Hellessey v MetLife Insurance Limited [2017] NSWSC 1284

Hellessey v MetLife Insurance Limited [2017] NSWSC 1284

MetLife's first alleged constructive rejection was not open on the amended pleading and was not established, and the first and second actual rejections were superseded by agreed reconsiderations. The operative third rejection was invalid because MetLife unreasonably rejected or discounted the sworn lay evidence and supporting medical evidence, relied on its own lay assessment of Facebook, horse-related and other activity evidence, failed to give proper weight to longitudinal treating psychiatric evidence, and treated evidence of activities as inconsistent with psychological incapacity without adequate medical support. On the evidence at trial, Ms Hellessey's chronic PTSD and depressive...

Jurisdiction
Australia
Judgment Date
25 September 2017
Procedural Posture
Insurance Claim for Total and Permanent Disablement Benefits Under Group Life Insurance Policies / Principal Judgment After Hearing
Outcome
The second defendant's rejection of the plaintiff's claim was not valid and effective, and the plaintiff established entitlement to TPD benefits at the assessment date.
Legal Topics
['total and Permanent Disablement' 'life Insurance' 'utmost Good Faith' "reasonableness of Insurer's Decision" 'constructive Rejection of Claim' 'psychological Injury' 'post Traumatic Stress Disorder' 'major Depressive Disorder']
['insurance Law' 'equity' 'superannuation'] ['total and Permanent Disablement' 'life Insurance' 'utmost Good Faith' "reasonableness of Insurer's Decision" 'constructive Rejection of Claim' 'psychological Injury' 'post Traumatic Stress Disorder' 'major Depressive Disorder']

Case Brief

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Procedural Posture

Insurance Claim for Total and Permanent Disablement Benefits Under Group Life Insurance Policies / Principal Judgment After Hearing

Legal Issues

  1. 1 ["Whether MetLife validly rejected Ms Hellessey's TPD claim." "Whether MetLife constructively rejected Ms Hellessey's claim by delay." 'Whether the first and second rejections could still be challenged after requests for review and reconsideration.' "Whether MetLife's third rejection was invalid because its reasoning process was unreasonable or failed to address the correct question." 'Whether Ms Hellessey was, at the assessment date, incapacitated to such an extent as to render her unlikely ever to engage in any gainful profession, trade or occupation for which she was reasonably qualified by education, training or experience.']

Ratio Decidendi

MetLife's first alleged constructive rejection was not open on the amended pleading and was not established, and the first and second actual rejections were superseded by agreed reconsiderations. The operative third rejection was invalid because MetLife unreasonably rejected or discounted the sworn lay evidence and supporting medical evidence, relied on its own lay assessment of Facebook, horse-related and other activity evidence, failed to give proper weight to longitudinal treating psychiatric evidence, and treated evidence of activities as inconsistent with psychological incapacity without adequate medical support. On the evidence at trial, Ms Hellessey's chronic PTSD and depressive...

Court Disposition

The second defendant's rejection of the plaintiff's claim was not valid and effective, and the plaintiff established entitlement to TPD benefits at the assessment date.

Orders

  • ["The second defendant's rejection of the plaintiff's claim was not valid and effective." 'The plaintiff has established that, at the assessment date, she was incapacitated by her psychological injury in a manner that satisfied the TPD definition in the policies.' 'The parties should agree the amount to which the...