Statement of Principles concerning adrenal insufficiency (Balance of Probabilities) (No. 72 of 2018)

The SOP rests on a small number of foundational concepts, each defined in the instrument and used to operationalise how causal connection is to be assessed in claims.

1. Statutory source and purpose (s3, s8). The RMA makes SOPs under s196B(3) of the VEA. Section 8 records the RMA's view, "On the sound medical‑scientific evidence available", that it is "more probable than not" that adrenal insufficiency and death from it can be related to relevant service. This locates the SOP as a medical‑causation guide to be used when applying the balance of probabilities in claims determinations.

2. Definition of adrenal insufficiency (s7(2)). The instrument defines adrenal insufficiency as "an endocrine disease characterised by biochemically‑demonstrated deficient production of adrenal cortical hormones, sufficient to produce clinical symptoms and signs, and to necessitate glucocorticoid, mineralocorticoid or adrenal androgen replacement therapy". The definition expressly includes drug‑induced adrenal insufficiency and excludes heritable and congenital forms. Notes supply clinical examples and the distinction between acute and chronic presentations (s7(2) Notes).

3. Clinical onset versus clinical worsening (s9, Schedule). The factors are applied either to clinical onset or to clinical worsening of adrenal insufficiency. Subsections 9(1)-9(12) focus on factors relevant to the clinical onset, while 9(13)-9(24) repeat many of those factors in the context of clinical worsening. Section 10(2) limits the latter group (9(13)-9(25)) to situations of material contribution or aggravation where the condition was suffered or contracted before or during, but did not arise out of, relevant service.

4. At least one factor required (s9). The SOP is framed so that, before causal connection is accepted on the balance of probabilities, at least one of the enumerated factors in s9 must be established. Those factors include autoimmune adrenalitis, infiltrative disorders, HIV infection, specified surgical or traumatic events to adrenal glands, haemorrhage or infarction, infection of the adrenal glands with listed organisms, treatment with specified drugs (Specified List 1), a defined category of glucocorticoid therapy, treatment with medroxyprogesterone/megestrol in particular contexts, hypopituitarism with ACTH deficiency, critical illness/injury, acute severe stressors for adrenal crisis, and inability to obtain appropriate clinical management (s9).

5. Temporal and dose thresholds (Schedule). Several factors require specific time windows before onset or worsening (for example, three months for certain drugs (s9(7), s9(19)), one year for surgical injury or haemorrhage (s9(4), s9(5), s9(16), s9(17)), seven days for acute severe stressors causing adrenal crisis (s9(12), s9(24))). "Glucocorticoid therapy as specified" is a composite, mode‑specific definition in the Schedule which sets cumulative dose, average daily rates, topical/inhaled/ocular/nasal/enema applications, concurrent use with CYP3A4 inhibitors (Specified List 2), and use that causes Cushing syndrome as qualifying scenarios.

6. Cross‑referencing to other SOPs (s11). If a factor in s9 refers to an injury or disease already covered by another SOP determined under s196B(3) 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 makes the present SOP intertwined with other SOPs for conditions that are causes or contributors.

7. Death from adrenal insufficiency includes deaths where adrenal insufficiency contributed to a terminal event (s7(5)). The instrument defines "terminal event" in Schedule 1 and includes examples such as pneumonia, respiratory failure, cardiac arrest and circulatory failure. This permits causation findings where adrenal insufficiency contributed to a fatal terminal event, not only where the death certificate names adrenal insufficiency as the proximate cause.

8. Exclusions and coding (s7(2)-(4)). The SOP reiterates that ICD‑10‑AM codes commonly associated with adrenal insufficiency are relevant (s7(3)-(4)), but the primary legal meaning for the SOP is the textual definition. Heritable and congenital forms are excluded (s7(2)(c)).

These concepts structure how evidence must be marshalled and how decision‑makers will treat onset versus worsening, timing, drug exposure and the clinical character of the condition. The Schedule contains numerous technical thresholds that convert clinical descriptions (for example, "glucocorticoid therapy as specified") into ascertainable evidentiary criteria.

Primarily, the instrument affects persons making claims to which section 120B of the VEA or section 339 of the MRCA applies (s5). The text does not name the decision‑maker that applies the SOP, but its application is introduced expressly in relation to those statutory claims provisions. In practice that means:

• Veterans or former members of the Forces or members who hold or claim "relevant service" under the definitions set out in the Schedule (see definition of "relevant service" in Schedule 1). "Relevant service" includes eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA. The SOP will therefore be applied to claimants whose service falls into those categories.
• Claimants who assert adrenal insufficiency (as defined in s7(2)) or death from adrenal insufficiency as a condition connected with their service. The instrument covers both active disease claims and death claims where adrenal insufficiency contributed to a terminal event (s7(5)).
• Medical practitioners, treating clinicians, and medico‑legal practitioners preparing evidence in support of claims. The SOP specifies biochemical demonstration of adrenal cortical hormone deficiency, the necessity for replacement therapy, and thresholds for various drug exposures and clinical events. These are evidentiary benchmarks that clinical reports are expected to address.
• Administrators and adjudicators working under the VEA and MRCA who must apply SOPs when assessing causation on the balance of probabilities. The RMA determined the SOP under its statutory power (s3), and section 8 records the RMA's view of the medical‑scientific evidence; that view is the articulated standard to be applied in claims covered by s5.

The instrument does not create new criminal offences, financial penalties, or regulatory obligations for third parties. It does, however, alter legal entitlements to service‑connected benefits or compensation insofar as adjudicators will rely on the SOP to determine whether adrenal insufficiency is connected with relevant service. The effect is distributive: claimants whose medical history and documentary evidence satisfy at least one of the factors in s9 and the relevant relationship to service in s10 are in the statutory framework that supports a finding of connection on the balance of probabilities.

A narrower immediate impact is on claimants whose adrenal insufficiency is congenital or heritable, which the SOP excludes explicitly (s7(2)(c)); such claimants cannot rely on this SOP to establish service connection. Also, claimants whose presentations do not meet the biochemical and replacement‑therapy requirement of s7(2)(a) are not within the SOP's definition of the condition for these purposes.

Finally, where a factor in s9 refers to a disease that is already the subject of another SOP under s196B(3), the other SOP's factors apply as they stand (s11). Therefore practitioners must track inter‑SOP relationships to know which instrument governs a particular causal pathway.

This SOP principally prescribes criteria for establishing a causal connection between adrenal insufficiency (or death from it) and relevant service. It does not itself impose administrative duties on external parties, nor does it create freestanding statutory rights beyond shaping claim adjudication. Nonetheless, the instrument creates practical obligations and entitlements in the claims context that advisers and claimants must observe.

Rights and entitlements:

• Right to have a claim assessed against these factors: The SOP applies to claims covered by s120B VEA or s339 MRCA (s5). Where a claimant asserts adrenal insufficiency or death from adrenal insufficiency, adjudicators are to treat the SOP as the authoritative set of medical factors relevant to causation, including the RMA's stated medical‑scientific conclusion that a connection is "more probable than not" (s8).
• Inclusion of drug‑induced adrenal insufficiency: The SOP expressly includes drug‑induced forms (s7(2)(b)), which gives claimants with iatrogenic/adverse‑drug or drug‑interaction driven adrenal insufficiency a pathway to a service‑connection finding where the drug exposure ties to relevant service and meets the specified thresholds (s9(7), s9(19), Schedule definitions of Specified List 1 and Specified List 2, and "glucocorticoid therapy as specified").
• Right to a causal finding for death claims where adrenal insufficiency contributed to a terminal event: The SOP covers "death from adrenal insufficiency" which includes deaths where adrenal insufficiency contributed to a terminal event (s7(5) and Schedule definition of "terminal event").

Duties and evidentiary requirements implied by the SOP:

• Proof requirement of at least one factor: A claimant must establish, on the balance of probabilities, that at least one of the enumerated factors in s9 existed in the relevant temporal relationship to the clinical onset or clinical worsening (s9; s10(1)). This is an evidentiary duty to adduce medical records, biochemical tests, treatment histories, surgical notes, imaging, pathology, prescription records and other contemporaneous documentation.
• For factors tied to other SOPs, the claimant must establish the requirements of that other SOP where relied upon (s11). This means that reliance on a cross‑referenced condition imports the procedural and substantive tests from the other instrument.
• Temporal and dosing specifics must be established: Where the Schedule prescribes a minimum cumulative dose or a specified window (for example three months for specified drugs, one year for haemorrhage or surgery, seven days for stressors causing an adrenal crisis), the claimant bears the task of proving those precise facts. For glucocorticoid therapy there are distinct modes (oral/injectable, inhaled at specified microgram thresholds, topical potency applied to defined skin area, ocular/nasal/enema durations, or cumulative dose equivalents) that determine whether the qualifying "glucocorticoid therapy as specified" factor is available (Schedule).
• Relationship to relevant service: Section 10 requires that the existence of any factor in s9 must be related to the person's relevant service. This introduces a two‑part obligation: establish the medical factor and then establish its link to the service period or service activities that constitute "relevant service" under the Schedule definition.
• Distinction between onset and aggravation: Subsections 9(13)-9(25) and s10(2) draw a duty distinction for cases where adrenal insufficiency pre‑existed service or was suffered during service but did not arise out of it; those factors can only be used to prove material contribution or aggravation. Practitioners must identify whether the case concerns onset, worsening, or aggravation and present evidence accordingly.

Practical consequences for decision‑makers:

• The SOP provides adjudicators with a discrete list of medically‑recognised causal links and quantitative thresholds. Decision‑makers will use those criteria as a framework to accept or reject causal assertions on the balance of probabilities (s8-9). The RMA's express medical view (s8) guides the medically relevant inferences that may be drawn where the prescribed factors are established.

The instrument does not create procedural rights beyond its application to relevant statutory claims. It does not, for example, specify evidentiary standards beyond the balance of probabilities, set timelines for decision‑making, or provide enforcement mechanisms; those remain matters for the underlying statutes and administrative processes that apply to VEA/MRCA claims.

The SOP itself contains no penalties, criminal sanctions, or administrative fines. It is an evidentiary/medical instrument intended for use in the statutory schemes under the Veterans' Entitlements Act 1986 and the Military Rehabilitation and Compensation Act 2004 (s3, s5). Its enforcement role is administrative: it provides a set of medical factors and definitions that are to be applied when adjudicating claims under the cited provisions of those Acts.

Key enforcement‑related points grounded in the instrument:

• Application to statutory claims: Section 5 states that "This instrument applies to a claim to which section 120B of the VEA or section 339 of the MRCA applies." The enforcement of the SOP therefore occurs within the administrative adjudication process established by those Acts; the SOP is a tool for adjudicators determining service connection. Any penalties or remedies for a successful claim are consequences of the VEA or MRCA regimes, not this SOP itself.
• No sanctioning power: The RMA's power under subsection 196B(3) of the VEA is to determine Statements of Principles; the instrument does not purport to authorise sanctions against third parties, employers or prescribing clinicians. It does not change standards of professional regulation or criminal liability for medical negligence, nor does it alter regulatory frameworks for medicines or prescribing.
• Repeal and currency: Section 4 repeals the previous SOP No. 75 of 2009. Adjudicators must therefore ensure they apply the current SOP (No. 72 of 2018) from its commencement date (s2), and not prior SOPs. Section 11 also makes clear that where a factor refers to an injury or disease covered by another SOP, the factors in that other SOP apply "as in force from time to time", meaning decision‑makers must apply the operative version of cross‑referenced SOPs.
• Evidentiary enforcement via decision outcomes: The practical enforcement mechanism is decision outcomes under the VEA/MRCA: acceptance or rejection of a claim for service connection based on whether the requisite factors and relationship to service (s9-s10) are established. Those outcomes may trigger downstream administrative consequences (entitlements, compensation, rehabilitation obligations) under the relevant statutes, but such outcomes and their enforcement are grounded in the underlying Acts.

In short, this SOP is not an enforcement instrument in the punitive sense; its "teeth" are its use by decision‑makers in claims processes established by the VEA and MRCA. It is an authoritative medical standard for causation, and non‑compliance with its evidentiary thresholds will result in claims being unsuccessful rather than criminal or regulatory sanctioning of any party by virtue of the SOP itself.

The SOP is explicitly situated within the VEA/MRCA legal framework and interacts with other instruments and legal constructs in several ways set out in the instrument.

1. Source statute and application (s3, s5). The SOP is made under subsection 196B(3) of the VEA (s3) and applies to claims under section 120B of the VEA or section 339 of the MRCA (s5). Consequently, the SOP does not operate independently of those statutes; its role is to inform causation determinations made in the statutory claims processes governed by the VEA and MRCA.

2. Cross‑references to other Statements of Principles (s11). Section 11 provides an interaction rule: if a factor in s9 refers to an injury or disease that has its own SOP determined under s196B(3) of the VEA, then "the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time." This creates a system of interlocking SOPs. Practically, a claimant who relies on a factor that points to another disease must ensure compliance with that other SOP's requirements. The instrument therefore requires adjudicators and practitioners to check the current version of cross‑referenced SOPs when applying s9 factors.

3. Clinical classification and external standards (s7(3)-(4)). The SOP notes the ICD‑10‑AM codes commonly associated with adrenal insufficiency (E27.1, E27.2, E27.3, E27.4, E89.6, A18.7, A39.1), but clarifies that the statutory meaning for the SOP is the textual definition in s7(2). It also defines the ICD‑10‑AM edition referred to (Tenth Edition, effective 1 July 2017) and identifies the copyright owner (Independent Hospital Pricing Authority) and ISBN (s7(4)). This positions the SOP alongside diagnostic coding systems but indicates coding alone is not dispositive.

4. Interaction with pharmacology and therapeutics (Schedule). The Schedule contains two specified drug lists (Specified List 1 and Specified List 2) and detailed definitions of glucocorticoid therapy thresholds, equivalent glucocorticoids and inhaled equivalents. Where a factor refers to drug exposure (s9(7), s9(19); "glucocorticoid therapy as specified" in s9(8) and s9(20)), the SOP imports pharmacological dose, route and interaction concepts that may also be relevant to other regulatory regimes (for example, therapeutic standards, pharmaceutical labelling and clinical prescribing guidelines). The SOP, however, does not alter those other regimes; it merely uses pharmacological criteria as evidentiary thresholds for causation.

5. Medical causation standard and administrative law. The SOP articulates the RMA's medical‑scientific assessment appropriate for balance‑of‑probabilities findings (s8). Administrative decision‑makers applying the SOP will integrate this medical standard into their statutory decision processes under the VEA and MRCA. The SOP does not, by itself, create procedural rights of judicial review or appeal; such review remains governed by the administrative law and appeal mechanisms inherent in the VEA, MRCA and administrative tribunals.

6. Exclusions and constitutional/other legal limits. The SOP excludes heritable and congenital forms (s7(2)(c)). That exclusion interacts with broader legal definitions of service‑relatedness and disease causation in the VEA/MRCA context: a claimant whose adrenal insufficiency is congenital or heritable is outside the scope of this SOP's causal factors (and must rely on other legal avenues if any exist). The instrument does not override or modify substantive obligations under other statutes (for example, workers' compensation) but may be persuasive or relevant if similar medical causation issues arise elsewhere.

7. Repeal of prior SOP (s4). The instrument repeals the prior RMA SOP No. 75 of 2009. This means that any interpretive or evidentiary practice that relied on the earlier instrument must now be aligned with No. 72 of 2018. Section 11's cross‑reference rule further requires monitoring of updates to other SOPs.

In sum, the SOP is an embedded piece of the VEA/MRCA administrative matrix. It interfaces with diagnostic coding standards, clinical pharmacology, other SOPs, and the statutory frameworks that govern claims. Its role is to supply a medical‑evidential structure for causation; it neither creates nor eliminates the underlying statutory adjudicative processes, and practitioners must consider both the SOP and the governing Acts when preparing or deciding claims.

The instrument itself contains minimal amendment history because it is a single legislative instrument issued in 2018 and it records the repeal of a predecessor SOP. The express items in the text relevant to amendment and currency are:

• Date of determination and commencement: The Statement of Principles is dated 24 August 2018 (cover page) and "commences on 24 September 2018" (s2).
• Repeal of prior SOP: Section 4 repeals "The Statement of Principles concerning adrenal insufficiency No. 75 of 2009 (Federal Register of Legislation No. F2009L04046) made under subsection 196B(3) of the VEA." This is the only repeal or amendment action recorded in the instrument itself.
• Cross‑reference to other SOPs: Section 11 contemplates that other SOPs may be "in force from time to time" and requires that factors referring to an injury or disease covered by another SOP "apply in accordance with the terms of that Statement of Principles as in force from time to time." This means that the operation of the SOP will be affected by subsequent determinations or amendments to other SOPs, even though No. 72 itself does not list subsequent amendments.
• Versioning via statutory instrument processes: The instrument does not include an express clause on amendment procedures for the SOP itself; amendments would proceed by subsequent RMA determinations under subsection 196B(3) of the VEA, and by federal legislative instrument processes (publication, registration) as required by the enabling statute and legislative instrument rules. The SOP, where it refers to other SOPs, imports their versions "as in force from time to time" (s11) so claimants must monitor the Federal Register of Legislation and RMA publications for any later changes to cross‑referenced SOPs.

No further amendments, variations, or revocations are recorded in the text provided. There is therefore a straightforward amendment history in the instrument itself: it replaced the 2009 SOP when it commenced on 24 September 2018. Practitioners should take that repeal as a clear signal to use the 2018 SOP for claims arising on or after its commencement, and to check the Federal Register of Legislation for any later changes to this SOP or to other SOPs referenced herein.

The instrument as provided contains no record of litigation, judicial consideration, appellate decisions or case citations that interpret or apply this specific Statement of Principles. The SOP itself does not list any cases. It cites only the statutory source (subsection 196B(3) of the VEA) and references to other statutory provisions (section 120B VEA, section 339 MRCA) and to diagnostic coding (ICD‑10‑AM).

Consequent implications for practitioners:

• Absence of authority in the instrument: Because the SOP does not include, and the provided text does not identify, any cases construing No. 72 of 2018, practitioners cannot rely on judicial gloss within this instrument. Any relevant litigation history,decisions of administrative tribunals or courts applying this SOP,must be identified by separate legal research outside the instrument.
• Use in administrative and judicial review processes: Although not evidenced here, SOPs are commonly relied upon in VEA/MRCA claim adjudication and may be considered in administrative appeals and judicial review proceedings. Where parties litigate causation issues, courts and tribunals will typically examine (a) whether the decision‑maker correctly identified the applicable SOP, (b) whether the factual findings satisfy the SOP's factors on the balance of probabilities, and (c) the correctness of the legal application of the VEA/MRCA. None of this jurisprudence is set out in the instrument; therefore advisers must search tribunal and court databases for any decisions invoking SOP No. 72 of 2018.
• No specific cases named in the SOP: The instrument contains technical and medical definitions and lists but does not reference prior RMA determinations or external jurisprudence to justify the specific factor choices. It relies on the RMA's statement in s8 that the SOP reflects "sound medical‑scientific evidence", but the instrument itself does not reproduce that evidence nor cite primary studies or case law.

Practitioners preparing claims or advising on appeals should therefore treat the SOP as the authoritative administrative medical standard to be applied at the adjudication level, but should conduct independent research for any tribunal or court decisions that may have interpreted how the SOP operates in contested cases since its commencement in 2018.

This SOP contains many technical thresholds and cross‑references that create practical traps for claimants, treating clinicians and advisers. Below are specific "gotchas" grounded in the text that can materially affect the success of a claim.

1. Textual definition trumps ICD coding (s7(2)-(4)). Although the SOP notes ICD‑10‑AM codes associated with adrenal insufficiency (s7(3)), it expressly provides that the meaning of "adrenal insufficiency" for the SOP is the textual definition in s7(2). A diagnosis coded in the medical records is helpful but not decisive; the claimant must show biochemical demonstration and replacement therapy as required by s7(2)(a). Relying solely on an ICD code without supporting biochemical/treatment evidence risks rejection.

2. Exclusion of congenital/heritable forms (s7(2)(c)). If a claimant's adrenal insufficiency is heritable or congenital, this SOP expressly excludes it. That exclusion is absolute in the text; advisers must consider alternative legal avenues if such forms are alleged to be service‑connected.

3. At least one enumerated factor required (s9). The SOP does not allow free‑form causation arguments outside the listed factors. If none of the s9 factors is established, the SOP does not support a finding of connection. Evidence of general stressors or non‑listed exposures will not, under this SOP, satisfy the RMA's enumerated causal links.

4. Strict temporal windows (s9, Schedule). Several factors require precise timing:

   • Specified drugs: within 3 months before clinical onset or worsening (s9(7), s9(19)).
   • Glucocorticoid therapy as specified: last dose within 1 year before onset or worsening if therapy ceased/decreased (s9(8), s9(20)).
   • Surgery/injury to adrenal glands or haemorrhage/infarction: within 1 year before onset or worsening (s9(4)-(5), s9(16)-(17)).
   • Acute severe stressor for adrenal crisis: within 7 days before onset or worsening (s9(12), s9(24)). Claims that do not fit within these timeframes may fail even where the clinical picture suggests a link.

5. Complex glucocorticoid thresholds (Schedule). "Glucocorticoid therapy as specified" has multiple pathways to qualification (topical potency on ≥10% skin area daily for ≥3 months; inhaled doses at specified thresholds; cumulative oral/injectable doses and minimum average daily rates; concurrent use with CYP3A4 inhibitors for ≥4 weeks; ocular/nasal/enema use for specified durations; therapy producing Cushing's syndrome). Advisers must map actual prescribing records to these alternative criteria; misunderstanding the dose equivalents or route distinctions is a frequent evidentiary pitfall.

6. Drug interaction nuance (Schedule , Specified List 2). The Schedule identifies agents that are moderate to strong CYP3A4 inhibitors (Specified List 2). A claimant using a glucocorticoid concurrently with one of those drugs for four weeks qualifies under a pathway in "glucocorticoid therapy as specified". But absence of documented concomitant timing or exact agents will defeat this pathway. Similarly, the Specified List 1 identifies drugs that can cause adrenal insufficiency; proof requires timing within 3 months and identification of the specific agent.

7. Onset versus worsening and the service‑relationship distinction (s9, s10). Subsections 9(13)-9(25) address clinical worsening and s10(2) restricts their application to "material contribution to, or aggravation of" adrenal insufficiency where the condition was suffered or contracted before or during but did not arise out of relevant service. This creates a procedural and conceptual complexity: if the claimant's adrenal insufficiency pre‑dated service, different parts of s9 apply and the causal standard is material contribution/aggravation rather than causal origin. Failing to characterise the chronology correctly will lead to misapplication of the SOP.

8. "Inability to obtain appropriate clinical management" is a factor (s9(25)) but is necessarily linked to the requirement in s10 that the factor be related to relevant service. Proving inability to obtain appropriate management will require evidence of service‑related causes of that inability (for example, service‑related location or disability restricting access). Absent such links, the generality of the phrase will not establish service‑connection.

9. Death claims require contribution to a terminal event (s7(5), Schedule definition of "terminal event"). It is not enough to show adrenal insufficiency existed prior to death; evidence must support that adrenal insufficiency contributed to the terminal event (examples listed include pneumonia, respiratory failure, cardiac arrest). Medical cause of death documentation and expert interpretation will be essential.

10. Cross‑referenced SOPs can change applicable tests (s11). If a s9 factor points to another disease governed by its own SOP, a claimant must comply with that other SOP "as in force from time to time." That means that waiting or subsequent amendments to other SOPs can change the evidentiary posture of a claim. Advisers should check the operative versions of any cross‑referenced SOPs at the time of the claim.

11. Ambiguity in common clinical presentations. The Schedule notes that symptoms of adrenal insufficiency are nonspecific (nausea, fatigue, weight loss, depression etc.). Because these symptoms overlap with many conditions, diagnosis must be supported by "biochemically‑demonstrated deficient production of adrenal cortical hormones" and the requirement that this deficiency is "sufficient to produce clinical symptoms and signs, and to necessitate replacement therapy" (s7(2)(a)). Reliance on symptoms alone is insufficient.

12. The RMA's "more probable than not" medical view (s8) frames causation at the balance of probabilities, but claimants must still produce evidence satisfying the quantitative thresholds. The presence of the RMA's view does not eliminate the need for precise documentary proof mapped to the SOP's criteria.

These "gotchas" concentrate on timing, precise dosing/route thresholds, the necessity of biochemical proof, the exclusion of congenital forms, cross‑SOP dependencies, and the need to align clinical chronology (onset vs worsening) with the correct subsection of s9 and the service relationship rule in s10.

To maximise the prospects of a successful claim under this SOP, claimants, treating clinicians and advisers should assemble evidence that directly maps to the textual requirements of the instrument. The following is a practical, source‑grounded checklist, aligned with the SOP's structure (citations in parentheses are to the instrument's sections and Schedule).

1. Establish the condition as defined in s7(2):

   • Obtain objective biochemical evidence showing deficient production of adrenal cortical hormones. This may include cortisol measurements, ACTH stimulation testing, and other endocrine assays. The SOP requires "biochemically‑demonstrated deficient production" (s7(2)(a)).
   • Document that this deficiency produced clinical symptoms and signs and that the patient required glucocorticoid, mineralocorticoid or adrenal androgen replacement therapy (s7(2)(a)). Include treatment start dates and treatment rationale in clinical notes.

2. Map the claim to at least one s9 factor (and its timing):

   • Review the enumerated factors (s9(1)-(25)). Identify which factor or factors the claimant can potentially satisfy. Each factor has precise temporal or dosage requirements. For example:
     • Autoimmune adrenalitis present at clinical onset or worsening (s9(1), s9(13)).
     • Infiltration of the adrenal glands from a specified list (s9(2), s9(14)); corroborate with imaging, biopsy, or pathology reports and confirm the infiltrative disorder appears on the Schedule's specified list.
     • Infection with HIV before onset or worsening (s9(3), s9(15)); supply serology and clinic notes.
     • Surgery or injury to adrenal glands within 1 year of onset/worsening (s9(4), s9(16)); include operative notes and discharge summaries showing laterality and indication (for example single gland surgery for Cushing syndrome).
     • Haemorrhage or infarction of adrenal glands within 1 year (s9(5), s9(17)); gather imaging, pathology or ICU records showing adrenal haemorrhage/infarction and cause.
     • Infection of adrenal glands with a specified organism at time of onset/worsening (s9(6), s9(18)); provide microbiology, cultures, PCR or histopathology linking the organism to adrenal infection.
     • Treatment with a drug from Specified List 1 within 3 months before onset/worsening (s9(7), s9(19)); provide prescription records, pharmacy dispensing, and documentation of indications.
     • Glucocorticoid therapy as specified before onset/worsening, with last dose within 1 year if ceased/decreased (s9(8), s9(20)); compile dosing history and map to Schedule thresholds.
     • Treatment with medroxyprogesterone acetate or megestrol acetate for malignancy or HIV for at least 4 continuous weeks and last dose within 3 months if ceased (s9(9), s9(21)); provide oncology or HIV clinic records and pharmacy records.
     • Hypopituitarism with ACTH deficiency at onset/worsening (s9(10), s9(22)); supply endocrine testing and pituitary imaging.
     • Critical illness or injury within 1 year (s9(11), s9(23)); obtain ICU admission records, ventilation records, organ failure documentation matching Schedule definition of critical illness/injury.
     • For adrenal crisis, evidence of an acute severe stressor within 7 days (s9(12), s9(24)); provide emergency presentations, precipitating event records and contemporaneous vital signs documenting adrenal crisis features (Schedule definition).
     • Inability to obtain appropriate clinical management (s9(25)); produce contemporaneous evidence (medical appointments missed for service‑related reasons, geographic barriers linked to service, or administrative evidence of denied care), remembering the need under s10 to link this inability to relevant service.

3. For glucocorticoid evidence, apply the Schedule definition precisely:

   • If the case relies on oral or injectable glucocorticoid exposure, compute cumulative dose and average daily dose, and show that the thresholds are met: cumulative hydrocortisone ≥600 mg and minimum average 20 mg/day (or equivalent glucocorticoid therapy as per the Schedule table) (Schedule: equivalent glucocorticoid therapy; "glucocorticoid therapy as specified").
   • For inhaled glucocorticoids, show daily inhaled doses meet the Schedule thresholds (for example, inhaling at least 1,600 micrograms of budesonide or equivalent for at least three months, or equivalent inhaled glucocorticoid definitions).
   • For topical glucocorticoids, show application of a high or very high potency topical glucocorticoid to at least 10% total skin surface area daily for a continuous period of at least three months (Schedule definitions).
   • If relying on drug interaction pathways, clearly demonstrate concurrent use with a drug that inhibits CYP3A4 by ≥30% using the Schedule's Specified List 2 or show therapeutic equivalence in enzyme inhibition and provide dates/durations.

4. Document timing and relationship to service (s10):

   • Provide service records and medical timelines that demonstrate how the qualifying factor (for example drug exposure, surgery, infection) is related to the individual's defined "relevant service" (see Schedule definition of relevant service).
   • For factors intended to prove material contribution or aggravation (s9(13)-9(25)), ensure documentation shows the adrenal insufficiency existed before or during service and that the post‑service event materially contributed to worsening.

5. For death claims (s7(5)):

   • Obtain the death certificate, hospital records, terminal event documentation and any autopsy records. Demonstrate that adrenal insufficiency contributed to the terminal event (the Schedule lists pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function as examples of terminal events).
   • Where adrenal insufficiency is not recorded as the proximate cause, provide expert opinion linking the endocrine failure to the terminal sequence.

6. Where a s9 factor refers to another SOP (s11):

   • Identify the other Statement of Principles and obtain the operative version. Ensure the claim meets that SOP's factors "as in force from time to time". Do not rely solely on No. 72; ensure cross‑referenced SOPs' requirements are met.

7. Present clear expert evidence:

   • Where the causal pathway involves complex pharmacology, drug interactions, or less common infectious or infiltrative disorders, obtain expert clinical reports that map facts to the SOP wording. Experts should address the biochemical criteria, the mode and level of glucocorticoid exposure, and the temporal nexus to relevant service.
   • For adrenal crisis, the expert should address the constellation of symptoms and signs (hypotension, tachycardia, shock, hypoglycaemia, seizures, coma) and attest to the timing relative to the stressor.

8. Maintain documentary chain:

   • Pharmacy dispensing records, hospital notes, ICU/ventilation records, surgical operation notes, pathology and microbiology reports, endocrine test results, and service records should be collated and dated. Because the SOP hinges on specific dates and durations (three months, one year, seven days), contemporaneous documentation is essential.

9. Clarify exclusions early:

   • If congenital or heritable forms are present, consider whether any alternative SOP or legal pathway applies, because No. 72 expressly excludes heritable/congenital adrenal insufficiency (s7(2)(c)).

10. Be mindful of coding but do not rely on it:

• Use ICD‑10‑AM coding (the SOP references the Tenth Edition effective 1 July 2017) to identify cases and diagnostic labels (s7(3)-(4)), but ensure the clinical and biochemical evidence meet the SOP's textual definition.

11. Monitor for SOP or SOP‑cross changes:

• Because s11 imports other SOPs "as in force from time to time", advisers should confirm they are working with the current versions of any cross‑referenced Statements of Principles and check the Federal Register of Legislation for updates or revocations.

Adherence to these steps will align case preparation with the substantive and temporal tests in the SOP. The instrument sets predictable, medicalised thresholds for causation; success depends on documentary precision, correct mapping of clinical timelines to the enumerated factors, and where necessary, expert clinical exposition of how the facts meet the SOP's definitions.