Claimant Who Suffered an Unforeseen Medical Episode Not Wholly or Mostly at Fault

In Brief

• A Claimant is entitled to ongoing statutory benefits unless they suffered a threshold injury or they were wholly or mostly at fault for their accident.
• In wholly or most at fault disputes, the onus of proof is on the Insurer.
• A Claimant is not wholly or mostly at fault if their accident was caused by an unexpected medical episode.

Facts

The decision in McManus v QBE Insurance (Australia) Limited [2026] NSWPIC 175 was delivered on 23 March 2026 and published on 2 April 2026.

On 25 January 2025, the Claimant was driving along Williwa Creek Road at Portland when he lost control and rolled his vehicle. The Claimant attributed his loss of control to pre-existing left cubital tunnel syndrome which caused his left arm and hand to lock-up whilst he was driving.

On Internal Review, the Insurer found that the medical evidence did not support the Claimant’s argument that his left cubital tunnel syndrome caused his loss of control. Rather, the Insurer concluded that the Claimant was wholly or mostly at fault for his accident because he failed to adjust his driving to negotiate a bend in the gravel road.

The Member’s Decision

The Member decided that the Claimant was not wholly or mostly at fault for the following reasons:

• In order to be entitled to statutory benefits, the Claimant did not need to show that another party was responsible or culpable for their injury.
• The Claimant is entitled to ongoing statutory benefits unless they are wholly or mostly at fault for their accident (or their only injuries are threshold injuries).
• The onus is on the Insurer to demonstrate that the Claimant was wholly or mostly at fault.
• On the evidence, the Claimant was travelling at 40 kph, before the accident, and he was driving in a cautious manner having regard to the gravel conditions and the presence of horses in the area.
• On the evidence, the accident was wholly caused by the Claimant suffered an unforeseen medical episode.

Why This Case is Important

The decision in McManus turned on its own facts given that the Member accepted the Claimant’s evidence regarding his medical condition and rejected the Insurer’s argument that the accident was caused by his speed.

Be that as it may, having made those factual findings, the Member applied the Supreme Court’s decision in Evic by concluding that the only issue was whether the Claimant was wholly or mostly at fault. There was no need to enquire into whether any other party was at fault.

Given the finding that the accident was caused by an unexpected medical episode, no fault could be attributed to the Claimant and it followed that he was neither wholly nor mostly at fault.