Statement of Principles concerning conjunctivitis (Reasonable Hypothesis) (No. 76 of 2020)

This instrument is a Statement of Principles (SOP) under the Veterans' Entitlements Act 1986 (VEA) that sets the medical‑scientific criteria for when a "reasonable hypothesis" is raised linking conjunctivitis (and death from conjunctivitis) to a person’s relevant service. The instrument is made by the Repatriation Medical Authority under subsection 196B(2) of the VEA (s 3). It applies to claims where section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 (MRCA) is engaged (s 5). The SOP therefore operates as a medical‑evidentiary rule used by decision makers assessing entitlement claims under those statutes.

Mechanically, the instrument does three things. First, it defines the condition to which it relates: conjunctivitis, including blepharoconjunctivitis and keratoconjunctivitis (s 7(1)-(3)). It states the ICD‑10‑AM codes associated with conjunctivitis for reference (s 7(3)-(4)), but expressly provides that the legal meaning is the clinical definition in s 7(2). Second, it records the RMA's view that there is sound medical‑scientific evidence that conjunctivitis and death from conjunctivitis can be related to relevant service (s 8). Third, and most practically, it lists the alternative factors , specific clinical states, exposures, timings and drug associations , of which at least one must exist before a reasonable hypothesis is considered raised that links conjunctivitis (or death from it) to relevant service (s 9). The instrument also specifies timing rules for aggravation/material contribution where the condition pre‑existed service (s 10(2)), and how to treat factors that refer to other SOPs (s 11).

The SOP is not itself an entitlement provision. It does not create benefits or administrative remedies; rather it provides a statutory medical standard used in the adjudication of claims under the VEA and MRCA. For claims assessors and medical reviewers, the SOP prescribes both the universe of accepted risk factors and the temporal thresholds (for example, exposure within 24 hours, topical medication within 48 hours, drug use for at least seven days prior, or improvement within seven days of stopping a drug) that convert clinical findings into a legally significant link to relevant service (s 9). The Schedule supplies definitions that refine those factors (Schedule 1).

The instrument has been compiled and amended; the original SOP was registered 2 November 2020 and commenced 30 November 2020, and an amendment instrument (No. 90 of 2022) commenced 19 September 2022 (Endnote 3). The 2022 amendment added a sensitising exposure factor (s 9(5A)) and its definition in the Schedule (Endnote 4). Decision makers must apply the SOP as in force from time to time; the instrument expressly contemplates that factors may refer to, and import, other SOPs (s 11).

The SOP concentrates on three interlocking legal‑medical concepts: the definition of the injury, the RMA's view as the evidentiary basis, and the list of factors that raise a reasonable hypothesis linking the injury to relevant service.

Definition of the injury: Conjunctivitis is defined as inflammation of the conjunctiva and includes blepharoconjunctivitis and keratoconjunctivitis (s 7(2)). While four ICD‑10‑AM codes are identified (H10, H13.1, H13.2, H16.2), the instrument stresses that the operational meaning for the SOP is the clinical definition in s 7(2) (s 7(3)-(4)). For death claims, conjunctivitis includes death from a terminal event or condition that was contributed to by the person's conjunctivitis; "terminal event" is defined in the Schedule and includes proximate or ultimate causes such as pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function (s 7(5); Schedule).

RMA’s evidential posture: Section 8 records the RMA's view that "sound medical‑scientific evidence" shows conjunctivitis and death from conjunctivitis can be related to relevant military service. That statement supplies the statutory justification for prescribing the factors in s 9 but does not itself specify how the RMA or decision makers quantify or weigh "sound medical‑scientific evidence" in a particular case. The SOP is therefore a proxy for an evidentiary standard: it signals which clinical findings and exposures the RMA regards as sufficiently linked to service to raise a reasonable hypothesis.

Factors raising a reasonable hypothesis: Section 9 contains a long, alternative list of discrete factors, any one of which suffices as the minimal requirement to raise a reasonable hypothesis. The list includes pre‑existing ocular conditions (for example blepharitis, infection of the conjunctiva, specified anatomical conditions) at the time of clinical onset (s 9(1)-(4)); exposures shortly preceding onset such as ocular exposure to an allergen, irritant, foreign body, mustard gas, or injury to the conjunctiva, with specific time windows typically expressed as "within 24 hours" (s 9(5), (12)-(16)); medication and drug associations with specified timing rules (topical medication within 48 hours; drugs from the specified list taken for at least seven days; drug‑induced onset/worsening with improvement on discontinuation within seven days or redevelopment on rechallenge) (s 9(9)-(11), (27)-(29)); immunological and systemic states (autoimmune disease, graft versus host disease, diabetes mellitus, immunocompromised states as specified) (s 9(6)-(8), (24)-(26), (36)); and one operationally significant non‑medical factor , inability to obtain appropriate clinical management for conjunctivitis (s 9(37)). The Schedule supplies definitions (for example, "immunocompromised state as specified", "infection of the conjunctiva", "injury to the conjunctiva", "specified list of drugs" etc.) that calibrate these factors.

Primary affected groups

• Veterans, members of Peacekeeping Forces and members of the Forces whose claims are assessed under VEA provisions (notably s 120A) or members under the MRCA where s 338 applies. The SOP applies to "a claim to which section 120A of the VEA or section 338 of the MRCA applies" (s 5). Those persons are the claimants who may rely on these factors to establish a reasonable hypothesis linking conjunctivitis or death from conjunctivitis to relevant service.

• Decision makers within the Department responsible for adjudicating VEA and MRCA claims. Although the instrument does not itself impose administrative procedures, it is a statutory instrument produced by the Repatriation Medical Authority (s 3) and will be used as the medical standard when assessing claims. Medical assessors and statutory decision makers will apply these factors as part of their assessment toolkit.

Secondary affected groups

• Treating clinicians and medical experts who prepare clinical reports and opinions for claims. The SOP sets out specific clinical findings, timing windows and definitions (Schedule 1) that clinicians must address in their reports if they are to establish a reasonable hypothesis under the SOP. Examples: documentation of blepharitis at onset, records of an allergen exposure within 24 hours, medication histories showing seven days of exposure, and evidence of improvement within seven days of stopping a drug where drug‑induced conjunctivitis is alleged (s 9).

• Administrators and case managers handling evidence gathering, who will need to secure particular types of contemporaneous clinical records, medication histories, exposure histories and, where relevant, evidence of inability to access clinical management (s 9(37)).

• Lawyers, advocates and representatives advising claimants. They must frame evidence against the SOP’s discrete factors and temporal thresholds and consider whether a factor is "related to the relevant service" per s 10(1) and whether aggravation/material contribution rules in s 10(2) apply.

Tertiary effects and institutions

• The Repatriation Medical Authority (RMA) itself, which maintains and updates SOPs, and other statutory bodies relying on these SOPs for consistency in assessment.

• Providers of ICD coding and hospital data where the SOP references ICD‑10‑AM codes (s 7(3)-(4)). The instrument specifies the Tenth Edition effective 1 July 2017 as the edition relied on for code cross‑reference, which affects mapping of records to the SOP (s 7(4)).

Statutory duty‑like effects

• Use of the SOP in assessments: While the instrument itself does not explicitly direct administrative processes, it is made under s 196B(2) of the VEA (s 3). SOPs determined under that power function as the statutory medical standard for whether a reasonable hypothesis exists; hence decision makers assessing claims under s 120A of the VEA or s 338 of the MRCA will apply this SOP when determining if a medical link to service has been raised (s 5). The practical effect is that decision makers must take the SOP into account in reaching decisions about medical causation for the listed condition.

Claimant rights and entitlements

• The SOP creates a legal pathway for claimants: if a claimant adduces evidence that at least one of the factors in s 9 existed and was related to relevant service, a "reasonable hypothesis" can be said to be raised under the statutory framework. That raises the legal standard necessary to trigger further statutory presumptions or evidentiary inferences within the VEA/MRCA claims process (the SOP itself is part of that chain). The instrument does not itself confer benefits; benefits remain subject to the substantive and procedural rules of the VEA and MRCA.

Duties on medical reporters and treating clinicians

• Evidentiary specificity: The SOP’s enumerated factors impose an evidentiary expectation on expert medical reports. Reports that do not address the specific factors (for example provide no medication history covering the seven‑day threshold, or omit timing of exposures within 24 or 48 hours) risk failing to raise a reasonable hypothesis under the SOP. For alleged drug‑induced conjunctivitis, the SOP requires either improvement within seven days of stopping drug therapy or redevelopment on rechallenge, where treatment lasted at least seven days before onset (s 9(11), (29)). A clinician’s duty in practice is to document these permutations where relevant.

Duties on claim administrators

• Evidence gathering: Administrators must collate and present to decision makers the clinical evidence necessary to demonstrate one or more of the listed factors and their temporal relation to relevant service (s 9; s 10). For factors that refer to other SOPs, administrators must import and apply those other SOPs in accordance with s 11.

No criminal or civil penalties in the instrument

• The SOP contains no penalty provisions. It does not criminalise any act nor impose monetary penalties. Enforcement is administrative and procedural (application of the SOP to claims decisions), not penal.

No penal sanctions in the instrument

• The Statement of Principles contains no criminal, civil or administrative penalty provisions. The instrument itself prescribes medical evidentiary criteria; it does not establish offences or fines. There are no enforcement mechanics such as infringement notices, public enforcement agencies, or penal sanctions within its text.

Enforcement by administrative application

• Enforcement of the SOP takes place inside the adjudicative process of VEA and MRCA claims. The instrument is a statutory tool used by decision makers to determine whether a reasonable hypothesis linking conjunctivitis to relevant service exists. Where a decision maker finds, using this SOP, that a reasonable hypothesis has been raised, that finding triggers subsequent statutory consequences under the VEA or MRCA claims framework (the SOP does not itself specify those consequences; it plugs into the VEA/MRCA process , s 5). Conversely, where the SOP’s criteria are not met, decision makers may lawfully reject a claim on medical causation grounds pursuant to the substantive Act provisions applicable to the claim.

Decision maker responsibilities and judicial review

• Decision makers applying the SOP must record and reason how the facts meet (or do not meet) one or more of the factors in s 9 and must demonstrate the relationship to relevant service per s 10(1). Administrative decisions remain subject to the usual avenues of internal review and judicial review under administrative law. The SOP does not itself define review mechanisms; those are supplied by the VEA and MRCA frameworks and general administrative law.

Reliance on other SOPs

• Section 11 prescribes that, where a factor points to an injury or disease for which another SOP exists, the other SOP’s factors apply as they stand. Enforcement thus requires cross‑instrument application and coordination across SOPs. Failure to import or correctly apply another SOP where required could be an administrative error in a claims decision.

Practical enforcement implications for providers and claimants

• Although there are no statutory penalties for poor evidence, a claimant who fails to provide evidence that satisfies at least one factor in s 9 and the relationship to relevant service per s 10 will likely have their claim refused on causation grounds. The "sanction" is therefore non‑payment or denial of entitlements under the VEA/MRCA decision framework. This is an economic and procedural enforcement effect rather than a penal sanction.

Primary statutory interplay

• Veterans' Entitlements Act 1986 (VEA): The instrument is made under subsection 196B(2) of the VEA (s 3). It expressly applies to claims to which s 120A of the VEA applies (s 5). The SOP forms part of the VEA’s statutory architecture for medical causation in claims. While this instrument does not quote s 120A (which is outside the text provided), its application clause ties it directly into the substantive entitlement and procedural rules of the VEA.

• Military Rehabilitation and Compensation Act 2004 (MRCA): The instrument also applies where s 338 of the MRCA applies (s 5). That means the SOP governs reasonable hypothesis assessments for claims brought under the MRCA’s relevant provisions. The SOP therefore functions across the two legislative schemes used for veteran compensation and rehabilitation.

Cross‑referencing to other Statements of Principles

• Section 11 provides an active cross‑reference mechanism: if a factor in s 9 refers to an injury or disease that itself has a SOP determined under s 196B(2) of the VEA, then the factors in that other SOP "apply in accordance with the terms of that Statement of Principles as in force from time to time." This creates a network effect among SOPs: overlapping or referenced conditions import the RMA’s other standards and definitions. Practically this means adjudicators must be familiar with relevant SOPs beyond this instrument and must apply them together where factors overlap.

Medical classification and hospital coding regimes

• ICD‑10‑AM codes are referenced (s 7(3)-(4)). The SOP links its clinical definition to particular ICD codes but makes clear the clinical definition in s 7(2) controls the application. The instrument fixes the edition of ICD‑10‑AM used for code references (Tenth Edition, effective 1 July 2017) and cites the publisher and ISBN (s 7(4)). This creates an interaction with hospital coding and record systems: claims reliant on coded hospital data must map to the cited edition, which may raise issues if medical records use a later edition or variant coding. Decision makers and medical reviewers must take care to reconcile code editions when using coded records as evidence.

Administrative law and review

• As an instrument used in administrative decision making, application of this SOP will be reviewable under administrative law principles. The SOP itself does not create procedural rights to merits review; those rights are supplied by the VEA, the MRCA and general administrative law. Errors in applying the SOP or failing to import another SOP where s 11 requires it could form grounds for review.

Compiled instrument and amendment instruments

• The compilation states it includes amendments up to Amendment Statement of Principles concerning conjunctivitis (Reasonable Hypothesis) (No. 90 of 2022) with compilation date 19 September 2022 (cover page and Endnote 3). The original instrument, No. 76 of 2020, was registered 2 November 2020 and commenced on 30 November 2020 (Endnote 3). The amendment instrument No. 90 of 2022 was registered 29 August 2022 and commenced on 19 September 2022 (Endnote 3).

Specific changes recorded in endnotes

• Endnote 4 (Amendment history) lists the specific changes made by amending instruments. It records that subsection 9(5A) was added by No. 90 of 2022 (Endnote 4). The Schedule 1 definition of "sensitising exposure to an allergen" was also added by No. 90 of 2022 (Endnote 4). These are concrete textual insertions: s 9(5A) now provides that having a sensitising exposure to an allergen before the clinical onset of conjunctivitis is itself a listed factor; the Schedule defines the term and explains the timing rules for sensitising exposure and subsequent symptomatic re‑exposure.

Other recorded amendments

• Endnote 4 also lists "Section 2… rep LA s 48D" and "Section 4… rep LA s 48C" as affected provisions. The compilation’s table indicates those provisions were repealed by provisions of the Legislation Act (LA) as cited. The published amendment history therefore records formal housekeeping changes made under the Legislation Act, though the compilation shows the operative text as currently in force as at 19 September 2022.

Practical effect of the 2022 amendment

• The addition of s 9(5A) and the Schedule definition for "sensitising exposure to an allergen" formalises a sensitisation model where an initial, asymptomatic exposure (the sensitising exposure) followed by a symptomatic exposure within two weeks can meet the SOP’s factor list (s 9(5A); Schedule). The Schedule notes the initial sensitising exposure may have occurred months to years earlier but that the symptomatic onset must occur within two weeks of re‑exposure. Administratively, this expands the set of factual scenarios that can raise a reasonable hypothesis by recognising delayed sensitisation followed by relatively proximate re‑exposure.

Version fixation and coding references

• The instrument fixes the ICD‑10‑AM edition referenced (Tenth Edition, 1 July 2017) (s 7(4)). Amendments have not altered that reference in the text provided. If future amendments change the edition or the list of codes, decision makers must use the edition expressly stated at the time of claim assessment.

No cases named or litigation recorded in the instrument

• The instrument itself does not mention any court decisions or tribunal findings. The text contains no case citations, and the endnotes (Endnotes 1-4) record only compilation and amendment history. There is therefore no litigation history included in this compilation.

Implications for practitioners

• Absence of recorded litigation in the instrument’s endnotes does not preclude that questions of interpretation might arise in tribunal or court proceedings. However, there are no reported judicial interpretations supplied within this instrument. Practitioners should therefore rely on the statute and SOP text and, where necessary, search administrative decisions or judicial databases for any decisions applying this specific SOP since its commencement.

Common areas that may generate litigation (based on instrument content)

• Relationship to relevant service: s 10(1) requires the listed factor(s) be "related to the relevant service". Disputes often focus on what factual connection satisfies that statutory link. The SOP defines factors but leaves the "related to" legal link to the adjudicator’s fact‑finding; that is a typical ground for review where conclusions are contested.

• Application of aggravation/material contribution rules: s 10(2) limits subsections 9(19)-(37) to cases where conjunctivitis pre‑existed before or during service but did not arise out of service, and applies only to material contribution or aggravation. The distinction between aggravation during service and causation arising out of service is a classic disputes area.

• Interpretation of timing windows and drug‑related criteria: the instrument prescribes narrow windows (for example within 24 hours, 48 hours, seven days). Litigation could occur about whether evidence meets those windows or whether clinical uncertainties (for example where onset timing is imprecise) should be resolved in favour of the claimant.

No recorded judicial gloss in endnotes

• Because the compilation contains no litigation history, practitioners must not assume judicial or tribunal precedent addressing this SOP exists. If a claim depends on a contentious legal or medical construction of the SOP, consider that this may be novel and prepare reasoned submissions grounded in the SOP text, the Schedule definitions and the RMA’s stated view in s 8.

Narrow timing windows and strict temporal formulations

• The SOP sets precise temporal thresholds that are legally decisive: ocular or periocular exposure to an allergen or irritant, mustard gas exposure, foreign body contact, or injury must be "within the 24 hours before the clinical onset" or "clinical worsening" (s 9(5), (12), (13), (14), (15), (23), (30), (31), (32), (33)). Topical medication must be applied within 48 hours before onset/worsening (s 9(9), (27)). Drugs in the specified list must have been taken "for at least the seven days before" onset/worsening (s 9(10), (28)). For drug‑induced causation or aggravation, the SOP requires either improvement within seven days of discontinuing or tapering drug therapy, or redevelopment on rechallenge, with the treatment having continued for at least seven days before onset/worsening (s 9(11), (29)). These narrow windows mean that gaps in clinical records or imprecise onset dates can be fatal to a claimant’s ability to satisfy the SOP. Practitioners must gather temporally precise evidence.

"At least one factor" threshold , but must be related to service

• Section 9 requires "At least one of the following factors must as a minimum exist" (s 9). While the threshold itself is low in number (one factor suffices), s 10(1) requires that the factor "must be related to the relevant service rendered by the person." The need to prove the relationship to service remains. A factor that exists but has no evidential link to service (for example a community allergic exposure occurring well after discharge and unrelated to service) will not satisfy s 10(1).

Aggravation vs causation distinction for subsections 9(19)-(37)

• Subsections 9(19)-(37) apply only "to material contribution to, or aggravation of, conjunctivitis where the person's conjunctivitis was suffered or contracted before or during (but did not arise out of) the person's relevant service" (s 10(2)). This is a legal pivot: these factors are intended to support findings of material contribution or aggravation, not primary causation arising out of service. Confusing the two can result in misframed claims. Evidence must show pre‑existence and that service materially contributed to or aggravated the condition.

Definition control over ICD coding

• Although the SOP lists ICD‑10‑AM codes that "conjunctivitis attracts" (s 7(3)), it also clarifies that "in applying this Statement of Principles the meaning of conjunctivitis is that given in subsection (2)" (s 7(3)). Practically, a claimant cannot rely solely on a coded hospital entry; the clinical definition and the Schedule’s details control. Conversely, a clinician’s diagnosis that maps to one of the listed ICD codes but does not satisfy the clinical definition or the listed factors may still fail to raise a reasonable hypothesis.

Evidence mapping to the SOP factors

• Start by mapping the claim file to the discrete factors in s 9. Each factor has a specific evidentiary element (condition present, exposure type, timing, drug duration, response to discontinuation/rechallenge, or access issues). Prepare a checklist for each listed factor to ensure the claim file addresses: presence of the condition; timing relative to clinical onset/worsening; relationship to relevant service; and any cross‑references to other SOPs (s 9; s 10(1); s 11).

Timing evidence

• Ensure clinical records and witness statements document precise dates and times for onset and worsening of symptoms. The SOP uses tight timing windows: 24 hours for many exposures, 48 hours for topical medication, and seven days for drug exposure and drug‑stop improvement windows (s 9). Where onset timing is uncertain, consider obtaining contemporaneous GP notes, emergency department records, ambulance records, pharmacy dispensing dates, and workplace incident reports that can narrow the window.

Medication and drug causation evidence

• For allegations involving drugs in the specified list, obtain full medication histories: start and stop dates, dosages, prescriber notes, pharmacy dispensing records, and any notes indicating objective improvement within seven days of stopping or tapering. If rechallenge occurred, document dates and symptom recurrence. For drugs not on the specified list but alleged to cause conjunctivitis, obtain a medical expert opinion linking the drug to conjunctivitis and addressing whether the SOP’s drug‑related criteria are met (s 9(10)-(11), (28)-(29); Schedule).

Allergen and sensitisation claims

• For allergen exposure claims, document exposure events in detail and provide contemporaneous clinical notes linking exposure to onset within 24 hours per s 9(5) or to the sensitisation chronology in s 9(5A) and the Schedule. For sensitising exposure claims (added in 2022), gather evidence of an earlier asymptomatic exposure and then of a re‑exposure within two weeks before symptom onset as required by the Schedule’s definition.

Immunocompromise and systemic disease

• Where the claimant alleges immunocompromised state factors (s 9(18), (36); Schedule), obtain specialist records showing the diagnosis, lab results (for example GFR values for chronic renal failure where relevant to the Schedule’s definition), prescriptions for immunosuppressive drugs, oncology records for malignancy, transplant records or dialysis treatment histories. Be precise about the timing: the condition must exist "at the time of the clinical onset" or "clinical worsening" (s 9).