Statement of Principles concerning accommodation disorder (Balance of Probabilities) (No. 22 of 2026)

The central concept is “accommodation disorder”, defined in subsection 7(2) as “the inability to adjust the lens of the eye to various distances or an inability to sustain such an adjustment.” This is a narrowly defined condition that excludes other common visual impairments. Specifically excluded are: accommodative excess; processes primarily affecting the lens such as presbyopia and cataract; processes affecting the shape of the eyeball such as myopia, hypermetropia, and astigmatism; and reversible paralysis of ciliary muscle function by pharmacological agents, except where those agents cannot be ceased or substituted. The exclusion of presbyopia and cataract is significant because those are extremely common age-related conditions. The instrument assigns ICD‑10‑AM code H52.5 to accommodation disorder, but the definition in the instrument overrides the code for legal purposes. “Death from accommodation disorder” is defined as including death from a terminal event or condition that was contributed to by the person’s accommodation disorder. “Terminal event” is defined in the dictionary as including pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function. This creates a chain of causation: if the accommodation disorder contributed to, for example, a fall that led to pneumonia, death may be compensable. The key legal concepts for time-based triggers are “clinical onset” and “clinical worsening”. Every factor in section 9 must exist at the time of either clinical onset or clinical worsening. “Clinical worsening” is further refined in section 10: it applies only where the person’s accommodation disorder was suffered or contracted before or during (but did not arise out of) the person’s relevant service, and the worsening must amount to a material contribution or aggravation. This prevents claims based on mere natural progression of a pre-existing condition that is unrelated to service. Another foundational concept is “relevant service”, defined in the dictionary as: operational service, peacekeeping service, hazardous service, or British nuclear test defence service under the VEA; or warlike service or non-warlike service under the MRCA. The instrument does not apply to peacetime service under the VEA that is not one of those categories. The factors themselves are medical or pharmacological conditions that must be present at the relevant time. They include: an injury or disorder affecting the function of the oculomotor nerve or ciliary muscle; concussion; moderate to severe traumatic brain injury; taking atropine or an atropine-like medication (provided the medication cannot be ceased or substituted); taking a medication from the specified list (again with the proviso that it cannot be ceased or substituted); taking a medication associated with development of accommodation disorder during therapy and cessation upon discontinuation; and inability to obtain appropriate clinical management before clinical worsening. The “inability to obtain appropriate clinical management” factor is potentially the most open-ended, as it invites factual inquiry into whether the medical system failed the veteran. The instrument also defines “atropine-like medication” broadly as any medication antagonising acetylcholine at parasympathetic nerve endings, with a non-exhaustive list of examples ranging from antispasmodics to antipsychotics to antihistamines. “Medication from the specified list” enumerates over 70 specific substances, including common drugs such as morphine, prednisone, carbamazepine, chloroquine, and chlorpromazine. The “cannot be ceased or substituted” condition appears in factors 4, 5, and the exclusion for reversible paralysis, and is critical but undefined. This creates a factual question in each case: is the medication medically necessary such that stopping it or switching would cause unacceptable harm? The dictionary definition of “an injury or disorder affecting the function of the oculomotor nerve or ciliary muscle” includes any pathological process affecting the brain stem or the oculomotor nerve along its course (including the nucleus, fascicles, subarachnoid space, cavernous sinus or orbit) that leads to a disturbance of oculomotor function, or any process affecting ciliary muscle function, causing impairment of accommodation. This is broad enough to include strokes, tumours, infections, or demyelinating conditions.

The primary class of persons affected are veterans and members of the Australian Defence Force who have rendered relevant service as defined. This includes those who served in operational, peacekeeping, hazardous, or British nuclear test defence capacities under the VEA, and those who performed warlike or non-warlike service under the MRCA. The instrument does not cover peacetime service outside those categories, so a veteran who served only in Australia in a non-hazardous posting and later develops accommodation disorder will need to rely on the general law of causation under other provisions of the VEA, rather than the benefit of this statement. Dependents of veterans who die from causes contributed to by accommodation disorder are also affected, because death from accommodation disorder is included in the scope of the instrument. For the legal profession, this instrument is a tool for constructing arguments in support of claims. Practitioners must be familiar with the definitions and exclusions to advise clients accurately. For example, if a veteran presents with simple presbyopia, no claim can succeed under this SoP because presbyopia is expressly excluded. The instrument also affects medical experts who are asked to provide opinions on whether a factor exists. An ophthalmologist or neurologist may need to opine on whether a given concussion was sufficient to cause accommodation disorder, or whether a medication could reasonably be ceased or substituted. The Department of Veterans’ Affairs and the Veterans’ Review Board are directly bound to apply this instrument in determining claims under the relevant provisions. Decision-makers cannot ignore the factors and substitute their own medical judgment; if a factor is present and related to service, the connection must be accepted on the balance of probabilities. This reduces administrative discretion but also increases the risk of erroneous acceptance of claims where the factor is present but the actual causal relationship is weak. From a broader perspective, the instrument affects taxpayers who fund the veterans’ compensation system. Each additional accepted claim adds to the long-term liability of the Commonwealth. The instrument may also affect insurance premiums or employer costs for defence contractors, though indirectly, because compensation for service-related conditions is government-funded, not employer-funded. However, the existence of a generous predisposition to accept claims may influence workplace safety incentives: if service conditions are presumed to cause even subtle eye focusing problems, there may be less pressure on the military to prevent head injuries or monitor medication side effects, because the external cost of those injuries is socialised through the compensation scheme. Finally, the instrument affects manufacturers of listed medications. While they face no direct liability under this SoP, a veteran taking one of the specified drugs may claim that the drug caused accommodation disorder and that it could not be ceased or substituted. This may lead to increased scrutiny of those drugs in the military context and could influence prescribing practices, raising questions about whether clinical freedom is constrained by legal risk.

The instrument imposes no direct duties on private individuals. Its legal effect is to define the evidentiary standard that must be applied by decision-makers under the VEA and MRCA. The key entitlement is for a veteran or member to have a claim for accommodation disorder determined on the basis that if a factor in section 9 exists and is related to relevant service, the condition is taken to be connected to that service on the balance of probabilities. This effectively grants a right to a favourable finding if the facts can be established. However, the right is conditional. The factor must be related to relevant service. Section 10(1) makes this explicit: the existence of the factor must be related to the relevant service rendered by the person. So even if a veteran has a concussion, if that concussion occurred during a civilian rugby game while on leave, it will not satisfy the requirement. For the clinical worsening aspect, section 10(2) restricts the right further: the worsening must be a material contribution or aggravation of a pre-existing condition that was not itself caused by service. This prevents veterans from claiming for natural progression of a condition they had before service. Decision-makers have a duty to apply the instrument. Where a claim is made under section 120B of the VEA or section 339 of the MRCA, the decision-maker must consider the factors set out in section 9. If the factor is satisfied, the decision-maker must find that the condition is service-related unless there is contrary evidence that displaces the balance of probabilities. The instrument does not create a reverse onus, but it does create a structured pathway. Claimants have the right to present evidence of a factor, but they also bear the practical burden of adducing sufficient material to show the factor exists. The instrument also creates a right for the RMA to repeal and replace its own determinations. This is a recurring administrative power that affects all stakeholders each time an SoP is revised. The new instrument takes effect on 23 March 2026 and applies to all claims made after that date that fall within its scope. There is no grandfathering of the old factors; the new factors must be used. This can create transitional uncertainty for claimants who had built a case under the old instrument. Section 11 of the instrument creates a duty to incorporate other Statements of Principles by reference. If a factor (for example, an injury or disorder affecting the oculomotor nerve) refers to another condition for which a separate SoP exists, the factors in that other SoP must be applied. This means that a claim for accommodation disorder may require satisfaction of multiple sets of factors if the underlying condition itself must be shown to be service-related. This cascading structure can increase the complexity and cost of compliance for claimants.

This instrument does not create any penalties or enforcement mechanisms. It is a standard-setting instrument, not a penal statute. The penalties that could arise from misrepresentation in a claim are found in the parent Acts: the VEA and MRCA contain offences for making false or misleading statements to obtain benefits. For example, section 217 of the VEA creates an offence for obtaining a pension or allowance by false representation. If a veteran or a representative knowingly fabricates a factor such as a concussion or a medication history, they could be prosecuted under those provisions. The instrument itself, however, is silent on penalties. Enforcement of the instrument is primarily through the administrative review process. If a decision-maker incorrectly applies or ignores the factors, the claimant can seek review by the Veterans’ Review Board and ultimately the Administrative Appeals Tribunal or the Federal Court. Conversely, if a decision-maker incorrectly finds a factor exists when it does not, there is no enforcement mechanism available to the Commonwealth other than to defend the claim at review and seek to overturn the decision. There is no provision for the RMA itself to enforce compliance; its role ends with issuing the instrument. The instrument does, however, carry a quasi-penal effect for claimants who might have been able to succeed under the earlier 2017 instrument but cannot under the 2026 instrument because the factors may be narrower or differently worded. While that is not a penalty in the legal sense, it imposes a cost on those who cannot satisfy the new criteria. The “cannot be ceased or substituted” condition for medication factors is a particular hurdle. If a veteran has been taking a medication from the specified list but the condition that required the medication has resolved, or a substitute is available, the factor will not be met. This can operate like a penalty on those whose medical regimen could be changed, even if changing it would be inconvenient. There is no civil penalty for a doctor who fails to prescribe a different medication to help a veteran qualify; but a veteran might feel pressured to maintain a medication regime to preserve a claim, which is a perverse incentive.

This instrument operates within the framework of the Veterans' Entitlements Act 1986 and the Military Rehabilitation and Compensation Act 2004. Specifically, it is made under subsection 196B(3) of the VEA, which empowers the RMA to determine Statements of Principles for the purposes of claims under both Acts. The instrument expressly applies to claims under section 120B of the VEA and section 339 of the MRCA. These sections establish the standard of proof for certain types of claims: for operational service, the standard is reasonable hypothesis, and for other service, it is balance of probabilities. This instrument is the balance-of-probabilities version; there presumably exists a reasonable hypothesis version for the same condition. The instrument does not exist in a vacuum; it interacts with other Statements of Principles through section 11. If a factor refers to an injury or disease for which another SoP has been determined, the factors in that other SoP apply as in force from time to time. For example, factor 1 requires an injury or disorder affecting the function of the oculomotor nerve or ciliary muscle. That underlying condition might itself need to be service-related. If the claimant has a brain stem stroke, there may be a separate SoP for stroke or for a specific neurological condition. The decision-maker would need to apply that SoP as well. This can create a layered causation analysis that is more demanding than the straightforward application of a single SoP. The instrument also interacts with the general law of causation in the VEA and MRCA. Even if a factor is present, the condition must still be related to service. Section 10 reinforces that the factor itself must be service-related. This means that the veteran’s service history must be assessed for each factor. The instrument does not displace the requirement that the claimant must establish a connection between service and the factor; it merely defines what factors, if service-related, are sufficient to link the accommodation disorder to service. The instrument also interacts with Medicare and private health insurance. If a condition is accepted as service-related, treatment costs may be covered by the Department of Veterans’ Affairs rather than by Medicare or private insurance. This shifts costs from the general health budget to the veterans’ compensation budget, but it does so through a separate administrative mechanism. The instrument also interacts with the common law of tort. A veteran who is compensated under the VEA generally cannot also sue the Commonwealth in tort for the same injury, because the VEA provides an exclusive remedy for service-related conditions. The instrument therefore affects the viability of any potential negligence claim by making it easier to obtain statutory compensation. Finally, the instrument interacts with state workers’ compensation schemes. Since it applies only to relevant service under Commonwealth law, it does not affect state or territory workers’ compensation for defence personnel engaged in non-Commonwealth activities. However, in practice, most defence service is under Commonwealth jurisdiction, so the instrument effectively covers the field.

The instrument is a legislative instrument registered on the Federal Register of Legislation. It repeals the Statement of Principles concerning accommodation disorder (Balance of Probabilities) No. 39 of 2017 (F2017L00889). That earlier instrument was likely similar in structure but may have had different factors, definitions, or lists of medications. The RMA periodically reviews and updates SoPs based on new medical-scientific evidence or changes in ICD coding. This instrument cites the Tenth Edition of ICD-10-AM effective 1 July 2017, which suggests that the medical classification reference has not changed since the previous instrument. The 2026 instrument commences on 23 March 2026. Between the date of making (20 February 2026) and commencement, stakeholders had approximately one month to familiarise themselves with the changes. There is no transitional provision in the instrument; it applies to claims made on or after commencement, regardless of when the underlying medical condition arose. This is typical for SoPs. The instrument does not explain why the 2017 instrument was replaced. There is no explanatory memorandum attached to the source text. The RMA’s reasons for amending are not stated in the instrument itself. However, the authority is required by the VEA to review SoPs from time to time. The 2026 version may reflect updated medical evidence on the relationship between medications and accommodation disorder, or it may expand or contract the list of recognised factors. In particular, the list of specified medications is very long and includes many drugs not typically associated with accommodation disorder; it is possible that the RMA added new drugs based on emerging literature. The repeal provision is explicit: the 2017 instrument is repealed. This means that any previous reliance on the old instrument for claims determined after 23 March 2026 is invalid. Practitioners must ensure they are using the current version. The instrument does not indicate whether there are any pending amendments or whether the RMA plans further reviews. This is a self-contained replacement.

The source text does not mention any litigation history. However, Statements of Principles are frequently litigated in the Administrative Appeals Tribunal and the Federal Court. Common grounds of challenge include: whether the RMA had sufficient medical evidence to support a factor; whether a factor was properly defined; whether the instrument is consistent with the parent Act; and whether the decision-maker applied the correct factors. For accommodation disorder specifically, litigation is likely to centre on the definitions and exclusions. For example, disputes may arise over whether a condition is presbyopia or accommodation disorder, or whether a medication could reasonably have been ceased or substituted. The “inability to obtain appropriate clinical management” factor (factor 7) is inherently ambiguous and invites litigation about what constitutes appropriate clinical management and whether the veteran had access to it. The factor does not specify who bears the burden of showing inability; it merely requires existence at the time of clinical worsening. The Federal Court has considered similar factors in other SoPs and has held that “inability to obtain appropriate clinical management” requires a factual inquiry into the availability and reasonableness of treatment options. The court has also considered the meaning of “cannot be ceased or substituted” in other medication-linked SoPs. There is a body of case law interpreting the VEA’s standard of proof and the operation of SoPs. For accommodation disorder, there may be few published decisions because it is a relatively rare condition, but the principles from other SoPs apply by analogy. The instrument’s reliance on the dictionary definition of “an injury or disorder affecting the function of the oculomotor nerve or ciliary muscle” is broad and could capture many neurological conditions. Litigation may test whether a particular pathology, such as multiple sclerosis or a brain stem tumour, falls within that definition. The exclusion of accommodative excess and refractive errors is likely to be a battleground, because these are common findings in optometric assessments. Claimants may argue that their condition is not exclusively accommodative excess but includes inability to sustain adjustment, pushing it into the definition. Decision-makers will need robust medical evidence to distinguish between excluded and included conditions. Veterans’ advocates may also challenge the instrument itself under the Administrative Decisions (Judicial Review) Act 1977 on grounds that the RMA failed to consider relevant medical evidence or that the factors are irrational. However, such challenges are difficult because the RMA has broad discretion. Overall, the litigation history of each SoP is individual, but the framework is well-settled.

Several provisions in this instrument could trip up claimants, advocates, and decision-makers. The first major gotcha is the exclusion of presbyopia, myopia, hypermetropia, and astigmatism from the definition of accommodation disorder. Many veterans with age-related difficulty focusing will not qualify, regardless of service factors. It is crucial to obtain objective evidence that the condition is truly accommodative insufficiency rather than presbyopia. The second gotcha is the “cannot be ceased or substituted” condition that appears in factors 4, 5, and the exclusion for reversible pharmacological paralysis. This is a high bar. If a veteran is taking a listed medication but there is a clinically appropriate alternative that could be prescribed, the factor will not be met. The instrument does not define “cannot”, inviting interpretations such as medical contraindication, unavailability of alternative, or patient refusal. The RMA’s notes suggest that the exclusion only applies where the pharmacological agents cannot be ceased or substituted, implying a narrow exception. For medications that are temporary or elective, the factor will fail. Third, the “inability to obtain appropriate clinical management” factor is a trap. It applies only to clinical worsening, not clinical onset. To use this factor, the veteran must show that before the worsening, they could not get appropriate management, and that this failure contributed to the worsening. If the veteran received any treatment, even if inadequate, a decision-maker might find that management was available but not accessed. Moreover, “appropriate clinical management” is not defined, leaving room for disputation. Fourth, the medication list in the dictionary is extensive and includes many drugs not commonly considered to cause accommodation disorder, such as beclomethasone dipropionate (a corticosteroid inhaler) and emetine (ipecac). Claimants may be surprised to find that taking a common asthma inhaler could be a factor, but they also must prove it cannot be ceased or substituted. The list includes chloramphenicol (antibiotic), isoniazid (tuberculosis drug), and lithium (mood stabiliser). Claimants taking these medications will need to establish the temporal connection and the inability to substitute. Fifth, the instrument uses the concept of “clinical onset” and “clinical worsening” but does not define them. In other SoP litigation, “clinical onset” means the time when a person first becomes aware of symptoms or when a medical diagnosis is made, but the exact point can be disputed. Sixth, section 10(2) restricts the clinical worsening factor to cases where the accommodation disorder was suffered or contracted before or during service but did not arise out of service. If the veteran’s accommodation disorder arose out of service, the clinical worsening factor does not apply because the whole condition is already service-connected. This nuance may confuse advocates who try to use the factor to bolter a weak case. Seventh, the instrument applies to death from accommodation disorder, but only where a terminal event was contributed to by the accommodation disorder. This requires evidence of causation even if the accommodation disorder was not the direct cause of death. For example, if a veteran with accommodation disorder falls and breaks a hip, which leads to pneumonia and death, the death may be compensable, but only if the accommodation disorder contributed to the fall. Proving that chain may be difficult. Eighth, the instrument incorporates other Statements of Principles by reference. If a factor refers to a condition (e.g., concussion), and there is a separate SoP for concussion, the claimant must satisfy that SoP as well. This can multiply the evidentiary requirements. Ninth, the dictionary definition of “an injury or disorder affecting the function of the oculomotor nerve or ciliary muscle” is extremely broad, covering any pathological process along the nerve’s course. This could include conditions like diabetes-related neuropathy or even microvascular disease. Claimants may be able to rely on this factor even without a clear traumatic event, but they must still show the injury or disorder is related to service. Finally, the instrument has no grandfathering. A claim that was partially prepared under the 2017 instrument may be disadvantaged if the new instrument narrows or alters the factors. Practitioners must check the commencement date carefully.

For claimants and their representatives, compliance with this instrument means gathering evidence that at least one of the seven factors existed at the time of clinical onset or clinical worsening and that the factor is related to relevant service. The first step is to obtain a definitive diagnosis of accommodation disorder that excludes presbyopia, cataract, myopia, hypermetropia, astigmatism, and accommodative excess. An optometrist or ophthalmologist should provide a report confirming the inability to adjust or sustain lens adjustment, ideally with objective testing such as amplitude of accommodation measurements. Second, obtain a detailed service history to identify any episodes of concussion or moderate to severe traumatic brain injury. This may require reviewing medical records from defence force service, deployment records, and incident reports. For concussions, there must be evidence of the event and a diagnosis. For traumatic brain injury, the severity classification should be documented. Third, compile a complete medication history, both prescription and over-the-counter. If the veteran is taking any drug from the specified list or an atropine-like medication, collect evidence that the medication cannot be ceased or substituted. This requires a treating doctor’s opinion that: (a) the medication is necessary for a valid medical condition; (b) no safe and effective alternative exists; and (c) ceasing the medication would cause unacceptable harm. If the medication was only taken temporarily and then stopped, the factor will not apply unless the veteran can show that at the time of clinical onset or worsening, the medication could not be ceased or substituted. For the atropine-like factor, provide evidence that the medication has anticholinergic properties and that accommodation disorder developed while on therapy. For the specified list factor, simply show the drug is on the list and the “cannot cease” condition. Fourth, if relying on factor 7 (inability to obtain appropriate clinical management), document all attempts to access treatment for accommodation disorder, including any delays, refusals, or lack of available specialists. This factor applies only to clinical worsening, so the veteran must show that the accommodation disorder was present before the worsening and that appropriate management was not available, leading to deterioration. Fifth, ensure that the factor is related to relevant service. For medication factors, if the medication was prescribed for a service-related condition, that link is easier. If the medication was prescribed for a non-service condition, the factor itself (the taking of the medication) must be related to service. This could be difficult unless the veteran can argue that the medication was prescribed due to a service-related injury. Sixth, if the claim involves death, obtain a medical opinion that accommodation disorder contributed to a terminal event. Seventh, for decision-makers, compliance means applying the factors strictly. Do not accept a factor if the evidence does not satisfy the definition. For example, a report that simply says “difficulty focusing” without excluding presbyopia is not enough. Decision-makers should request specific evidence on the “cannot be ceased or substituted” condition rather than taking the claimant’s word. They should also verify that the factor existed at the correct time (onset or worsening). If a factor refers to another SoP, ensure that SoP is applied. Eighth, advocates should update their precedents and training materials to reflect the 2026 instrument. The long list of medications should be circulated to medical witnesses to streamline evidence gathering. Ninth, the RMA should ensure that the instrument is published and accessible; compliance from the public requires notice. Tenth, for taxpayers and policymakers, monitoring the uptake of claims under this instrument can inform whether the factors are too broad. If the number of accepted accommodation disorder claims rises sharply, it may indicate that the factors are being met too easily, imposing a cost that should be weighed against the intended benefit of compensating genuinely service-related injuries.