Statement of Principles concerning central serous chorioretinopathy (Balance of Probabilities) (No. 46 of 2018)

The central definition under s 6(2) is critical: central serous chorioretinopathy means a serous detachment of the neurosensory retina affecting central vision, and expressly includes acute, recurrent, and chronic serous retinal detachment. The exclusion of rhegmatogenous retinal detachment, choroidal neovascularisation, choroidal tumours, choroidal metastases, and posterior uveitis is deliberate - it confines the instrument to idiopathic central serous chorioretinopathy, which has a distinct risk‑factor profile. The ICD‑10‑AM code H35.7 is referenced only for administrative convenience; the legal definition in s 6(2) prevails over any clinical coding system.

The concept of “relevant service” is defined in the Schedule 1 dictionary to mean eligible war service (other than operational service) under the VEA, defence service (other than hazardous service and British nuclear test defence service) under the VEA, or peacetime service under the MRCA. This is a narrower class than all service - it excludes operational service, hazardous service, and British nuclear test defence service. In practice, this means the SoP applies primarily to peacetime or non‑operational defence service claims. Operational service claims under the VEA use a different causation standard (reasonable hypothesis) and different SoPs.

The factors in s 8 are the operational heart. They are: (1) systemic corticosteroid treatment (excluding inhaled) within 30 days before onset; (2) taking a drug from the specified list (ephedrine, fingolimod, MEK inhibitors, ecstasy, nasal sympathomimetic decongestants, ocriplasmin, or pseudoephedrine) at onset; (3) Cushing syndrome in the year before onset; (4) second or third trimester of pregnancy at onset; (5) chronic renal failure at onset; and parallel factors for clinical worsening in subsections 8(6)-(10), plus the catch‑all of inability to obtain appropriate clinical management (8(11)).

The instrument adopts a “balance of probabilities” evidentiary standard, consistent with s 120B(3) of the VEA for non‑operational service claims. The Repatriation Medical Authority’s basis statement in s 7 records that, on sound medical‑scientific evidence, it is “more probable than not” that CSC can be related to relevant service. This is a proactive finding by the RMA that justifies the instrument’s existence; it does not mean every claim with a factor succeeds, because the factor must also be related to the person’s service under s 9.

“Clinical onset” and “clinical worsening” are not separately defined, but their meaning is derived from case law and common usage. The instrument does not define “inability to obtain appropriate clinical management”, leaving it to be interpreted by decision‑makers. Given that factor 8(11) applies only to worsening, it likely covers situations where service‑related restrictions on access to timely ophthalmological care worsened the prognosis. The specified list of drugs is narrow and includes both prescription and illicit substances, notably ecstasy (methylenedioxymethamphetamine) - an acknowledgment of recreational drug use as a risk factor.

The dictionary definitions for chronic renal failure (glomerular filtration rate under 15 mL/min/1.73 m² for three months, need for dialysis or transplantation, or undergoing chronic dialysis) are precise and objective, minimising interpretive disputes.

The primary affected class is veterans and members of the Australian Defence Force who have rendered relevant service (as defined in the instrument) and who suffer from central serous chorioretinopathy or die from it. This includes former members claiming under the VEA for eligible war service or defence service, and current or former members claiming under the MRCA for peacetime service. It does not cover operational service, hazardous service, or British nuclear test defence service claims, which fall under different SoP frameworks. Because CSC is relatively rare and typically affects working‑age adults, the claimant population is likely small, but the financial stakes can be high: entitlements include medical treatment, incapacity payments, and permanent impairment lump sums.

Decision‑makers within the Department of Veterans’ Affairs (DVA), the Military Rehabilitation and Compensation Commission, and the Veterans’ Review Board are obliged to apply this instrument. The SoP effectively curtails their discretion: if no factor in s 8 exists, they must deny the claim, even if in a particular case a causal link appears plausible. This reduces decision‑maker error but also creates a gate‑keeping effect that may discourage certain claims.

Medical practitioners, particularly ophthalmologists, are indirectly affected. Their clinical opinions are now less likely to be outcome‑determinative; instead, the key factual questions are usually administrative: did the veteran take a corticosteroid injection, receive a prescribed drug from the list, have Cushing syndrome, or was the veteran in the second or third trimester of pregnancy at onset? Practitioners may need to record these exposures in medical notes to assist claimants. The Repatriation Medical Authority (RMA) itself is affected: it must keep the SoP under review and, if new medical evidence emerges, it may issue a replacement SoP.

The taxpayer funds the compensation system. Because the SoP narrows eligibility, it may reduce total payout costs for CSC compared to a regime without a rigid checklist - but only if the factors genuinely capture all service‑connected cases. If the factors are under‑inclusive, some veterans who would have succeeded under an open‑evidentiary system are excluded, reducing costs and liability but potentially shifting costs to other public programs (e.g., Medicare) or to the claimants’ private resources. The existence of factor 8(11) (inability to obtain appropriate clinical management) provides an escape valve for worsening cases that may otherwise fall outside the listed medical factors, which likely increases cost for those with poor service‑related access to care.

Legal practitioners and advocates for veterans must become familiar with the definitions and temporal windows. The 30‑day window for corticosteroids, “at the time of” clinical onset for the specified drug list, the one‑year window for Cushing syndrome, and the trimester requirement for pregnancy are strict. Failure to adduce evidence matching these windows results in claim denial, regardless of the strength of the underlying medical link.

The instrument does not impose duties on private persons; rather, it confers a right of a specific kind: the right to have a CSC claim assessed according to these codified factors. The practical effect is that a claimant who can demonstrate one of the factors in s 8, and that the factor is related to their relevant service, has a strong path to success on the balance of probabilities. The corresponding duty lies on the decision‑making authority to accept the claim if the evidence satisfies the factor and the service relationship.

The most significant duty hidden in the instrument is the obligation on the decision‑maker to apply the dictionary definitions strictly. For example, “chronic renal failure” requires a GFR below 15 for at least three months, or current dialysis, or transplantation need. A claimant with a GFR of 20 but with other evidence of renal impairment does not meet the factor. Similarly, “corticosteroid” treatment explicitly excludes inhaled corticosteroids, so a veteran using an asthma inhaler cannot rely on factor 8(1) or 8(6) for CSC onset or worsening.

For clinical worsening claims, factor 8(11) (“inability to obtain appropriate clinical management”) creates a duty on the decision‑maker to assess whether the person’s service circumstances prevented them from accessing proper treatment. This is a broad inquiry that could involve questions about availability of ophthalmologists at defence bases, deployment‑related barriers, or service‑induced financial constraints. The duty is to decide based on the evidence, not to presume inability.

There is also a cross‑referencing duty under s 10: if a factor in s 8 refers to another injury or disease for which a separate Statement of Principles exists, the decision‑maker must apply that SoP to determine whether the person has that factor. For instance, Cushing syndrome is not defined in this instrument; the decision‑maker must turn to the SoP for Cushing syndrome (if one exists) to see if the person’s condition meets that definition. This layered approach means a claimant cannot simply assert “I had Cushing syndrome” - they must satisfy the relevant SoP for that condition. This can increase evidentiary burdens.

Claimants have no duty under the SoP itself, but they bear the practical burden of proof (on the balance of probabilities) to establish the factor and the service connection. The instrument does not alter the standard of proof; s 120B of the VEA and s 339 of the MRCA remain the governing provisions. The SoP merely defines what counts as sufficient proof of causal connection.

The instrument does not create any new rights to review. The usual merits review and judicial review avenues apply. However, because the SoP is a legislative instrument, a claimant cannot challenge its validity in a claim proceeding - only through separate administrative law proceedings in the Federal Court, which is rare. In practice, the only practical right is to argue that the evidence satisfies the factor, or that the factor is related to service. If the factor is not met, the claim must be refused.

This instrument does not create any penalties or criminal offences. It is a rule for determining entitlement to benefits, not a prohibition or requirement backed by sanction. However, enforcement of its terms occurs through the claim and review process. If a decision‑maker fails to apply the SoP correctly, the claimant may seek merits review at the Veterans’ Review Board or the Administrative Appeals Tribunal, and ultimately judicial review in the Federal Court for jurisdictional error.

The practical “penalty” for a claimant who cannot satisfy a factor is denial of the compensation claim. There is no other adverse consequence. For a decision‑maker who deliberately or negligently misapplies the SoP, the consequence is potential reversal on review, which may lead to internal administrative consequences but no external penalty in the instrument itself. The SoP does not contain any civil penalty provisions, infringement notices, or enforcement mechanisms.

The absence of penalties is typical for a Statement of Principles. The RMA does not enforce compliance; its role ends at issuing the instrument. The DVA and MRCC are bound to apply it because the VEA and MRCA require them to have regard to the SoP. If they ignore it, the error can be corrected on review. There is no independent watchdog or prosecutorial body for SoP compliance.

Nevertheless, there is an indirect enforcement effect: a claimant who knowingly submits false evidence to meet a factor (e.g., falsely claiming corticosteroid treatment) could face fraud proceedings under the Criminal Code or the VEA’s own penalty provisions for false statements. This is general law, not specific to this SoP.

The instrument’s enforcement is thus entirely reactive: it operates as a gate that is opened by evidence. The “enforcement” is the logical consequence of the rule: if the evidence does not match, the gate stays shut. The decision‑making body has a positive duty to correctly apply the instrument; if it does not, the claimant’s remedy is to challenge the decision. This creates litigation risk for the government if decisions are made inconsistently, but that risk is managed through internal training and precedent.

The instrument operates as a delegated legislative instrument under the VEA and the MRCA. Its paramount interaction is with s 120B of the VEA and s 339 of the MRCA, which require the Commission to determine claims for non‑operational service by having regard to any relevant Statement of Principles determined under s 196B(3). The SoP is thus a mandatory relevant consideration. If the Commission ignores it, the decision is likely affected by jurisdictional error.

The SoP also interacts with other Statements of Principles. Section 10 provides that if a factor in s 8 refers to an injury or disease for which another SoP has been made, the decision‑maker must apply that SoP. For example, factor 8(3) (Cushing syndrome) triggers a need to consult the SoP concerning Cushing syndrome (if one exists). This creates a chain of causation: to establish the CSC factor, the claimant may need to first satisfy the Cushing syndrome SoP, which itself may require factors like corticosteroid use. This can lead to circularity and increased complexity.

The instrument interacts with the general law of evidence and the Administrative Appeals Tribunal Act 1975 in review proceedings. The Tribunal is bound to apply the SoP as a legislative instrument; it cannot substitute its own medical judgment about whether the condition is service‑related outside the factors.

The dictionary definition of “relevant service” specifically excludes operational service and hazardous service. This means that for operational service claims under the VEA, a different SoP (or the reasonable hypothesis standard without a SoP) may apply. The RMA may issue separate SoPs for operational service claims under s 196B(2), but the present instrument is made under s 196B(3) only. Thus, it does not apply to operational service.

The instrument also interacts with the Social Security Act 1991 and other compensation schemes indirectly. If a veteran receives compensation under VEA or MRCA for CSC, they may be precluded from also receiving social security disability support, due to the compensation preclusion provisions. But that interaction is governed by other laws, not this SoP.

Finally, the SoP is itself subordinate legislation. If it were inconsistent with the VEA or MRCA, the parent Act would prevail. However, the RMA has power to determine factors, and the instrument is consistent with the governing Acts.

This instrument, “Statement of Principles concerning central serous chorioretinopathy (Balance of Probabilities) (No. 46 of 2018)”, commenced on 28 May 2018. The RMA does not publicise a full amendment history within each SoP. However, because this is an instrument that replaced an earlier version, it is important to note that the RMA periodically reviews and revokes old SoPs and issues new ones. The current instrument’s number (No. 46 of 2018) suggests it was the 46th SoP made in 2018. The instrument itself contains no textual amendment history; it is a standalone new determination.

There is no indication that this SoP has been amended since its commencement. It remains in force as of the date of writing, subject to potential future revocation and replacement. The RMA often issues new versions after reviewing recent medical literature. A practitioner should check the Federal Register of Legislation to see if a later SoP has superseded this one. If a later SoP exists, it automatically revokes this one under s 196E of the VEA.

The amendment history is thus simple: one original instrument, no amendments. But the SoP numbering system indicates that the RMA makes multiple SoPs each year, and that CSC may have been revisited later. For example, there may be a “No. X of 2022” version. The reader should verify.

The SoP instrument itself has not been directly challenged in court, but its application in specific claims has been the subject of review at the Veterans’ Review Board and the Administrative Appeals Tribunal. There is a body of case law interpreting earlier versions of the CSC SoP, particularly concerning the definition of “corticosteroid” and the temporal requirement of “within the 30 days before the clinical onset.” Tribunals have considered whether delayed‑onset reactions can satisfy the 30‑day window. There is also case law on the meaning of “clinical worsening” and whether a mere fluctuation in symptoms qualifies.

The AAT has held that the factors are exhaustive and that a decision‑maker cannot invent new causal pathways. The instrument has been applied strictly. For example, a claimant who used prednisolone 35 days before onset would fail the 30‑day test, even if the corticosteroid was the likely cause. This rigid application has been upheld.

There is no High Court authority specifically on this SoP. However, the Full Federal Court has discussed the framework of Statements of Principles generally, including the standard of review and the role of the RMA. These decisions confirm that the RMA’s determination is binding and that the Tribunal cannot go behind it.

A search of AustLII would reveal AAT decisions referencing “central serous chorioretinopathy”. These typically involve disputes over whether the drug was taken, whether pregnancy was in the relevant trimester, and whether chronic renal failure existed at onset. The Catch‑22 for claimants is that many of the risk factors (corticosteroids, pregnancy, Cushing syndrome) are themselves associated with underlying conditions that may be unrelated to service.

Several traps lie in the fine print. First, the exclusion of inhaled corticosteroids (s 8(1) and (6)) is absolute. A veteran using an inhaled corticosteroid for asthma or COPD cannot rely on that factor, even if systemic absorption occurs. Only systemic corticosteroids (oral, injectable, topical potent enough to cause systemic effects) count. This is a source of frequent claim rejections because claimants often forget to distinguish inhaled from systemic.

Second, the specified list of drugs in Schedule 1 is exhaustive and narrow. It includes only ephedrine, fingolimod, MEK inhibitors, ecstasy, nasal sympathomimetic decongestants (e.g., oxymetazoline, but not all decongestants are sympathomimetic), ocriplasmin, and pseudoephedrine. Many other drugs that may be associated with CSC (e.g., anticholinergics, some antibiotics) are not listed. A claimant taking another drug cannot use factor 8(2) even if the drug causes CSC.

Third, the temporal windows are strict: 30 days for corticosteroids, “at the time of” for the specified drugs (meaning the drug must be present at onset, not necessarily taken within a specific window), one year for Cushing syndrome, and the second or third trimester for pregnancy. If a claimant had corticosteroid treatment 31 days before onset, factor 8(1) fails. The only potential extension is the inability to obtain clinical management factor (8(11)), but that applies only to worsening, not onset. This creates a structural gap.

Fourth, the catch‑all factor 8(11) is often misunderstood. It does not create a general “any inability to manage” factor; it requires that the inability to obtain appropriate clinical management itself caused the worsening. If the veteran had access to care but chose not to seek it, factor 8(11) does not apply.

Fifth, the definition of “relevant service” excludes operational service. A veteran with operational service cannot use this SoP but must rely on the “reasonable hypothesis” standard under s 120(1) of the VEA. Even if they have the same medical history, the evidentiary path is entirely different.

Sixth, factor 8(2) and 8(7) refer to “a drug or a drug from a class of drugs from the specified list”. The instrument does not define “class of drugs” further. This could be a source of dispute: is “nasal sympathomimetic decongestants” a class of drugs, or is each specific drug within that class the factor? The note to the dictionary defines the specified list of drugs as seven subparagraphs. Each subparagraph could be a “drug or a drug from a class”. The language is ambiguous.

Seventh, the instrument says nothing about dosage. For corticosteroids, any dose counts, even a single dose. For drugs, no minimum dose or duration is specified. This is generous to claimants but also means a single exposure could be sufficient if within the window.

Eighth, the note to section 8 says “specified list of drugs is defined in the Schedule 1 - Dictionary.” That definition is reproduced above. The definitions of “central serous chorioretinopathy” and “chronic renal failure” are critical to get right. A claimant with a GFR of 18 but only for two months does not have chronic renal failure under the definition.

Ninth, section 9(2) limits the clinical worsening factors (8(6)-(11)) to circumstances where the person’s CSC was suffered or contracted before or during (but did not arise out of) relevant service. If the CSC arose out of service, then the onset factors apply, not the worsening factors. This prevents double‑dipping but also means a veteran who developed CSC during service cannot then rely on a worsening factor for a later aggravation unless the aggravation is separate.

Tenth, the instrument is silent on multiple factors. If more than one factor exists, that is fine - only one is needed. But the decision‑maker must still ensure that the factor is related to service under s 9(1). A factor that exists but is unrelated to service (e.g., pregnancy unrelated to service) does not establish a connection.

For a claimant, compliance means gathering medical records that demonstrate one of the listed factors existed within the relevant temporal window to the clinical onset or worsening of CSC. The most straightforward paths are:

• Corticosteroid use: Obtain records of systemic corticosteroid administration (oral prednisone, IV methylprednisolone, intra‑articular injection, etc.) within 30 days before the first documented serous detachment. Exclude inhaled corticosteroids. The 30‑day window is from exposure to first symptom or diagnosis - if the diagnosis was delayed, the claimant should still rely on the date of onset as determined by medical opinion.
• Specified drug use: Document current use of ephedrine, fingolimod, MEK inhibitors, ecstasy, nasal sympathomimetics, ocriplasmin, or pseudoephedrine at the time of onset. Prescription records, drug‑chart entries, or self‑reported history (if credible) will suffice. For illicit drugs like ecstasy, the veteran may need to provide sworn evidence.
• Cushing syndrome: Provide a diagnosis of Cushing syndrome (confirmed by biochemical tests and clinical features) within one year before onset. The diagnosis itself must meet the SoP for Cushing syndrome if one exists - the claimant should check if a separate SoP applies.
• Pregnancy: For female veterans, record of pregnancy in second or third trimester at onset (ultrasound or obstetric records). This factor is time‑limited.
• Chronic renal failure: Demonstrate a GFR below 15 mL/min/1.73 m² for three consecutive months, or current dialysis, or documented need for renal replacement therapy at the time of onset. Renal function test results are essential.
• Inability to obtain clinical management (worsening only): This is harder. The claimant must show that service‑related circumstances (e.g., posting to a remote location, lack of access to ophthalmologist, inability to afford treatment due to service‑related financial hardship) prevented them from receiving appropriate care, and that this lack of care caused clinical worsening. Medical evidence of worsening and an opinion linking it to lack of access are needed.

For decision‑makers, compliance is a matter of matching the evidence to the factor and confirming the factor is related to service. The decision‑maker must not extrapolate beyond the factors. If the evidence is ambiguous, the decision‑maker may need to request further information before making a negative determination. The AAT has held that the decision‑maker cannot substitute a factor not listed.

For legal practitioners, compliance means meticulously checking the definitions. Do not assume that a condition labelled “renal failure” in a clinical note meets the definition - check the GFR and duration. Do not assume “steroid” means corticosteroid - check the route.

The instrument also imposes a need to stay updated: the RMA may issue a new SoP that revokes this one. Practitioners should check the Federal Register of Legislation before filing evidence. If a new SoP comes into force between the claim and the decision, the decision‑maker must apply the new SoP if it is in force at the time of decision, unless transitional provisions say otherwise.

Finally, for the Department, compliance involves training staff to recognise the factors and to ask the right questions: Did you take any steroids? Did you use any of these drugs? Were you pregnant? Have you been diagnosed with Cushing syndrome or chronic renal failure? Proper data collection at intake reduces later disputes.