of injury to ambulance personnel and to hospital staff. Further from there, the claimant provides inconsistent times as to when the accident occurred, including within a statement provided to NSW Police and on his claim form.
Whilst the claimant has provided explanations for the various inconsistencies, those explanations are still open to assessment as to whether they are sufficient to verify the accident. The claimant points out he was under the influence of medication and was in immense pain from the injuries received. Further he asserts that he was affected by psychological symptoms. At this stage, assertions as to his psychological state are open to interpretation in the absence of persuasive medical evidence.
Further there is a suggestion of a concussion to explain the earlier inconsistent reports of the mechanism of injury. However, there is limited to no evidence that supports such a contention.
However, on the other hand the claimant has provided a number of pieces of evidence that are consistent with his version of events. Those includes photographs of the damage to his protective clothing and the motorbike itself, consistent with his injuries. Also provided is medical evidence from appropriate medical experts that support the contention that the injuries received are consistent with a high impact motor bike accident.
The claimant has also provided photographic evidence of him being on a ride in the eastern suburbs area of Sydney in the afternoon of the accident. However, the timing of such photographs, being a number of hours prior to the accident, are likely of limited weight in supporting the claimant’s allegations.
The LINKT account records are also consistent with the claimant’s contention that he was riding his bike in a northerly direction on the Eastern Distributer at 8.10pm. I note the ambulance records recording a call being made to them requesting an ambulance attend his home in Wahroonga at 8.54pm.
It is conceivable on that timeline that the claimant could have had the accident shortly after passing through the toll on the Eastern Distributor, then got back up his motorbike and returned home and then called an ambulance.
However, on the evidence it does seem somewhat extraordinary that the claimant was able to negotiate a journey home on his motorbike after suffering very significant injuries. In this regard, the ambulance and hospital records record the claimant being in a severe level of pain when attended to. The claimant has provided an explanation for this situation by stating that his military training is such that he was capable of pushing through the pain to get home.
To my mind, however, there still remains a question as to why a call to NSW ambulance was not made at the scene of the alleged accident given the significant injuries sustained.
The ultimate question of whether the claimant was injured in a motor accident is yet to be the subject of an assessment. Whilst the claimant has provided a number of pieces of evidence that are consistent with his version of events, it remains the case that a number of inconsistencies remain. I accept the claimant has provided explanations for the inconsistencies, those explanations are largely subjective in nature. Accordingly, I consider it reasonable that the insurer continue to seek verification of the assertions made by gathering further evidence.
In my view, in light of the remaining inconsistencies surrounding the mechanism of injury, I consider it a reasonable request that the claimant provide the name of his mobile phone service provider so that information can be sought from them as to the geolocation of the claimant during the relevant period on the day of the alleged motor accident.
I acknowledge and appreciate the claimant’s concerns regarding privacy and the information of third parties that he may have phoned. I also acknowledge the claimant’s assertions regarding the sensitive nature of the conversations he may have had during the day. The insurer emphasised that the only time period they seek information is the day of the motor accident, and no information before. It was also confirmed that the content of conversations is not information that is sought. The information is to verify the location of the claimant at various times during the lead up and after the accident to reconcile with the claimant’s account of events. Any sensitive information obtained would be subject to the privacy legislation and the insurer’s obligations in such regard.
CONCLUSION
For the reasons set out above, I consider the request for the claimant to provide the name of his mobile service provider is reasonable.
I consider the claimant does not have a reasonable excuse for failing to comply with the request.
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