Statement of Principles concerning albinism (Balance of Probabilities) (No. 32 of 2023)

This instrument uses a narrow set of medical and procedural concepts that determine its scope and application. The primary medical concepts are the definition of “albinism”, the treatment of death “from albinism”, and the single listed factor (inability to obtain appropriate clinical management) that must be established to link the condition to relevant service.

Albinism is defined in substantive, rather than purely classification, terms. Subsection 7(2) defines it as “one of a group of genetic disorders of melanin biosynthesis, commonly involving a reduction in hair, skin or eye pigmentation, misrouting of optic nerve fibres and other ocular abnormalities”, and expressly includes oculocutaneous and ocular albinism. The SoP notes, separately, that albinism attracts ICD‑10‑AM code E70.3 but clarifies that the legal meaning for this instrument is the textual definition in s7(2), not the code itself (s7(3)-(4)). The ICD reference is to the Tenth Edition, effective 1 July 2017 (s7(4)), but the statutory meaning is the text of s7(2).

Death from albinism is not limited to deaths where albinism is the immediate cause. Subsection 7(5) makes clear that, for the purposes of the SoP, albinism in relation to a person includes “death from a terminal event or condition that was contributed to by the person’s albinism”. The Schedule’s definition of “terminal event” identifies examples such as pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function. Thus, to bring a death within the ambit of this SoP, a causal contribution by albinism to a terminal event must be shown.

Causation and evidentiary standard: The RMA states its evidentiary threshold as the balance of probabilities: “on the sound medical‑scientific evidence available, the RMA is of the view that it is more probable than not that albinism and death from albinism can be related to relevant service” (s8). The SoP then specifies the factual factor(s) that, if established and related to relevant service, meet that threshold (s9-10).

The single listed factor that must exist is inability to obtain appropriate clinical management for albinism (s9(1)). This is a material contribution/aggravation type factor and is constrained by the temporal relationship in s10(2): it only applies where the person’s albinism was suffered or contracted before or during (but did not arise out of) relevant service. Section 10(1) imposes the additional requirement that any factor in s9 must be related to the person’s relevant service.

Inter‑SoP linkage: Section 11 provides a mechanism for cross‑reference. If a factor in this SoP refers to an injury or disease that is the subject of another SoP, then the factors in that other SoP apply as in force from time to time. That preserves the RMA’s established approach of mutual reference where overlapping medical conditions exist.

Definitions governing scope: The Schedule defines “relevant service” narrowly for this instrument as 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 scope therefore excludes operational service, hazardous service and British nuclear test defence service for the purposes of the listed relevant service categories in this instrument, as set out in the Schedule.

Overall, the main concepts link a genetic diagnosis, a conditional causal pathway through inadequate clinical management, and a specified set of service types. The SoP functions as a rule for administrative causal attribution under a balance of probabilities standard rather than as a clinical guideline to be applied in isolation from the VEA/MRCA claim processes.

The instrument applies to claimants whose claims fall within the statutory claim provisions identified in s5: claims to which section 120B of the VEA or section 339 of the MRCA applies. The SoP therefore affects persons (or their dependants, in death claims) bringing claims under those specific provisions of the VEA and MRCA in which the causal connection between a medical condition and relevant service is in issue.

By its Schedule definition, “relevant service” for the instrument is limited to:

• eligible war service other than operational service under the VEA;
• defence service other than hazardous service and British nuclear test defence service under the VEA;
• peacetime service under the MRCA.

Consequently, the SoP will be applied to veterans or members whose service falls inside these categories. It follows that claimants whose service is characterised as operational service, hazardous service or British nuclear test defence service will, for the purposes of this SoP’s definition of “relevant service”, not be covered by those categories in the Schedule; whether their claims fall under some other SoP or other statutory pathway is outside the instrument itself.

The instrument also affects administrative decision‑makers and medical assessors who determine whether a claimant’s albinism,or death from albinism,meets the required causal nexus to relevant service. The RMA’s SoP provides the medical and causation template used in decision‑making under the VEA/MRCA frameworks; thus claims officers, medical panels and tribunals adjudicating under those Acts will rely on the SoP’s definitions and factors when applying the balance of probabilities standard referenced in s8.

Medical practitioners preparing expert reports for claimants are also affected in a practical sense: the SoP identifies the specific medical features that must be addressed (diagnosis in the terms of s7(2), assessment of access to appropriate clinical management, and, where relevant, whether albinism materially contributed to a terminal event as defined in the Schedule).

Finally, the instrument affects the administration of records and evidence where the ICD‑10‑AM coding is used for classification. While s7(3) clarifies that the legal meaning is the textual definition in s7(2), the SoP nonetheless references ICD‑10‑AM E70.3 (s7(3)-(4)), which may guide clinical coding and recordkeeping practices.

Who does not fall within the instrument is as material as who does: the SoP’s temporal limitation in s10(2) excludes scenarios where albinism “arose out of” the person’s relevant service. Given the genetic definition of albinism in s7(2), that limitation is likely intended to confine the SoP to cases where service factors (such as access to care) materially affected an already existing condition, rather than cases where service is alleged to have caused the genetic disorder.

This SoP does not itself create express statutory duties or impose criminal or civil penalties. Instead, it establishes the RMA’s medical‑causal framework to be applied in the adjudication of relevant claims under the VEA and MRCA (s3, s5, s8). The principal “duties” and “rights” created or affected by the instrument are therefore procedural and evidentiary, rather than prescriptive obligations on private parties.

Rights:

• Claimants have the right to have their claim for albinism or death from albinism assessed against the SoP when their claim falls under section 120B of the VEA or section 339 of the MRCA (s5). The SoP supplies the RMA’s view of the medical evidence necessary to meet the balance of probabilities standard (s8).
• Where a claimant establishes, on the balance of probabilities, that at least one of the factors in s9 exists and that the factor is related to their relevant service (s9-10), the causal link contemplated by the SoP is satisfied for the purposes of the relevant determinations under the VEA/MRCA processes. The SoP thus operates as a binding medical template for administrative decision‑makers considering causal connection (insofar as these SoPs are used within the VEA/MRCA frameworks; see s3 and s5).

Duties and obligations on decision‑makers:

• Administrative decision‑makers applying the VEA or MRCA provisions to claims that fall under s120B or s339 must apply the SoP’s content as the RMA’s view of the medical‑scientific evidence on causal connection (s3, s8). Section 11 also requires decision‑makers to give effect to any interrelated SoP where a factor in this instrument refers to an injury or disease already covered by another SoP.

Evidentiary obligations on claimants:

• The SoP creates an evidentiary expectation that claimants will need to address the textual elements it sets out: diagnosis of albinism as defined in the instrument (s7(2)); proof that the inability to obtain appropriate clinical management existed and that it was related to the person’s relevant service (s9-10); and, for death claims, evidence that death was from a terminal event contributed to by albinism (s7(5) and Schedule definition of terminal event).

Operational implications for practitioners:

• Medical experts and treating clinicians preparing reports for claims will effectively be required to frame their opinions in terms that map to the SoP: diagnosis as per s7(2), assessment of whether clinical management was appropriate and whether there was an inability to obtain it, temporal relationship to relevant service, and whether albinism materially contributed to a terminal event.

What the SoP does not do:

• It does not itself award benefits, prescribe payment levels, or create enforcement powers. That remains the function of decision‑makers and the statutory benefit regimes under the VEA and MRCA. The SoP functions as a medical causation standard to be used in those determinations (s3, s5, s8).

In short, the SoP shapes the rights of claimants to have claims assessed under a defined causal framework and imposes an evidentiary duty on claimants to prove the specified factor(s) related to their relevant service. It imposes an operational duty on decision‑makers to use this RMA‑set framework when adjudicating relevant claims.

The instrument itself contains no express penalties, fines, criminal sanctions, or enforcement provisions. It is a statutory Statement of Principles issued by the RMA under subsection 196B(3) of the VEA and functions as a medico‑legal template for assessing causal connection in claims under specified provisions of the VEA and MRCA (s3, s5, s8). The SoP does not, on its face, create standalone enforcement mechanisms or compliance sanctions.

Enforcement and application take place within the administrative framework of claims under the VEA and MRCA. Section 5 specifies that the instrument applies to a claim to which section 120B of the VEA or section 339 of the MRCA applies. Accordingly, any “enforcement” effect is mediated through the adjudicative processes and remedies that those Acts provide for: decision‑makers applying those Acts will use the SoP’s factors and definitions when determining whether a claimant has established, on the balance of probabilities, that albinism or death from albinism is connected with relevant service (s8-10). The instrument therefore has practical effect through administrative decision‑making rather than by imposing sanctions.

Where a factor in this SoP refers to an injury or disease covered by another SoP, section 11 requires that the factors in that other SoP apply in accordance with their terms. This cross‑application can alter the evidentiary framework that decision‑makers use, which has downstream effects on claim outcomes. But again, that is an administrative linkage rather than a new enforcement power.

Because the SoP functions as part of the VEA/MRCA decision‑making machinery, any contested application of the SoP in an individual claim would be resolved through the review and appeals mechanisms established under the VEA and MRCA regimes, or through judicial review where applicable. The SoP itself does not prescribe those review mechanisms, nor does it specify procedural sanctions for non‑compliance; those details reside in the broader statutory frameworks referenced in s5.

Finally, the SoP’s repeal of the 2015 albinism SoP (s4) means that determinations and claims lodged after the commencement date will be adjudicated against the 2023 instrument. The practical enforcement implication is that administrative decisions must reference the current SoP; failure to apply the updated SoP in determining claims may be a ground of procedural error in subsequent review, again under the processes provided in the VEA/MRCA, not under this instrument itself.

This SoP explicitly situates itself within the VEA/MRCA statutory frameworks. Section 3 states the RMA’s authority to make the instrument under subsection 196B(3) of the VEA. Section 5 limits the application of the instrument to claims to which section 120B of the VEA or section 339 of the MRCA applies. Those cross‑references are the principal statutory interactions the instrument contains.

Inter‑SoP interaction: Section 11 provides an express mechanism for interaction with other Statements of Principles. If a factor in this SoP refers to an injury or disease that is the subject of another SoP determined under subsection 196B(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.” Practically, that means decision‑makers must apply the contemporaneous terms of any other relevant SoP where overlap exists. This preserves the hierarchical and interlinked SoP structure used by the RMA across multiple medical conditions.

Statutory claim frameworks: By applying to claims under specified sections of the VEA and MRCA (s5), the SoP operates as an evidentiary input into determinations under those Acts. It does not replace the statutory criteria for entitlement in those Acts but supplies the RMA’s medical opinion on causation which decision‑makers use in applying those statutory criteria.

Classification systems: The SoP references ICD‑10‑AM coding (s7(3)-(4)), identifying that albinism attracts code E70.3 in the Tenth Edition of the ICD‑10‑AM (effective 1 July 2017). The instrument stresses that the legal meaning of albinism for this SoP is the textual definition in s7(2), but the ICD reference links clinical classification systems to the administrative framework. That interaction will be relevant where clinical records and coding are used as evidence in claims.

Repeal and transitional interactions: The instrument repeals the previous SoP concerning albinism No. 20 of 2015 (s4). The practical legal interaction is that the 2015 SoP no longer applies once this instrument commences (s2-s4). Decision‑makers must therefore apply the 2023 SoP to claims whose adjudication post‑commencement falls within the instrument’s application (s2, s5).

Limitations and exclusions embedded in the Schedule: The Schedule’s definition of “relevant service” excludes operational service, hazardous service and British nuclear test defence service in the specified categories (see Schedule definitions). That creates an interaction with the broader definitions and service classifications in the VEA and MRCA: whether a particular period of service is “operational”, “hazardous” or otherwise characterised under the VEA/MRCA will determine whether the SoP applies to a given claimant’s period of service. The instrument does not itself define those excluded service categories; it relies on the statutory frameworks of the VEA/MRCA to supply those definitions.

No direct displacement of other legal causes: The SoP is limited to its role as an evidentiary template for causation under the VEA/MRCA claims it covers. It does not purport to displace other causes of action, statutory entitlements, or compensation schemes outside the specified VEA/MRCA provisions. Matters such as non‑VEA civil claims, workers’ compensation, or other administrative compensation regimes are not addressed by the instrument and remain governed by their own legal tests and statutory criteria.

In summary, the instrument interacts directly with the VEA and MRCA claim frameworks by supplying the RMA’s medico‑legal view on causation for albinism, cross‑refers and defers to other SoPs where relevant, ties into ICD coding for clinical classification, and replaces the earlier 2015 albinism SoP.

The instrument records limited but specific amendment and replacement history within its own terms. Key chronological and textual changes stated in the instrument are:

• Determination date and signature: The instrument is dated 24 April 2023 and bears the Common Seal of the Repatriation Medical Authority affixed at the direction of the Chairperson (front matter). That provides the documentary record of the RMA’s determination under its statutory power.

• Commencement: The instrument commences on 23 May 2023 (s2). Any transitional or retrospective application is not articulated in the text; the commencement provision is the operative date for when the instrument becomes effective.

• Repeal of prior SoP: Section 4 expressly repeals the Statement of Principles concerning albinism No. 20 of 2015 (Federal Register of Legislation No. F2014L01825), which was itself made under subsection 196B(3) of the VEA. The repeal is absolute in form; the instrument does not include savings, transitional provisions, or grandfathering language in the text provided. Accordingly, the 2015 SoP ceases to apply from the commencement date of this instrument.

• ICD edition reference: Section 7(4) identifies the ICD‑10‑AM Tenth Edition, effective 1 July 2017, as the edition referenced for the E70.3 code. This is an explicit technical reference point and may be relevant where clinical coding is examined; the instrument does not provide for future automatic updates to the ICD reference, nor does it specify a mechanism for revision beyond noting that the definition of albinism for the instrument is the textual definition in s7(2) (s7(3)).

• Substantive content: The 2023 instrument condenses the causal framework to a single qualifying factor (s9(1)),inability to obtain appropriate clinical management,together with temporal limits (s10). Whether and how that represents a substantive tightening, loosening, or recharacterisation of the 2015 instrument cannot be inferred from the 2023 text alone; the instrument simply replaces the earlier version.

• No express amendment schedule: The instrument contains no separate schedules of amendments beyond the express repeal of the 2015 SoP. There is no transitional provision in the instrument text addressing claims commenced before the commencement date but determined after it, nor any explicit provision addressing decisions already made under the 2015 SoP. Those matters, if they arise, would be governed by the VEA/MRCA administrative and review frameworks or by the terms of the repealed SoP as they apply prior to its repeal.

• Future amendments: The instrument does not specify a sunset, review date, or automatic revision mechanism. Amendments would therefore require further determinations under subsection 196B(3) of the VEA to alter the SoP, as was done here to repeal the 2015 SoP and replace it.

In sum, the 2023 instrument’s amendment history is limited to its repeal of the 2015 albinism SoP and its own commencement. The text contains the RMA’s current medico‑legal position as at 24 April 2023, effective 23 May 2023.

The instrument itself contains no internal record of litigation or case law. It repeals the prior SoP of 2015 (s4) but does not cite any judicial decisions, tribunal determinations or precedent as the basis for its content. The instrument’s only courtroom‑adjacent content is the RMA’s statement of the medical‑scientific view it takes on causation (s8), and the textual cross‑references to other SoPs (s11).

Because the instrument is a medical‑statutory instrument, disputes as to its application would arise in the context of claims under the VEA and MRCA and be resolved through the administrative review and merits review processes those Acts provide, or through judicial review where appropriate. The instrument does not record whether particular provisions have been litigated in those forums prior to its making.

Absent information in the instrument about prior litigation or contemporary challenges, the text provides no basis within itself to identify reported cases, tribunal findings, or appeals that have considered the 2023 SoP. The instrument also does not indicate whether the 2015 SoP was the subject of litigation, nor does it reference any authorities by name. Therefore, from the instrument alone:

• There is no litigation history recorded.
• Any claim that the SoP will be the subject of litigation must be assessed by reference to the VEA/MRCA dispute and review mechanisms and the facts of individual cases, not by reference to the SoP text.

Practitioners should therefore treat the instrument as the current RMA determination on causation for albinism as at the commencement date and expect that any legal challenges to its application will emerge in the course of decisions under the VEA/MRCA rather than being prefigured in the instrument’s text.

The instrument contains several drafting points and practical features that can catch claimants, practitioners and decision‑makers if not anticipated. These “gotchas” are matters of scope, proof, temporal limitation, and cross‑SoP interaction that arise directly from the instrument’s text.

Single factor requirement and its narrow wording (s9(1)): The SoP lists only one factor that must exist to connect albinism or death from albinism with relevant service: “inability to obtain appropriate clinical management for albinism.” The wording is compact and conceptually specific: the claimant must establish an inability to obtain appropriate clinical management, not merely suboptimal management or a general health disadvantage. That distinction matters in evidentiary practice. The SoP does not elaborate what constitutes “appropriate” clinical management, leaving that medical assessment to expert evidence in each claim.

Temporal and causal constraints (s10(2)): The factor in s9(1) “applies only to material contribution to, or aggravation of, albinism where the person's albinism was suffered or contracted before or during (but did not arise out of) the person's relevant service.” This clause has several consequences:

• It excludes claims where albinism “arose out of” relevant service. Given the genetic definition of albinism (s7(2)), the restriction likely intends to confine the SoP to situations where service circumstances (for example, lack of access to care) materially worsened an existing genetic condition, rather than where service is alleged to have caused the genetic disorder.
• The requirement that albinism be “suffered or contracted before or during” service embeds a temporal threshold that claimants must prove, which may be difficult where medical records are sparse.
• The clause limits the s9(1) factor to situations of material contribution or aggravation; mere correlation or coincidence between service and lack of management may not suffice.

Burden of proof and evidentiary mapping (s8, s9, s10): The RMA frames its standard as “more probable than not” that albinism can be related to relevant service (s8). Operationally, the claimant bears the task of adducing evidence that maps onto the SoP’s elements: diagnosis aligned to s7(2), proof of inability to obtain appropriate clinical management, and a service‑related causal link. Because the SoP supplies the RMA’s view of what evidence makes causation more probable than not, failure to address these elements directly in medical reports risks adverse findings.

Death claims and “contribution” to a terminal event (s7(5); Schedule): For death claims, the SoP requires that a terminal event or condition be contributed to by the person’s albinism. The Schedule lists examples of terminal events such as pneumonia and respiratory failure. Establishing that albinism contributed to such a terminal event will often require detailed clinical and forensic evidence tying ocular or cutaneous features of albinism to broader physiological vulnerability. The SoP does not specify thresholds for “contribution” (for example, whether a contributory or precipitating role is sufficient), leaving that to medical evidence and adjudicator judgment.

Cross‑SoP references (s11): If a factor in this SoP refers to an injury or disease covered by another SoP, 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.” Practitioners must therefore identify overlapping SoPs and ensure medical and factual evidence addresses both instruments where relevant. Failure to do so can result in misframed submissions.

ICD coding is advisory not determinative (s7(3)-(4)): The SoP notes that albinism attracts ICD‑10‑AM code E70.3 but clarifies that, for the SoP’s purposes, the meaning of albinism is the textual definition in s7(2). Practitioners relying solely on ICD coding in clinical records without aligning diagnoses to the s7(2) definition risk mismatch between evidence and the SoP’s textual standard.

Service classification pitfalls (Schedule): The Schedule defines “relevant service” with exclusions (for example, “other than operational service”; “other than hazardous service and British nuclear test defence service”). Accurately classifying a claimant’s service in accordance with those categories is essential. Misclassification can lead to the SoP being inapplicable to a claim even where medical elements are otherwise satisfied.

Repeal and timing (s2-s4): The 2015 SoP is repealed (s4). Claims assessed around the commencement date must be carefully considered for which SoP applies to the decision at issue. The instrument contains no transitional provisions; administrative timing and whether earlier decisions are revisited should be handled through the governing statutes and administrative processes.

No procedural details provided: The SoP prescribes medical/causal content but supplies no procedural guidance on how claimants should present evidence or how decision‑makers should weigh competing medical opinions. Practitioners must therefore translate the SoP elements into evidentiary strategies without procedural scaffolding from the instrument itself.

In short, the key practical pitfalls are the narrow and singular factor, the temporal limitation excluding conditions “arising out of” service, the need to tie medical evidence precisely to the SoP text rather than to coding alone, and the requirement to identify and cross‑address any other relevant SoPs.

Compliance with this SoP, in the context of preparing or defending claims under the VEA and MRCA provisions identified in s5, is primarily an exercise in evidence mapping: ensure that the facts and medical evidence directly address the SoP’s textual elements and the balance of probabilities standard set out in s8. The following practical steps flow directly from the instrument’s content.

1. Establish the diagnosis in the terms of the instrument (s7(2)):

   • Obtain clinical records that document a diagnosis of albinism consistent with s7(2): a genetic disorder of melanin biosynthesis, with relevant features such as reduced pigmentation and ocular abnormalities. While clinical codes (ICD‑10‑AM E70.3) may appear in records, ensure expert reports explicitly map the clinical findings to the s7(2) textual definition (s7(3)-(4)).

2. Demonstrate the required factor , inability to obtain appropriate clinical management (s9(1)):

   • Collect contemporaneous medical records, referral histories, appointment logs, wait‑list evidence, correspondence with health services, and any statements that document barriers to accessing care (for example, geographic isolation, service‑related posting without specialist access, or denial of services).
   • Secure a medical expert opinion that explains why the claimant was unable to obtain “appropriate” clinical management, what constitutes appropriate management for the claimant’s phenotype of albinism, and how the lack of that management materially contributed to or aggravated the condition. The expert should explain causally how the lack of management led to material contribution or aggravation.

3. Prove the temporal and causal connection to relevant service (s10(1)-(2) and Schedule definition of relevant service):

   • Provide service records establishing that the claimant’s relevant service falls within the Schedule’s definition of “relevant service” (eligible war service other than operational, defence service other than hazardous and British nuclear test defence service, or peacetime service under the MRCA).
   • Demonstrate that the claimant’s albinism was “suffered or contracted before or during” (but did not arise out of) their relevant service. This will usually require pre‑service medical history, service medical records, and post‑service clinical documentation.
   • The medical expert should address how the inability to obtain appropriate clinical management is causally connected to the claimant’s relevant service period. That nexus is expressly required by s10(1).

4. For death claims, prove contribution to a terminal event (s7(5) and Schedule):

   • If the claim concerns death from albinism, obtain the death certificate, autopsy reports, treating notes, and an expert medico‑legal opinion that articulates how albinism contributed to the terminal event (examples given in the Schedule include pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function).
   • The expert opinion should explain the pathophysiological pathway by which albinism materially contributed to the terminal event.

5. Address cross‑SoP issues (s11):

   • Identify any conditions referenced in the claimant’s records that are the subject of other SoPs. If the s9 factor refers to such a condition, ensure the medical evidence also engages with the factors set out in those other SoPs, because s11 mandates their application in accordance with their terms “as in force from time to time.”

6. Anticipate definitional and coding issues:

   • Although ICD‑10‑AM coding is cited (s7(3)-(4)), ensure that expert opinions and medical records are not reliant on code alone. The SoP’s legal definition is the text in s7(2); practitioners should map clinical findings to that text.

7. Prepare legal submissions that mirror the SoP structure:

   • Frame submissions to decision‑makers so that each element of the SoP is addressed: diagnosis per s7(2); existence of inability to obtain appropriate clinical management per s9(1); temporal and service nexus per s10; contribution to terminal event for death claims per s7(5) and Schedule.

8. Record keeping and contemporaneous evidence:

   • Since the SoP requires proof of inability to obtain appropriate clinical management, contemporaneous evidence of attempts to obtain care and obstacles encountered is crucial. This can include email correspondence, travel logs, proof of specialist availability, denial letters, or evidence of system constraints.

9. Consider timing relative to commencement and repeal (s2-s4):

   • Be mindful of the commencement date (23 May 2023) and that the 2015 SoP has been repealed (s4). For claims bridging the repeal/commencement, confirm which SoP is operative for the decision at issue through the claim process and any administrative guidance.

10. Use experts who can directly address the SoP:

• Engage clinicians and medico‑legal experts who can provide opinion evidence explicitly tied to the SoP’s elements: diagnosis per s7(2), an opinion on what constitutes appropriate clinical management for the claimant’s presentation, whether there was an inability to obtain it, and whether that inability was related to the person’s relevant service in a manner that materially contributed to or aggravated the condition.

Following the SoP means building an evidentiary package that directly addresses the instrument’s textual requirements. Because the SoP supplies the RMA’s view of the medical‑scientific evidence that satisfies the balance of probabilities standard (s8), submissions and expert reports that fail to address the SoP’s discrete elements risk failing to persuade the decision‑maker. The SoP leaves open clinical judgment on what is “appropriate” management, and the degree of causal contribution required, so the quality and specificity of medical expert evidence are critical.