Statement of Principles concerning central serous chorioretinopathy (Reasonable Hypothesis) (No. 45 of 2018)

Central serous chorioretinopathy (CSC) is defined as a serous detachment of the neurosensory retina affecting central vision, and includes acute, recurrent and chronic serous retinal detachment. It expressly excludes retinal detachment from a retinal tear (rhegmatogenous) and leakage through the retinal pigment epithelium caused by choroidal diseases such as neovascularisation, vasculopathy, tumours, metastases and posterior uveitis. This definition narrows the scope of conditions eligible for the causal link. The instrument operates under the “reasonable hypothesis” standard, a lower evidentiary threshold than proof on the balance of probabilities. However, the RMA has codified this standard by specifying exactly what factual elements must exist before a hypothesis can be considered reasonable. There are two groups of factors: factors relating to clinical onset (subsections 8(1) to 8(9) and 8(18)) and factors relating to clinical worsening (subsections 8(10) to 8(17) and again 8(18)). “Clinical onset” and “clinical worsening” are not separately defined in the instrument, but they are standard terms in military compensation law. The dictionary defines key terms: “chronic renal failure” means a glomerular filtration rate below 15 mL/min/1.73m2 for at least three months, a need for renal replacement therapy, or chronic dialysis. “Primary hyperaldosteronism” means excess endogenous aldosterone production from adrenal hyperplasia, adenoma, carcinoma or ectopic source. “Specified list of drugs” includes ephedrine, fingolimod, MEK inhibitors, MDMA (ecstasy), nasal sympathomimetic decongestants, ocriplasmin, phosphodiesterase-5 selective inhibitors (sildenafil, tadalafil, vardenafil), pseudoephedrine, and testosterone. “Relevant service” is defined in the dictionary and includes operational service, peacekeeping service, hazardous service, British nuclear test defence service under the VEA, and warlike or non-warlike service under the MRCA. The instrument also cross-references other Statements of Principles where a factor refers to an injury or disease covered by another SoP (section 10), meaning that the factors for that underlying condition must also be satisfied. This interlocking framework creates a cascading set of evidentiary requirements, increasing the compliance burden for claimants who have multiple conditions.

The primary group affected are veterans, members of Peacekeeping Forces, and members of the Forces under the VEA, as well as members under the MRCA, who suffer or have suffered from central serous chorioretinopathy and who make a claim for compensation or medical treatment. Their dependants may also be affected if death from CSC is claimed. The instrument directly binds the Repatriation Commission and the Military Rehabilitation and Compensation Commission in determining such claims. It also affects Veterans’ Review Boards, the Administrative Appeals Tribunal, and the Federal Court when reviewing decisions. Medical practitioners who provide reports or give evidence in support of claims must be familiar with the specific factors, including the time windows (e.g., corticosteroid treatment within 30 days before clinical onset). The specified list of drugs touches on prescribers: doctors who prescribe drugs like PDE5 inhibitors, testosterone, ephedrine, or pseudoephedrine to veterans may inadvertently create a causal pathway for a claim. However, the instrument does not impose any duty on prescribers; it is the existence of consumption, not prescription, that matters. The instrument can influence private choices: a veteran who uses sildenafil (a PDE5 inhibitor) for erectile dysfunction may later need to show that the use was related to their service, which may require evidence of a service-related cause for the underlying condition. The free-market lens suggests that the instrument could have a chilling effect on legitimate medical choices where the prescribed drug appears on the specified list, because a subsequent CSC claim may be harder to resist, but the instrument does not itself prohibit or tax any medication. The economic burden of successful claims falls on consolidated revenue. The instrument also affects the private insurance industry indirectly; veterans who are compensated under VEA or MRCA may have reduced reliance on private health insurance or workers’ compensation, but that is a downstream effect. The narrow disease definition excludes many veterans who have retinal detachment from other causes, limiting the class of potential claimants.

The instrument creates a right for a claimant to have a claim for CSC accepted as service-related if at least one factor in section 8 is present and that factor is related to the person’s relevant service. This right is contingent on satisfying the evidentiary requirements of the factor, including any temporal limitations. There is no right to have a claim accepted on a causal theory not listed; the instrument operates as a closed list. The duty on the decision-maker is to apply the instrument in assessing whether a reasonable hypothesis exists. Under section 9, every factor must be related to relevant service; a factor that arises from a non-service source (e.g., taking pseudoephedrine for a cold unrelated to service) will not automatically satisfy the test unless the consumption itself is related to service. Section 9(2) further provides that the clinical worsening factors (8(10) to 8(18)) apply only where the person’s CSC was suffered or contracted before or during, but did not arise out of, their relevant service. This means that a person who developed CSC entirely after service cannot rely on a worsening factor to bring the condition within the scope of the claim; only clinical onset factors apply. The instrument imposes no duties on private citizens or businesses; it is entirely a framework for administrative decision-making. The right of review under the VEA and MRCA exists independently. The instrument’s effect is to reduce the scope for medical opinion evidence: once the RMA has determined that a factor exists, decision-makers and tribunals are bound by that determination. This can be seen as reducing the cost and variance of litigation, but also as limiting the ability of a claimant to advance a novel medical theory. The specified list of drugs is exhaustive, so a claimant taking a drug not on the list but which nonetheless may cause CSC (if future research finds) cannot rely on that factor. This creates a risk of under-compensation for veterans who suffer from a condition caused by a drug not yet recognised by the RMA.

The instrument itself does not contain any penalty provisions. It is not a regulatory instrument that imposes fines or sanctions on individuals or entities. Enforcement of the requirements of the instrument occurs through the normal processes of the VEA and MRCA. If a decision-maker fails to apply the instrument correctly, the claimant can seek review by the Veterans’ Review Board, and then appeal to the Administrative Appeals Tribunal and the Federal Court. The ultimate enforcement mechanism is judicial review for error of law. There is no criminal sanction for non-compliance by claimants; they merely risk having their claim rejected. The Repatriation Commission is under a public law duty to apply the instrument, and failure to do so could lead to a direction from the tribunal. The instrument is made by the RMA under a statutory power, and the RMA itself is subject to oversight, but not directly by this instrument. The absence of penalties means that the instrument relies on the incentives of the claims process: decision-makers have an incentive to apply it correctly to avoid being overturned on review, and claimants have an incentive to adduce evidence fitting the factors. The specified list of drugs could, in theory, be seen as creating a “safe harbour” for the government: if a drug is not on the list, the government can resist claims, even if there is emerging evidence of a causal link. This creates an incentive for drug manufacturers to lobby the RMA to have their drugs added or removed, representing a potential rent-seeking risk. However, the instrument’s enforcement mechanisms are administrative and judicial, not penal.

This instrument is made under the VEA and is a legislative instrument for the purposes of the Legislation Act 2003. It interacts primarily with the VEA (section 120A) and the MRCA (section 338). Those provisions require that a claim cannot be determined unless the decision-maker has regard to any relevant Statement of Principles determined by the RMA. This means the instrument overrides general common law principles of causation in tort or workers’ compensation where they would otherwise apply to VEA/MRCA claims. It also interacts with other Statements of Principles through section 10: if a factor in this instrument (e.g., having chronic renal failure) refers to a condition covered by another SoP, the factors for that condition must also be satisfied. This creates a layered causation test. For example, a veteran claiming CSC due to chronic renal failure must also show that the chronic renal failure is itself related to service under the relevant SoP for renal failure. The instrument does not interact with state workers’ compensation schemes, private health insurance, or the tort system, except to the extent that compensation paid under the VEA may reduce or preclude other claims under the Safety, Rehabilitation and Compensation Act 1988 or common law. The ICD-10-AM coding reference (H35.7) only applies for classification purposes; the definition of CSC in subsection 6(2) is legally authoritative over the code. The instrument does not amend the Therapeutic Goods Act or any prescribing rules. It does not interact with medical indemnity insurance or professional standards for optometrists or ophthalmologists, other than indirectly through the evidence they may provide. The definition of “relevant service” incorporates terms from both VEA and MRCA, meaning the instrument applies to diverse service types, including British nuclear test defence service, which is a narrow category. The interaction with state laws is minimal because the VEA and MRCA are Commonwealth legislation.

The source text does not provide any amendment history. The instrument is titled “(No. 45 of 2018)”, and it commences on 28 May 2018. It is the current version. The RMA routinely reviews and revokes or replaces Statements of Principles as medical-scientific evidence evolves. A reasonable inference is that this instrument replaced an earlier SoP on central serous chorioretinopathy once the RMA considered new evidence sufficient to justify a new determination. The fact that it is numbered 45 of 2018 suggests it was one of many SoPs made in that year. The instrument may itself be revoked by a later SoP. In practice, claimants and decision-makers must check whether the instrument is still in force at the time of the claim, because a claim may be decided under an earlier or later version depending on the date of claim and the transition provisions in the VEA. The instrument does not contain a sunset clause; it continues until revoked. The absence of an explicit amendment history in the source means that anyone applying this instrument must conduct their own search for any amending instruments or revocations. This is a compliance burden for legal professionals: they cannot rely solely on a printed version; they must check the Federal Register of Legislation for up-to-date status.

The source text does not cite any litigation history. This is typical for a Statement of Principles; the instrument itself is not a court judgment. However, Statements of Principles have been the subject of extensive litigation in the Veterans’ Affairs jurisdiction. For example, the Federal Court has considered whether the RMA’s determinations were validly made, whether the factors were supported by sound medical-scientific evidence, and what constitutes a “reasonable hypothesis”. This particular instrument may have been challenged or applied in specific cases, but the source does not mention any. It is safe to state that any SoP can be judicially reviewed if it exceeds the RMA’s power under section 196B of the VEA. In practice, the High Court in Repatriation Commission v Hill (2002) and later cases have shaped the test for reasonable hypothesis, but the source does not name these cases, so they cannot be referenced except as general knowledge. The instrument itself does not create a cause of action; litigation arises from individual claim decisions. Therefore, the litigation history of this exact SoP is not accessible from the source. The precaution for the reader: any legal advice on applying this instrument must search for recent tribunal and court decisions that have interpreted the factors, particularly the temporal requirements and the definitions of chronic renal failure and primary hyperaldosteronism.

Several subtle features create traps for the unwary. First, factor 1 (corticosteroid treatment within 30 days before clinical onset) and factor 10 (corticosteroid treatment within 30 days before clinical worsening) require careful calculation of the 30-day window. A single dose outside that window will not satisfy the factor. The instrument does not say “any corticosteroid” but “being treated with a corticosteroid” - this includes topical, inhaled, or systemic administration? The source does not define “corticosteroid” further, so typical medical usage applies, but disputes could arise over nasal sprays or eye drops. Second, the specified list of drugs includes “nasal sympathomimetic decongestants” - a broad class that includes over-the-counter products. A veteran using a common cold remedy may inadvertently bring a claim within the factor. However, the note under factor (2) refers to the “specified list of drugs” which is defined in the dictionary. That definition lists only nine specific drugs or drug classes. It does not include all decongestants; only “nasal sympathomimetic decongestants” generically (category e). The scope of that category is ambiguous - does it include oral decongestants that are sympathomimetic? The dictionary item e says “nasal sympathomimetic decongestants”, which suggests only those administered nasally, not oral ones. This ambiguity is a gotcha. Third, factor 18 is “inability to obtain appropriate clinical management for central serous chorioretinopathy.” This factor can apply to both clinical onset and worsening. It does not require a specific time window; it is a continuing state. The term “inability to obtain” has no definition - it could refer to lack of access to an ophthalmologist, unavailability of treatment, or a medical decision that no treatment is warranted. This could be a broad catch-all, but it also carries risk for the government of claims based on delays in the healthcare system. Fourth, the temporal requirements for pregnancy: “being in the second or third trimester of pregnancy at the time of the clinical onset (or worsening).” This means a veteran who develops CSC in the first trimester cannot rely on this factor. Fifth, the definition of chronic renal failure requires a GFR below 15 for at least three months or a need for renal replacement therapy. A temporary acute renal injury would not qualify. Sixth, for primary hyperaldosteronism, the definition includes ectopic aldosterone-producing adenomas, but the condition must be diagnosed; subclinical excess may not be enough. Seventh, section 9(2) clarifies that worsening factors only apply if the person had CSC before or during service but did not arise from service. This means that a person who develops CSC entirely after service (e.g., years after discharge) cannot rely on a worsening factor to argue aggravation; only onset factors apply. Many practitioners may overlook this limitation. Eighth, the instrument cross-references other SoPs under section 10 - a factor like “chronic renal failure” itself must be service-related under its own SoP. This creates a double causation requirement.

Compliance with this instrument is primarily a task for decision-makers within the Repatriation Commission and tribunals, not for private individuals or businesses. However, for legal practitioners assisting veterans, compliance means systematically checking each factor against the evidence. Step one: obtain a definitive diagnosis of central serous chorioretinopathy as defined in subsection 6(2). A mere ICD code H35.7 is insufficient; the report must confirm serous detachment of the neurosensory retina and exclude the listed exclusions. Step two: identify whether the claim relates to clinical onset or clinical worsening. If the condition existed before service but did not arise from service, only worsening factors can be used (plus factor 18). If the condition arose during service or after, onset factors apply. Step three: for each potential factor, gather evidence of the timing. For corticosteroid use (factors 1 and 10), documentary evidence of prescription, dispensing, or administration within the 30-day window must be available. For drugs on the specified list (factors 2 and 11), confirm that the drug was taken at the time of onset or worsening - not just prescribed, but actually consumed. For Cushing syndrome, primary hyperaldosteronism, chronic renal failure, hypertension, and Helicobacter pylori infection, ensure that the diagnosis meets the instrument’s definitions and that it existed within the stated time frame. For pregnancy (factors 5 and 14), obtain obstetric evidence of gestational age. For blunt trauma (factor 9), obtain a history and documentation of trauma within two weeks. Factor 18 (inability to obtain appropriate clinical management) requires evidence that management was sought but not available or not provided - this could include medical records showing failed referrals, waitlists, or contraindications to treatment. Step four: relate the factor to relevant service under section 9. This may require evidence that the corticosteroid was prescribed for a service-related condition, or that the drug use (e.g., pseudoephedrine for a sinus condition) was itself due to service. Step five: if a factor refers to another condition (e.g., chronic renal failure), ensure that the conditions of the applicable Statement of Principles for that condition are also satisfied. The decision-maker must retain all evidence on file and assess the hypothesis as reasonable. There is no requirement to prove the factor on the balance of probabilities; only that there is some evidence pointing to its existence. However, the instrument is binding, so creative arguments outside the factors will not succeed. For veterans, the best approach is to ensure comprehensive medical records that document all medications, illnesses, and injuries during and after service, because a claim may depend on establishing precise temporal relationships. For prescribers, there is no direct compliance duty, but awareness of the specified list may alert them to potential claim implications; they should record the clinical reason for prescribing any listed drug, as that could assist a subsequent claim.