Statement of Principles concerning cerebrovascular accident (stroke) (Reasonable Hypothesis) (No. 45 of 2024)

Administered by Department of Veterans' Affairs

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EXPLANATORY STATEMENT

 

STATEMENT OF PRINCIPLES CONCERNING

CEREBROVASCULAR ACCIDENT (STROKE)

(REASONABLE HYPOTHESIS) (NO. 45 OF 2024)

 

VETERANS' ENTITLEMENTS ACT 1986

MILITARY REHABILITATION AND COMPENSATION ACT 2004

 

  1. This is the Explanatory Statement to the Statement of Principles concerning cerebrovascular accident (stroke) (Reasonable Hypothesis) (No. 45 of 2024).

Background

2.             The Repatriation Medical Authority (the Authority), under subsection 196B(8) of the Veterans' Entitlements Act 1986 (the VEA), repeals Instrument No. 65 of 2015 (Federal Register of Legislation No. F2015L00652) determined under subsections 196B(2) and (8) of the VEA concerning cerebrovascular accident.

3.             The Authority is of the view that there is sound medical-scientific evidence that indicates that cerebrovascular accident (stroke) and death from cerebrovascular accident (stroke) can be related to particular kinds of service.  The Authority has therefore determined pursuant to subsection 196B(2) of the VEA a Statement of Principles concerning cerebrovascular accident (stroke) (Reasonable Hypothesis) (No. 45 of 2024).  This Instrument will in effect replace the repealed Statement of Principles.

Purpose and Operation

4.             The Statement of Principles will be applied in determining claims under the VEA and the Military Rehabilitation and Compensation Act 2004 (the MRCA).

5.             The Statement of Principles sets out the factors that must as a minimum exist, and which of those factors must be related to the following kinds of service rendered by a person:

 operational service under the VEA;

 peacekeeping service under the VEA;

 hazardous service under the VEA;

 British nuclear test defence service under the VEA;

 warlike service under the MRCA;

 non-warlike service under the MRCA,

before it can be said that a reasonable hypothesis has been raised connecting cerebrovascular accident (stroke) or death from cerebrovascular accident (stroke), with the circumstances of that service.  The Statement of Principles has been determined for the purposes of both the VEA and the MRCA.

6.             This Instrument results from an investigation notified by the Authority in the Government Notices Gazette of 1 November 2022 concerning cerebrovascular accident in accordance with section 196G of the VEA.  The investigation involved an examination of the sound medical-scientific evidence now available to the Authority, including the sound medical-scientific evidence it has previously considered.

7.             The contents of this Instrument are in similar terms as the repealed Instrument.  Comparing this Instrument and the repealed Instrument, the differences include:

  • adopting the latest revised Instrument format, which commenced in 2015;
  • specifying a day of commencement for the Instrument in section 2;
  • revising the definition of 'cerebrovascular accident (stroke)' in subsection 7(2);
  • revising ICD-10-AM codes for 'cerebrovascular accident (stroke)' in subsection 7(3);
  • revising the reference to 'ICD-10-AM code' in subsection 7(4);
  • revising the factor in subsection 9(3) concerning inability to undertake any physical activity;
  • revising the factor in subsection 9(5) concerning binge drinking, for brain ischaemia only;
  • revising the factor in subsection 9(6) concerning binge drinking, for intra-cerebral haemorrhage only;
  • revising the factor in subsection 9(7) concerning having one of the following brain infections;
  • new factor in subsection 9(8) concerning having a Varicella-zoster virus infection;
  • revising the factor in subsection 9(10) concerning having one of the following systemic inflammatory disorders causing cerebral vasculitis;
  • new factor in subsection 9(11) concerning having gout;
  • revising the factor in subsection 9(12) concerning having one of the following vasculitides;
  • revising the factor in subsection 9(13) concerning having one of the following vessel disorders;
  • revising the factor in subsection 9(14) concerning having thrombotic thrombocyopaenic purpura, sickle cell disorder, sickle cell trait or vaccine-induced thrombotic thrombocytopaenia;
  • revising the factor in subsection 9(16) concerning using one or more of the following drugs;
  • revising the factor in subsection 9(17) concerning taking a selective serotonin reuptake inhibitor;
  • revising the factor in subsection 9(18) concerning taking an overdose of one or more serotonergic drugs;
  • revising the factor in subsection 9(19) concerning taking a non-topical, non-steroidal, anti-inflammatory drug, excluding aspirin;
  • revising the factor in subsection 9(21) concerning being envenomated;
  • revising the factor in subsection 9(24) concerning having one of the following cardiac conditions;
  • revising the factor in subsection 9(25) concerning having one of the following non-cardiac causes or cerebral arterial embolism;
  • revising the factor in subsection 9(26) concerning having a deep vein thrombosis or venous air embolism;
  • revising the factor in subsection 9(27) concerning undergoing one of the following procedures;
  • revising the factor in subsection 9(28) concerning having septicaemia or an infection requiring admission to hospital;
  • revising the factor in subsection 9(29) concerning having an injury or illness requiring admission to an intensive care unit or artificial ventilation;
  • revising the factor in subsection 9(30) concerning having a malignant neoplasm, excluding non-melanotic malignant neoplasm of the skin;
  • revising the factor in subsection 9(32) concerning having chronic kidney disease;
  • revising the factor in subsection 9(33) concerning experiencing a moderate to severe traumatic brain injury;
  • revising the factor in subsection 9(34) concerning being obese;
  • revising the factor in subsection 9(35) concerning having a waist to hip circumference ratio exceeding 1.0, for males;
  • revising the factor in subsection 9(36) concerning having a waist to hip circumference ratio exceeding 0.9. for females;
  • revising the factor in subsection 9(37) concerning being underweight, for intracerebral haemorrhage only;
  • revising the factor in subsection 9(38) concerning having symptomatic inflammatory bowel disease;
  • revising the factor in subsection 9(39) concerning having a clinically significant depressive disorder;
  • new factor in subsection 9(42) concerning experiencing a category 2 stressor;
  • new factor in subsection 9(45) concerning having clinically significant posttraumatic stress disorder;
  • new factor in subsection 9(46) concerning having clinically significant adjustment disorder;
  • new factor in subsection 9(47) concerning having clinically significant anxiety disorder;
  • new factor in subsection 9(48) concerning having clinically significant schizophrenia;
  • new factor in subsection 9(49) concerning having clinically significant bipolar disorder;
  • revising the factor in subsection 9(54) concerning where smoking has not ceased, for brain ischaemia only;
  • revising the factor in subsection 9(55) concerning where smoking has not ceased, for intracerebral haemorrhage only;
  • revising the factor in subsection 9(56) concerning where smoking has ceased, for brain ischaemia only;
  • revising the factor in subsection 9(57) concerning where smoking has ceased, for intracerebral haemorrhage only;
  • revising the factor in subsection 9(58) concerning having been exposed to second-hand smoke;
  • revising the factor in subsection 9(59) concerning having dyslipidaemia, for brain ischaemia only;
  • revising the factor in subsection 9(60) concerning having an upper respiratory tract infection, including sinusitis;
  • revising the factor in subsection 9(61) concerning being treated with intravenous immunoglobulin, for brain ischaemia only;
  • revising the factor in subsection 9(62) concerning taking a combined oral or non-oral estrogen-progestogen contraception, for brain ischaemia only;
  • revising the factor in subsection 9(63) concerning taking hormone replacement therapy, for brain ischaemia only;
  • revising the factor in subsection 9(64) concerning taking tamoxifen, for brain ischaemia only;
  • revising the factor in subsection 9(65) concerning having carotid artery disease, for brain ischaemia only;
  • revising the factor in subsection 9(66) concerning having a subarachnoid haemorrhage, for brain ischaemia only;
  • revising the factor in subsection 9(67) concerning hypercoagulable states, for brain ischaemia only;
  • revising the factor in subsection 9(68) concerning experiencing an acute hypotensive episode, for brain ischaemia only;
  • revising the factor in subsection 9(69) concerning having sleep apnoea;
  • revising the factor in subsection 9(70) concerning undergoing a course of therapeutic radiation;
  • revising the factor in subsection 9(71) concerning ionising radiation;
  • revising the factor in subsection 9(72) concerning having hyperhomocysteinaemia, for brain ischaemia only;
  • revising the factor in subsection 9(73) concerning having one of the following traumatic injuries, for brain ischaemia only;
  • revising the factor in subsection 9(74) concerning inhaling polluted air, for brain ischaemia only;
  • new factor in subsection 9(75) concerning inhaling chronically polluted air;
  • revising the factor in subsection 9(76) concerning undergoing anticoagulant therapy, for intracerebral haemorrhage only;
  • revising the factor in subsection 9(77) concerning taking one of the following antiplatelet drugs;
  • revising the factor in subsection 9(78) concerning undergoing thrombolytic (fibrinolytic) therapy, for intracerebral haemorrhage only;
  • revising the factor in subsection 9(79) concerning having one of the following disorders, for intracerebral haemorrhage only;
  • revising the factor in subsection 9(80) concerning bleeding of one of the following intracerebral space occupying lesions, for intracerebral haemorrhage only;
  • new factor in subsection 9(82) concerning being sedentary;
  • new factor in subsection 9(83) concerning taking anti-androgen medications;
  • new factor in subsection 9(84) concerning having bilateral orchiectomy;
  • new factor in subsection 9(85) concerning having compression of the carotid, vertebral, basilar or cerebral artery, for brain ischaemia only;
  • new factor in subsection 9(86) concerning taking an antipsychotic drug;
  • new factor in subsection 9(87) concerning taking tibolone;
  • new factor in subsection 9(88) concerning taking a systemic vascular endothelial growth factor (VEGF) inhibitor or monthly intra-vitreous injections of a VEGF inhibitor;
  • new factor in subsection 9(89) concerning taking alemtuzumab;
  • new factor in subsection 9(90) concerning taking ponatinib;
  • new factor in subsection 9(91) concerning taking a thalidomide;
  • deleting factor concerning having a lipid profile, for intracerebral haemorrhage;
  • new definitions of 'being sedentary', 'BMI', 'brain ischaemia', 'category 2 stressor', 'chronic kidney disease', 'chronically polluted air',  'exposed to second-hand smoke', 'MRCA', 'non-steroidal, anti-inflammatory drug', 'one pack-year' and 'VEA' in Schedule 1 - Dictionary;
  • revising the definitions of 'anticoagulant therapy', 'dyslipidaemia' and 'thrombolytic (fibrinolytic) therapy' in Schedule 1 - Dictionary; and
  • deleting the definitions of 'a cardiac condition with potential to give rise to a cerebral embolus', 'a drug or a drug from a class of drugs from the specified list', 'a haematological disease from the specified list', 'a haematological disorder from the specified list of haematological disorders that are associated with an excessive bleeding tendency', 'a hypercoagulable state as specified',  'a lipid profile as specified', 'a non-cardiac cause of cerebral arterial embolism', 'a potential route of paradoxical embolism from the specified list', 'a procedure from the specified list', 'a specified drug', 'a specified non-inflammatory disease of the cerebral vessels', 'a systemic vasculitis from the specified list', 'alcohol', 'an acute hypotensive episode', 'an infection from the specified list', 'an inflammatory connective tissue disease from the specified list', an intracerebral space occupying lesion', 'binge drinking', 'cerebral ischaemia', chronic liver disease' cigarettes per day, or the equivalent thereof in other tobacco products', 'DSM-5', 'hyperhomocysteinaemia', 'nephrotic syndrome', 'pack-year of cigarettes, or the equivalent thereof in other tobacco products', 'phobic anxiety' and 'trauma to the neck or the base of the skull'.

Incorporation

8.             The definition of "cumulative equivalent dose" contained in the Schedule 1 – Dictionary incorporates the Guide to calculation of 'cumulative equivalent dose' for the purpose of applying ionising radiation factors contained in Statements of Principles determined under Part XIA of the Veterans' Entitlements Act 1986 (Cth), Australian Radiation Protection and Nuclear Safety Agency, as in force on 2 August 2017.  This writing is incorporated pursuant to subsection 14(b) of the Legislation Act 2003.

9.             A copy of this document is available to any person on the website of the Repatriation Medical Authority at www.rma.gov.au or from the Repatriation Medical Authority, Level 8, 480 Queen St, Brisbane, Queensland 4000, by contacting the Registrar on telephone (07) 3815 9404.

Consultation

10.         Prior to determining this Instrument, the Authority advertised its intention to undertake an investigation in relation to cerebrovascular accident in the Government Notices Gazette of 1 November 2022, and circulated a copy of the notice of intention to investigate to a wide range of organisations representing veterans, service personnel and their dependants.  The Authority invited submissions from the Repatriation Commission, the Military Rehabilitation and Compensation Commission, organisations and persons referred to in section 196E of the VEA, and any person having expertise in the field.  No submissions were received for consideration by the Authority in relation to the investigation.

11.         On 16 April 2024, the Authority wrote to organisations representing veterans, service personnel and their dependants regarding the proposed Instrument and the medical-scientific material considered by the Authority.  This letter emphasised the deletion of factor relating to '6(qq)(iii) lipid profile as specified-onset'.  The Authority provided an opportunity to the organisations to make representations in relation to the proposed Instrument prior to its determination.  No submissions were received for consideration by the Authority.  No changes were made to the proposed Instrument following this consultation process.

Human Rights

12.         This instrument is compatible with the Human Rights and Freedoms recognised or declared in the International Instruments listed in Section 3 of the Human Rights (Parliamentary Scrutiny) Act 2011.  A Statement of Compatibility with Human Rights follows.

Finalisation of Investigation

13.         The determining of this Instrument finalises the investigation in relation to cerebrovascular accident as advertised in the Government Notices Gazette of 1 November 2022.

References

14.         A list of references relating to the above condition is available on the Authority's website at: www.rma.gov.au. Any other document referred to in this Statement of Principles is available on request to the Repatriation Medical Authority at the following address:

              

Email:    info@rma.gov.au

Post:      The Registrar

Repatriation Medical Authority

GPO Box 1014

BRISBANE    QLD    4001


Statement of Compatibility with Human Rights

(Prepared in accordance with Part 3 of the Human Rights (Parliamentary Scrutiny) Act 2011)

 

Instrument No.:   Statement of Principles No. 45 of 2024

Kind of Injury, Disease or Death: Cerebrovascular accident (stroke)

 

This Legislative Instrument is compatible with the human rights and freedoms recognised or declared in the international instruments listed in section 3 of the Human Rights (Parliamentary Scrutiny) Act 2011.

Overview of the Legislative Instrument

1. This Legislative Instrument is determined pursuant to subsection 196B(2) of the Veterans' Entitlements Act 1986 (the VEA) for the purposes of the VEA and the Military Rehabilitation and Compensation Act 2004 (the MRCA).  Part XIA of the VEA requires the determination of these instruments outlining the factors connecting particular kinds of injury, disease or death with service such being determined solely on the available sound medical-scientific evidence.

2. This Legislative Instrument:-

  • facilitates claimants in making, and the Repatriation Commission and the Military Rehabilitation and Compensation Commission in assessing, claims under the VEA and the MRCA respectively, by specifying the circumstances in which medical treatment and compensation can be extended to eligible persons who have cerebrovascular accident (stroke);
  • facilitates the review of such decisions by the Veterans' Review Board and the Administrative Appeals Tribunal;
  • outlines the factors which the current sound medical-scientific evidence indicates must as a minimum exist, before it can be said that a reasonable hypothesis has been raised, connecting cerebrovascular accident (stroke) with the circumstances of eligible service rendered by a person, as set out in clause 5 of the Explanatory Statement;
  • replaces Instrument No. 65 of 2015; and
  • reflects developments in the available sound medical-scientific evidence concerning cerebrovascular accident (stroke) which have occurred since that earlier instrument was determined. 

3. The Instrument is assessed as being a technical instrument which improves the medico-scientific quality of outcomes under the VEA and the MRCA. 

Human Rights Implications

4. This Legislative Instrument does not derogate from any human rights. It promotes the human rights of veterans, current and former Defence Force members as well as other persons such as their dependents, including:

  • the right to social security (Art 9, International Covenant on Economic, Social and Cultural Rights; Art 26, Convention on the Rights of the Child and Art 28, Convention on the Rights of Persons with Disabilities) by helping to ensure that the qualifying conditions for the benefit are 'reasonable, proportionate and transparent'[1];
  • the right to an adequate standard of living (Art 11, ICESCR; Art 27, CRC and Art 28, CRPD) by facilitating the assessment and determination of social security benefits;
  • the right to the enjoyment of the highest attainable standard of physical and mental health (Art 12, ICESCR and Art 25, CRPD), by facilitating the assessment and determination of compensation and benefits in relation to the treatment and rehabilitation of veterans and Defence Force members;
  • the rights of persons with disabilities by facilitating the determination of claims relating to treatment and rehabilitation (Art 26, CRPD); and
  • ensuring that those rights "will be exercised without discrimination of any kind as to race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status" (Art 2, ICESCR).

Conclusion

This Legislative Instrument is compatible with human rights as it does not derogate from and promotes a number of human rights.

 

Repatriation Medical Authority

 

 

 

 

 

 

 

[1] In General Comment No. 19 (The right to social security), the Committee on Economic, Social and Cultural Rights said (at paragraph 24) this to be one of the elements of ensuring accessibility to social security.

Overview

The Statement of Principles concerning cerebrovascular accident (stroke) (Reasonable Hypothesis) (No. 45 of 2024) was enacted to address the need for an updated framework concerning the connection between cerebrovascular accident (stroke) and various kinds of military service, as defined under the Veterans' Entitlements Act 1986 (VEA) and the Military Rehabilitation and Compensation Act 2004 (MRCA). This legislative instrument was determined by the Repatriation Medical Authority (the Authority) under subsection 196B(2) of the VEA, aiming to provide a clear set of medical-scientific criteria that must exist before a reasonable hypothesis can be raised that a cerebrovascular accident (stroke) or death from a cerebrovascular accident (stroke) is related to specific military service circumstances. The primary objective is to ensure that claimants can make informed claims, and that the Repatriation Commission and the Military Rehabilitation and Compensation Commission can effectively assess these claims by providing a precise outline of the required factors. This instrument replaces the previously repealed Statement of Principles No. 65 of 2015, incorporating the latest medical-scientific evidence and addressing changes in the understanding of cerebrovascular accidents (strokes) since the previous instrument was determined. It facilitates the review process by the Veterans' Review Board and the Administrative Appeals Tribunal and ensures compatibility with human rights, promoting the rights of veterans and their dependents without derogating from any human rights as recognised in international instruments.

Scope and Application

The Statement of Principles concerning cerebrovascular accident (stroke) (Reasonable Hypothesis) (No. 45 of 2024) applies to individuals who have experienced a cerebrovascular accident, commonly known as a stroke, and are seeking compensation or medical treatment under the Veterans' Entitlements Act 1986 (VEA) or the Military Rehabilitation and Compensation Act 2004 (MRCA). This includes veterans and members of the Australian Defence Force who have rendered operational service, peacekeeping service, hazardous service, or British nuclear test defence service, as well as those engaged in warlike or non-warlike service under the MRCA. The principles are designed to facilitate the assessment of claims by specifying the factors that must exist to establish a reasonable hypothesis connecting the stroke to the individual's service circumstances. The instrument replaces the previously repealed Statement of Principles No. 65 of 2015, reflecting updated medical-scientific evidence. It is applicable nationally and is subject to changes through subordinate instruments as the medical-scientific evidence evolves. There are no stated exclusions or exemptions within this instrument, though it is noted that the determination of a reasonable hypothesis is contingent on the existence of specified factors.

Key Provisions

The main operative sections of the Statement of Principles concerning cerebrovascular accident (stroke) (Reasonable Hypothesis) (No. 45 of 2024) establish the criteria that must be met for a reasonable hypothesis to be raised connecting a cerebrovascular accident (stroke) with particular types of military service. This includes operational service, peacekeeping service, hazardous service, British nuclear test defence service, warlike service, and non-warlike service, as outlined in section 5 of the Explanatory Statement. The Statement of Principles sets out specific factors, detailed in subsection 9, that must exist and be related to these service types before a connection can be considered valid. This instrument, which replaces Instrument No. 65 of 2015, reflects the latest sound medical-scientific evidence available to the Repatriation Medical Authority. The obligations imposed by this Act on the parties or entities it governs primarily concern the assessment and determination of claims related to cerebrovascular accidents (strokes) in the context of military service. Claimants must provide evidence that satisfies the criteria set out in the Statement of Principles to establish a reasonable hypothesis linking their condition to their service. The Repatriation Commission and the Military Rehabilitation and Compensation Commission are tasked with assessing these claims based on the medical-scientific evidence provided. The Veterans' Review Board and the Administrative Appeals Tribunal are responsible for reviewing any decisions made by these Commissions, ensuring that the processes are fair and that the rights of claimants are protected. The Act does not explicitly detail offences, penalties, or civil/criminal consequences for breaches in this context. However, the failure to provide adequate evidence or misrepresent information in a claim could lead to a rejection of the claim, with potential repercussions for the claimant's eligibility for benefits. The emphasis is on the accuracy and completeness of the medical-scientific evidence provided to substantiate the connection between the cerebrovascular accident (stroke) and the service rendered. The compatibility with human rights, as outlined in the Statement of Compatibility with Human Rights, ensures that the processes are fair and do not discriminate against any individual based on various attributes. This Statement of Principles is designed to facilitate the assessment and determination of claims for compensation and benefits related to cerebrovascular accidents (strokes) in military personnel, ensuring that the process is informed by the latest sound medical-scientific evidence. It reflects the commitment of the Repatriation Medical Authority to provide fair and transparent outcomes for veterans and service personnel affected by such conditions. The incorporation of the latest medical-scientific evidence and consultation with relevant stakeholders demonstrate a commitment to maintaining the relevance and accuracy of the criteria used in assessing these claims.

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