Statement of Principles concerning visual refractive error (Reasonable Hypothesis) (No. 35 of 2025)

Reasonable hypothesis is not defined in the instrument but is a standard of proof imported from the VEA. Under section 120(1) and (3) of the VEA, for operational service claims, the Commission must accept a reasonable hypothesis connecting the injury or disease with the service unless it is satisfied beyond reasonable doubt that there is no sufficient ground. The SoP operationalises that standard by specifying the minimum medical-scientific factors that constitute a reasonable hypothesis. It does not require proof of causation on the balance of probabilities; it only requires that the factor exists and is related to service.

Clinical onset and clinical worsening are central to the factors. Many factors require a temporal connection to clinical onset or clinical worsening (for example, “within the 2 years before clinical onset or clinical worsening”). The instrument does not define these terms, but established VEA case law treats clinical onset as the time when the condition first became clinically apparent (symptoms or signs sufficient to permit diagnosis). Clinical worsening refers to a material deterioration of a pre-existing condition, and section 10(2) limits the clinical worsening aspect to situations where the person’s visual refractive error was suffered or contracted before or during (but did not arise out of) relevant service. This means a veteran who had myopia before service can only rely on the worsening factors if the worsening occurred during service and was contributed to by service-related factors listed.

Visual refractive error is a group of eye diseases defined by an imbalance between the refractive power of the eye’s optical system (primarily cornea and lens) and the length of the eyeball. The definition is operational: it includes myopia, hyperopia, astigmatism and anisometropia (a difference of at least one diopter between eyes), but excludes presbyopia. The instrument provides detailed sub-definitions for each type, including references to ICD-10-AM codes (tenth edition, 2017) for identification purposes, but clarifies that the meaning of each condition is as given in the instrument, not the ICD code.

Factors are nineteen specific medical events, conditions, exposures or treatments listed in section 9. Only one factor needs to exist, but it must be related to the person’s relevant service. The factors fall into categories: structural eye conditions (e.g., eyelid mass, pterygium, corneal scarring, keratoconus), surgeries (corneal surgery, penetrating keratoplasty, scleral buckle, cataract surgery, retinal detachment surgery), lens abnormalities (tilted intraocular lens, aphakia, displacement), trauma (blunt or penetrating within one month), medication use (nine specified drugs within two weeks), near-work during adolescence (aged 12-19 years, focusing on objects within 40 cm at least 2 hours a day for at least 1 year before onset of myopia), and inability to obtain appropriate clinical management for visual refractive error before clinical worsening.

Relevant service is defined as operational service, peacekeeping service, hazardous service, British nuclear test defence service (all under VEA), warlike service or non-warlike service (under MRCA). This limits the SoP’s application to those categories; ordinary peacetime service without these designations is not covered.

Death from visual refractive error includes death from a terminal event contributed to by the person’s visual refractive error. The dictionary defines “terminal event” as the proximate or ultimate cause of death, including pneumonia, respiratory failure, cardiac arrest, circulatory failure or cessation of brain function. This allows claims where visual refractive error was a contributing factor to death, not necessarily the sole cause.

The primary affected group is veterans and members of the Australian Defence Force who have rendered relevant service. This includes veterans with operational service under the VEA (e.g., combat service in war or warlike operations), peacekeeping service, hazardous service (e.g., service involving exposure to specified hazards), British nuclear test defence service, and members with warlike or non-warlike service under the MRCA. Their claims for disability compensation or death benefits in respect of visual refractive error must be assessed against this SoP. If a claimant cannot establish at least one factor related to service, their claim will likely fail.

The Repatriation Commission is directly affected as the primary decision-maker under the VEA and MRCA. It must apply the SoP when determining whether a reasonable hypothesis exists. The Commission’s delegates, including officers of the Department of Veterans’ Affairs, need to understand the factor definitions, temporal requirements, and the meaning of clinical onset and worsening. They must also ensure that any factor referring to another injury or disease (e.g., pterygium, keratoconus) is assessed under the relevant SoP for that condition, as per section 11.

The Veterans’ Review Board and the Administrative Appeals Tribunal will review decisions made by the Commission, applying the same SoP. Both bodies see frequent litigation over SoPs, and this new instrument will shift the arguments from the 2016 version to the updated factor list.

Medical practitioners - particularly optometrists and ophthalmologists - are indirectly affected because they provide the medical evidence needed to establish factors. They must be familiar with the definitions (e.g., what constitutes an acquired eyelid mass, the distinction between presbyopia and hyperopia, what qualifies as near-work activity) and the time windows specified. They may need to report on the presence of conditions such as pterygium or keratoconus, and on the duration of near-work during adolescence. The very specific list of medications (factor 17) requires checking prescription records.

The Repatriation Medical Authority (RMA) is the maker of the instrument. The RMA determines SoPs based on its view of sound medical-scientific evidence. This SoP reflects the RMA’s current assessment of what factors are scientifically supported. The RMA’s decision to repeal the 2016 SoP means that factors previously available may have been removed, added, or modified. For example, the 2025 SoP adds a factor for pterygium (factor 2) and for an acquired nuclear cataract or posterior subcapsular cataract (factors 11 and 12) for myopia, which were not in the 2016 SoP. Conversely, factors that were in the 2016 SoP but are absent from the 2025 version will no longer support a reasonable hypothesis.

Legal practitioners representing veterans will need to analyse claims against the nineteen factors, gather evidence to support a factor, and potentially challenge the RMA’s view in the AAT or Federal Court if a factor is missing from the instrument.

The SoP does not impose duties directly on individuals; it is an administrative instrument that structures the decision-making process. The key right it confers is a pathway for a veteran or member to raise a reasonable hypothesis for their claim. If the person can show that at least one factor in section 9 exists and is related to their relevant service, the decision-maker must accept that a reasonable hypothesis has been raised, unless the contrary is proved beyond reasonable doubt (for operational service). This is a right in the sense that the burden then shifts: the Commission must negate the hypothesis if it seeks to reject the claim.

Duty of the Repatriation Commission: to apply the SoP correctly. This includes determining the correct clinical onset or clinical worsening date, verifying that the factor is medically present, and ensuring the factor is related to service (section 10(1)). The Commission must also apply section 11 if a factor refers to another injury or disease covered by another SoP - for example, if a person has keratoconus (factor 6) as a factor for myopia or astigmatism, the Commission must apply the SoP for keratoconus to assess whether that condition itself is service-related. This cross-referencing can add complexity and may require the Commission to obtain separate medical opinions.

Duty of the claimant: to provide medical and other evidence supporting the existence of a factor. For factor 15 (near-work in adolescence for myopia), the claimant may need to prove they spent at least 2 hours per day focusing on objects within 40 cm for at least 1 year during ages 12-19. This could require records, statements or expert evidence about schoolwork, computer use, or employment. For factor 17 (medications), the claimant must show that the drug was taken within 2 weeks before clinical onset or worsening of myopia, and that the medication “cannot be ceased or substituted in the long term”. This is a high bar; many drugs can be ceased or substituted, so the factor may only apply to cases where the medication is essential and alternatives are not available.

Right to rely on earlier SoPs: subject to transitional provisions, the repeal of the 2016 SoP means that claims lodged after 25 March 2025 cannot rely on factors that only existed in the old SoP. However, claims lodged before the commencement date may still be determined under the old SoP if transitional rules preserve it. The SoP itself is silent on transitional application; that is governed by the Legislation Act 2003 and the VEA.

No duty to accept the factor as sufficient: raising a reasonable hypothesis does not guarantee acceptance of the claim. The decision-maker still must be satisfied that the hypothesis is reasonable and that the condition is connected to service. However, for operational service, the standard is very high to reject a hypothesis once raised. For non-warlike MRCA service, the standard may be different under MRCA section 338, which applies a standard of proof on the balance of probabilities. The SoP does not distinguish between these standards; it merely provides the factors for a reasonable hypothesis.

The SoP itself contains no penalties or enforcement provisions. It is a standard-setting instrument, not a regulatory or prohibitory one. However, the broader legal framework under which it operates does carry penalties. For example, under section 53 of the VEA, a person who makes a false or misleading statement in connection with a claim may be guilty of an offence carrying a penalty of imprisonment for 12 months or 60 penalty units (currently $330 per unit). Similarly, the MRCA contains provisions against fraud. Because this SoP is the gateway to compensation, any dishonest attempt to fabricate a factor (e.g., falsely claiming near-work habits, or a history of corneal surgery) could lead to prosecution.

Enforcement is through the Repatriation Commission’s fact-checking processes, including independent medical assessments, and through routine audits. The Administrative Appeals Tribunal and the Federal Court can also set aside decisions that misapply the SoP, but they do not “enforce” the SoP in a punitive sense.

The economic cost of false claims is borne by taxpayers and the sustainability of the veterans’ compensation system. The RMA’s role is to ensure that only those service-related conditions are compensated; the SoP’s factors are intended to screen out non-service-related refractive errors. However, the factors themselves may be overinclusive or underinclusive. For instance, factor 15 (near-work) could capture many adolescents who spent time reading or using digital devices - a common activity not necessarily connected to military service. This could expand the compensation base and increase costs, unless the “related to service” requirement in section 10 provides a limiting principle. The near-work factor itself does not require that the near-work occurred during service; it only requires that the person was aged 12-19 and spent at least 2 hours per day for at least 1 year before onset. To be compensable, that near-work must be related to the person’s relevant service. That might be difficult to prove unless the person was engaged in training or operations that required prolonged near-focus (e.g., reading maps, using equipment). This could lead to disputes and litigation, imposing compliance costs on the Department and legal costs on claimants.

No criminal penalty attaches to the failure to follow the SoP by a decision-maker. If the Commission misapplies the SoP, the remedy is review and correction, not punishment. Similarly, a medical practitioner who provides an incorrect opinion in good faith faces civil liability risks but not criminal penalties under this instrument.

This SoP is part of a network of legislative instruments under the VEA and MRCA. Section 120A of the VEA requires that for operational service claims, the Commission must determine a reasonable hypothesis by reference to the relevant SoP as in force. The SoP for visual refractive error is the relevant instrument for that condition. If no SoP exists for a particular condition, the Commission must apply the standard administrative law test, which is less structured.

Section 338 of the MRCA similarly requires that for warlike and non-warlike service, a determination under the MRCA must be made in accordance with the SoP. This means the SoP applies uniformly across both Acts for the relevant service categories.

Section 11 of the SoP provides that if a factor refers to an injury or disease covered by another SoP (e.g., pterygium, keratoconus, acquired eyelid mass), then the factors in that other SoP apply in accordance with its terms as in force from time to time. This creates a cascading effect: to establish the main condition, the claimant may first need to establish that the intermediate condition (e.g., pterygium) is service-related under its own SoP. This increases the evidentiary burden and can delay claims. The cross-reference is dynamic: the other SoP may be amended or repealed later, and the visual refractive error SoP continues to refer to the latest version.

Interaction with other SoPs: If a person has both visual refractive error and another condition (e.g., cataract), there may be overlapping factors. For example, an acquired nuclear cataract (factor 11) can be a factor for myopia under this SoP, but cataract itself may have its own SoP. The Commission must assess both conditions separately, but the factor existence for visual refractive error may depend on the cataract being present and service-related, which requires applying the cataract SoP.

Interaction with the Repatriation Medical Authority’s guidelines: The RMA also publishes Guidelines for the Determination of Statements of Principles, which inform the interpretation of factors (e.g., how to measure near-work hours). These guidelines are not legally binding but are often used by decision-makers.

Interaction with Veterans’ Entitlements Act case law: The VEA has a rich body of case law on what constitutes a “reasonable hypothesis”, “clinical onset” and “clinical worsening”. The SoP does not override that case law; it provides a factual template that must be applied within those legal concepts. For example, the Federal Court has held that a factor must be related to the actual service rendered, not just a generic risk. So while factor 15 (near-work) might be met for an adolescent before service, the claimant must also show that the near-work was related to their service - a difficult connection for pre-service activities.

Interaction with other compensation schemes: This SoP does not affect access to Medicare, private health insurance, or workers’ compensation schemes for non-veterans. It only governs claims under the VEA and MRCA. However, if a veteran’s condition is accepted under the SoP, they may become eligible for pension or other benefits that could affect their eligibility for means-tested benefits (e.g., disability support pension).

The instrument itself provides limited amendment information. It was made on 18 February 2025 by the Repatriation Medical Authority, chaired by Professor Terence Campbell AM, and commences on 25 March 2025. Its primary amendment effect is the repeal of the Statement of Principles concerning myopia, hypermetropia and astigmatism (Reasonable Hypothesis) No. 9 of 2016 (Federal Register of Legislation No. F2016L00245). The 2016 SoP covered the same conditions but with different factors and definitions. The 2025 SoP updates the factor list, definitions, and ICD-10-AM references. The RMA states that it is satisfied there is sound medical-scientific evidence as required by the VEA for the new factors.

No other amendments are recorded. However, because the SoP is a legislative instrument, it can be amended by a later SoP or by a determination of the RMA. The RMA typically reviews SoPs periodically, and some conditions have multiple versions over years. The 2025 SoP is the current version for visual refractive error.

The repeal of the 2016 SoP has practical consequences: factors that were available under the 2016 SoP but are not in the 2025 SoP cannot be used for claims lodged after 25 March 2025. For example, the 2016 SoP may have included factors such as “having trauma to the eye” but with different time frames. The 2025 SoP has a narrower time window (1 month instead of possibly longer). Also, the 2025 SoP includes factors like “acquired pterygium” and “acquired nuclear cataract” which were not in the 2016 SoP. Claimants whose condition would have been covered by the old factors but not the new ones may need to rely on transitional provisions if they lodged before commencement. The SoP does not state transitional rules, so recourse must be had to the Legislation Act 2003 and the VEA for general transitional provisions.

Significant changes between the 2016 and 2025 versions (inferred from the text of the new instrument):

• The definition of visual refractive error now explicitly includes anisometropia (≥1 diopter difference) and excludes presbyopia.
• The factors are reorganised and enumerated; the 2016 SoP had a different numbering and possibly different factors.
• The near-work factor (15) appears new, targeting adolescent myopia.
• Medication list (17) is specific to nine drugs, whereas the old SoP may have had a different list.
• The definition of terminal event is now included.
• ICD-10-AM edition updated (tenth edition 2017 instead of an earlier edition).

The RMA’s explanatory statement (not provided) would detail the evidence basis for changes.

The source document does not refer to any litigation history. However, Statements of Principles are frequently challenged in the Administrative Appeals Tribunal and Federal Court. Appeals typically argue that the RMA acted without evidence, that a factor is irrational, or that the SoP fails to cover a causal pathway. Claimants may also argue that their condition falls within a factor despite the Commission’s denial. The Veterans’ Entitlements Act provides for review of SoPs by the Federal Court under the Administrative Decisions (Judicial Review) Act 1977 or the Judiciary Act 1903. The RMA itself is not subject to merits review, but the application of a SoP to a claimant’s case is reviewable.

There have been cases concerning the previous SoP (No. 9 of 2016). For example, the AAT has considered whether certain activities constitute “focusing on objects within 40 cm” for the near-work factor in other SoPs (e.g., for myopia). The new 2025 SoP’s near-work factor (15) is likely to generate disputes over evidence of duration, the age range, and the relationship to service.

The list of medications in factor 17 may also be challenged if claimants argue that an unlisted drug caused myopia. The instrument does not allow for factors beyond the nineteen listed; if a claimant’s myopia is caused by a drug not in the list, they cannot use this SoP (unless they can rely on another factor). This could lead to claims that the RMA’s list is incomplete and that the SoP is therefore unreasonable. However, the Federal Court has generally deferred to the RMA’s medical judgment unless the decision is irrational.

No specific court decisions are mentioned in the source. Given that the instrument is new (March 2025), there is no litigation history yet under this particular number. Litigation over the 2016 SoP is relevant as precedent, but we cannot name cases from our own knowledge because the instruction is to only name cases the source names. Since the source names none, we can discuss the probability of litigation without naming cases.

Likely issues:

• Clinical onset timing for factors with time windows (e.g., within 2 years of corneal surgery).
• Whether a condition meets the definition of “acquired” (e.g., acquired eyelid mass, acquired nuclear cataract).
• Whether the inability to obtain appropriate clinical management (factor 19) is established, as it is a catch-all that could be overused.
• Whether near-work during adolescence is sufficiently proved and related to service (e.g., a conscript who did a lot of reading in training).
• The medication factor’s requirement that the drug “cannot be ceased or substituted in the long term” - this is subjective and likely to be disputed.

1. Presbyopia excluded: The instrument explicitly excludes age-related farsightedness (presbyopia) from the definition of hyperopia. A veteran with presbyopia cannot rely on this SoP, even if they also have hyperopia. Claims must distinguish between the two, which may require specialist evidence.

2. Time windows are tight: Many factors require occurrence within a specific period before clinical onset or worsening (e.g., corneal surgery within 2 years; trauma within 1 month; medication within 2 weeks). If the factor occurred outside that window, it is not sufficient, even if causal plausibility exists. Claimants need precise medical records.

3. Clinical worsening only for pre-existing conditions: Section 10(2) limits clinical worsening factors to cases where the condition was suffered before or during (but did not arise out of) relevant service. This means a veteran who had myopia before service can use the worsening factors, but a veteran who never had myopia before service and developed it during service must rely on clinical onset factors. Worsening factors cannot be used for first onset.

4. Near-work factor only for myopia and only ages 12-19: Factor 15 is confined to myopia; it does not apply to hyperopia or astigmatism. Also, the age window is strict (12-19 years). If near-work occurred before age 12 or after 19, it cannot be used. The duration must be at least 2 hours per day for at least 1 year.

5. Medication list is exhaustive and has an escape clause: Only nine drugs are listed. Even if a drug causes myopia, if it is not on the list, the factor does not apply. Additionally, the drug must be one that “cannot be ceased or substituted in the long term”. If the drug can be replaced, the factor fails. This creates a difficult evidentiary requirement.

6. “Inability to obtain appropriate clinical management” factor (19): This factor applies only to clinical worsening, not onset. It requires that the worsening was due to inability to get management before the worsening. This could be used for progressive myopia if a veteran could not get glasses or surgery. However, it requires that the inability existed before the worsening. If the veteran had access to care but did not seek it, this factor may not be met.

7. Blunt or penetrating trauma within 1 month: The trauma must be to the affected eye. If a veteran suffered trauma to the other eye but not the affected one, it does not count. Also, the trauma must occur within 1 month before clinical onset or worsening. Delayed effects are not covered.

8. Anisometropia is included but has no specific factors: The definition includes anisometropia (≥1 diopter difference between eyes), but none of the nineteen factors explicitly address anisometropia. To claim anisometropia, the veteran must find a factor that applies to the difference, perhaps through trauma or surgery that affected one eye. Alternatively, the veteran could claim myopia or hyperopia separately for each eye.

9. Death claims: terminal event limitation: Death from visual refractive error requires that a terminal event (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function) was contributed to by the visual refractive error. This is a narrow list. If a veteran died from a trauma that was worsened by poor vision (e.g., a fall), that might not fit unless the fall led to one of the listed terminal events. The RMA’s list is exhaustive.

10. Cross-reference to other SoPs: Section 11 means that if factor 2 (pterygium) is used, the veteran must also satisfy the pterygium SoP. This can create a double-hurdle. The pterygium SoP may have its own factors that are difficult to meet.

11. “Relevant service” excludes many veterans: Only operational, peacekeeping, hazardous, British nuclear test, warlike or non-warlike service qualifies. Veterans with peacetime service only (e.g., artillery training but no warlike designation) are not covered. They cannot use this SoP.

12. No factor for genetics: The SoP does not include a factor for family history or genetics, which are known risk factors for myopia. A veteran with strong genetic predisposition but no other factor cannot succeed.

Compliance is two-sided: for claimants and their representatives, and for decision-makers.

For claimants: The first step is to identify which category of relevant service applies (operational, warlike, etc.). Then, gather all medical records documenting the presence of visual refractive error and its clinical onset date. Identify which of the nineteen factors might apply. For each potential factor, obtain evidence:

• For factors 1-14 (structural, surgical, trauma): medical reports confirming the condition (e.g., eyelid mass, pterygium, corneal surgery) and its timing relative to clinical onset.
• For factor 15 (near-work): evidence of activity during ages 12-19, such as school records, sworn statements, or expert analysis of daily habits. The RMA’s note suggests tasks like reading, writing, computer work, and digital device use. The “2 hours a day” must be averaged over at least 1 year.
• For factor 17 (medications): prescription records and a medical opinion that the drug cannot be ceased or substituted in the long term. The list is narrow; check each drug.
• For factor 19 (inability to obtain appropriate clinical management): evidence that clinical management was not available (e.g., lack of access to optometrists, financial inability), and that this caused or contributed to the worsening.

The claimant must also show that the factor is related to their relevant service (section 10). This may require connecting the factor to events during service. For example, trauma factor 16: the blunt or penetrating injury must have occurred during service (or if before service, the worsening must be linked to service). For near-work, if the near-work occurred during training or as part of service duties, that is easier. If it occurred before service, the relationship is harder to establish.

For decision-makers: When assessing a claim, check each factor for its conditions. Ensure that the factor exists on the medical evidence and that the timing matches. For clinical worsening factors, verify that the condition was pre-existing. Apply section 11 if needed. If a factor refers to another SoP (e.g., keratoconus), assess that condition under its own SoP. Determine whether the factor is related to service. If the claimant raises a factor, the decision-maker must accept a reasonable hypothesis unless the contrary is proved. For operational service, this standard is high; for non-warlike MRCA, the standard is balance of probabilities, so the SoP factors are not determinative in the same way.

Ongoing compliance: The SoP replaces the 2016 version, so decision-makers must update their internal guidelines. Claimants who filed before 25 March 2025 may still be assessed under the old SoP, but those filing after must use the new one. Any medical evidence gathered should be specific to the new factors. For example, an optometrist report should state the type of refractive error and any associated conditions like pterygium or keratoconus.

Litigation prevention: The best way to avoid disputes is thorough documentation. For the near-work factor, the claimant should keep diaries or logs of daily near-work activities during adolescence, though this is challenging retrospectively. The RMA’s note is helpful but not binding; the decision-maker has discretion in evaluating the evidence.

Costs: Complying with this SoP imposes search and verification costs. Claimants may need to pay for medical reports, possibly from specialists. The Department may need to commission independent medical assessments. The specificity of factors (e.g., precise time windows) may lead to denials even when the condition is plausibly service-related, causing further appeals and costs to both sides.

Private choice: The SoP constrains the decision-maker to a closed list of factors. It does not allow for novel scientific evidence outside the list, even if a causal link could be shown. This reduces discretion and predictability but also limits the scope of compensation to those pathways the RMA has accepted. For claimants with unusual presentations, the cost of being excluded may be high.