Statement of Principles concerning atrial fibrillation and atrial flutter (Balance of Probabilities) (No. 2 of 2023)

The SoP rests on a small set of structural legal‑medical concepts that determine how it will be applied in claims. Those concepts are: the covered conditions; the evidentiary standard; factor presence and timing; relationship to relevant service; aggravation/material contribution versus new onset; and cross‑application with other Statements of Principles.

1. Covered conditions. The SoP defines atrial fibrillation and atrial flutter in clinical terms (subsection 7(2)). It clarifies that although AF/AFL have ICD‑10‑AM code I48, the legal meaning for the SoP is the textual clinical definitions in subsection 7(2) (subsections 7(3)-(4)). Death is included where death resulted from a terminal event or condition contributed to by AF/AFL (subsection 7(4); "terminal event" is defined in Schedule 1).

2. Evidentiary standard. The RMA frames the SoP as expressing what it considers to be "more probable than not" on the sound medical‑scientific evidence available that AF/AFL can be related to relevant service (section 8). The SoP then sets out factors that must be present "before it can be said that, on the balance of probabilities," AF/AFL is connected with service (section 9). Practically, that places the SoP within the "balance of probabilities" causal paradigm used in veteran entitlements decisions.

3. Factors and timing. Section 9 is a catalogue of factors, many with explicit temporal windows relative to "clinical onset" or "clinical worsening" of AF/AFL (for example, pulmonary thromboembolism within 30 days before clinical onset; thoracic surgical procedure within 1 year; glucocorticoid therapy criteria; alcohol consumption thresholds). The Schedule supplies precise numeric thresholds and definitions (for example, "consuming an average of at least 150 grams of alcohol per week for a continuous period of at least the 5 years before the clinical onset" is anchored to the Schedule's 10 grams per standard drink note).

4. Relationship to relevant service. The SoP requires that any factor identified in section 9 must be related to the person's relevant service (section 10(1)). The SoP also distinguishes between factors that operate for new onset and those that apply only to material contribution/aggravation where AF/AFL pre‑existed or occurred before or during service (section 10(2)). The latter is specifically limited to subsections 9(38) to 9(75).

5. Interaction with other SoPs. Section 11 provides that if a factor in section 9 refers to an injury or disease covered by another SoP, 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 establishes cross‑reference and deference to separate RMA determinations for particular diseases that also appear as factors here.

6. Defined measurement thresholds. The Schedule supplies operational definitions used throughout the list , e.g. "being overweight or obese" via BMI or waist circumference; "binge drinking" via number of drinks in a two‑hour period or BAC threshold; "one pack‑year" and pack‑year calculation; MET as the unit of metabolic exertion; minimum cumulative/average rates for glucocorticoid therapy together with a conversion table of equivalent glucocorticoid doses; specification of certain drugs (adenosine, dobutamine, milrinone) and examples of chemotherapeutic agents (doxorubicin, trastuzumab, ibrutinib). These numeric standards are the SoP’s measurement anchors for claim assessment.

Together, these concepts convert a broad clinical condition into an administrable set of fact‑based triggers for causal inference in veteran entitlement claims. The SoP does not itself set procedural steps for decision‑making beyond stating its application to claims under the cited statutory sections (section 5), nor does it define "clinical onset" or "clinical worsening" in the Schedule; those terms are used as clinical reference points throughout section 9.

The primary legal‑operational audience for this instrument comprises claimants eligible under the VEA or MRCA provisions cited, adjudicators applying those Acts, medical experts preparing medico‑legal evidence for claims, and the administrators who implement veteran entitlements policy. Concretely:

• Claimants: Veterans or members of the Forces making claims to which section 120B of the VEA or section 339 of the MRCA applies (section 5). The instrument operates as the RMA’s medical‑scientific prescription for how AF/AFL causation is to be assessed for those claims. Claimants seeking entitlement for AF/AFL or death from AF/AFL will need to demonstrate that at least one of the listed factors existed and that it is related to their relevant service (section 9; section 10(1)).

• Medical advisers and experts: Medical practitioners producing clinical and medico‑legal reports for claims will need to address the RMA’s listed factors, the Schedule thresholds and definitions, and the temporal windows for onset and worsening. For example, a report must address whether the claimant consumed an average of at least 150 g alcohol per week for at least five continuous years (section 9 and Schedule), or whether thoracic surgery occurred within 1 year of clinical onset (section 9).

• Decision‑makers under the VEA/MRCA: While the instrument does not itself name the administrative decision‑maker, it applies to claims under the specified statutory sections (section 5). These decision‑makers must apply the SoP and the Schedule definitions when deciding whether AF/AFL is related to service on the balance of probabilities. If a listed factor refers to a condition that has its own SoP, the decision‑maker must apply the other SoP’s factors per section 11.

• Service record custodians and treating clinicians: Because many factors require documentary evidence (surgery records, prescriptions, dialysis, smoking history, recorded BMI or waist circumference, polysomnography for obstructive sleep apnoea, chemotherapy records, glucocorticoid dose records), those who hold or generate clinical records will be affected by requests for records and statements to establish or rebut the presence of the factors and their timing.

• Policy and actuarial/finance personnel: Changes in the SoP (repeal of 2014 version; new factors and thresholds) can affect the volume and nature of successful claims and therefore administrative forecasting. The instrument supplies precise criteria that can change claim outcomes and therefore impact cost projections administered under VEA/MRCA processes.

Indirectly, the instrument affects legal advisers, insurers (where private insurance intersects with veteran benefits), and researchers who track veteran health outcomes. Changes to the SoP may alter litigation strategies, the types of expert evidence obtained, and the evidentiary burdens placed on claimants. Where factors refer to issues like "inability to obtain appropriate clinical management" or thresholds that require lifestyle quantification (e.g. long‑term alcohol consumption, pack‑years), claimants may need to assemble heterogeneous documentary and testimonial evidence, which affects the claimant’s time and out‑of‑pocket costs.

This instrument primarily establishes evidentiary factors rather than prescriptive duties or enforceable private rights. The crucial operative duties and rights, as provided in the text, are as follows:

• Duty to link factors to relevant service. Section 10(1) states that the existence of any factor in section 9 "must be related to the relevant service rendered by the person." That is the central obligation for causation under this SoP: presence of a listed factor alone is not sufficient,the factor must be shown to be connected to the person's relevant service.

• Duty to apply aggravation/material contribution rules for pre‑existing conditions. Section 10(2) limits the application of subsections 9(38) to 9(75) to situations of material contribution or aggravation where AF/AFL was "suffered or contracted before or during (but did not arise out of) the person's relevant service." Thus, when AF/AFL pre‑existed or was present before/during service, the adjudicator must consider only those enumerated subsections for material contribution/aggravation.

• Right to have the SoP applied to eligible claims. Section 5 makes the SoP applicable to claims to which the cited VEA and MRCA provisions apply. That confers on claimants the procedural right to have their AF/AFL claim assessed against the factors and definitions set out in this instrument (within the statutory scheme of the VEA and MRCA).

• Right to cross‑application of other SoPs. Section 11 provides that where a factor in section 9 refers to an injury/disease that itself is the subject of another SoP, the factors in that other SoP apply "in accordance with the terms of that Statement of Principles as in force from time to time." That permits a claimant or decision‑maker to draw on the medical‑scientific rules set out in other determined SoPs where relevant.

• Evidentiary expectations embedded in definitions. Schedule 1 sets numerical thresholds and definitions (e.g. BMI >=25, binge drinking definitions, pack‑year calculations, glucocorticoid equivalences). These provide the measurement standards that parties must meet or rebut. For example, "consuming an average of at least 150 grams of alcohol per week for a continuous period of at least the 5 years" triggers an enumerated factor (section 9), and the Schedule clarifies that the Australian standard drink contains 10 grams of alcohol.

• Absence of criminal or civil penalties in the instrument. The SoP contains no penal sanctions. Its operative effect is administrative: it supplies the criteria for deciding whether AF/AFL is related to relevant service in claims under VEA/MRCA. Rights to benefits and duties to establish the SoP factors are exercised within the decision processes of those Acts rather than by this instrument alone.

Practically, the claimant is required to marshal evidence relevant to the listed factors and to demonstrate a relation of the factor to relevant service. The decision‑maker is bound by the SoP’s presence and cross‑references when applying the medical causal framework in claim determinations. The Schedule’s numeric definitions create discrete probative thresholds that transform clinical features into administrable legal criteria. For example, the table of equivalent glucocorticoid doses sets a cumulative‑dose and average‑rate threshold for "glucocorticoid therapy as specified" in the Schedule; the presence of that therapy in the relevant time window is a factor under sections 9(…) addressing drug therapy as a possible cause or aggravator.

The Statement of Principles itself does not create criminal offences, financial penalties, or a freestanding enforcement regime. It is an administrative medical‑scientific instrument intended to be applied in the statutory entitlement processes established by the VEA and the MRCA (section 5). The following points describe how enforcement and consequences manifest given the instrument’s text:

• Administrative enforcement via claims processes. The SoP applies to claims to which section 120B of the VEA or section 339 of the MRCA applies (section 5). Those cited sections in the parent statutes set the statutory mechanisms for entitlement and decision‑making; this SoP furnishes the medical‑scientific criteria that decision‑makers will apply within those mechanisms. The instrument does not itself specify procedures, time limits or appeal rights; those reside in the VEA and MRCA.

• Evidentiary consequence rather than sanction. The SoP’s role is evidentiary: it defines when a medical causal connection can be said to exist "on the balance of probabilities." There is no monetary penalty for non‑compliance with the SoP; the practical enforcement is that claims will succeed or fail depending on whether the factors and the relationship to relevant service can be established.

• Decision‑maker discretion constrained by definitions. Administrative decision‑makers applying the VEA/MRCA will apply the numerical thresholds and temporal windows in the SoP and Schedule when assessing whether AF/AFL is related to service. The SoP therefore constrains causal assessment by prescribing factors and measurement standards; it does not specify sanctions for incorrect claims but enables a reasoned basis for acceptance or rejection of claims.

• No civil‑law private right to damages created by the instrument. The SoP is not framed to create civil causes of action or private enforcement; it is a technical administrative determination under the VEA framework.

• Repeal and replacement. The SoP expressly repeals the earlier 2014 AF/AFL SoP (section 4). That repeal means the 2014 criteria no longer govern claims made under the statutory provisions after commencement; the new instrument's factors and definitions are the operative ones for applicable claims from 23 January 2023 (section 2).

In summary, the SoP’s enforcement is mediated through entitlement decision‑making under the VEA and MRCA. The instrument creates administrative criteria that shape the outcome of claims (acceptance, rejection, or partial acceptance) but does not itself impose penal sanctions or independent enforcement measures.

The instrument is made under a specific power in the VEA and is designed to be read into the decision‑making framework of both the VEA and the MRCA. The text provides several explicit cross‑references that determine how it interacts with other legal instruments and determinations:

• Legal basis and statutory context. The SoP is made under subsection 196B(3) of the VEA (section 3). It is applied to claims under section 120B of the VEA or section 339 of the MRCA (section 5). The SoP therefore sits as a subordinate instrument within the statutory schemes of those two Acts; the substantive rights and procedures for claim lodgement, assessment, review and appeal remain governed by the VEA and MRCA.

• Repeal of prior SoP. Section 4 repeals the Statement of Principles concerning atrial fibrillation and atrial flutter No. 50 of 2014. This is an internal interaction: subsequent decisions must use the 2023 instrument. Anyone relying on the 2014 SoP for precedent or assessment must update to the 2023 criteria.

• Cross‑application with other SoPs. Section 11 directs that if a factor in section 9 refers to an injury or disease covered by another SoP determined under subsection 196B(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." Practically, this means that where section 9 cites, for example, "chronic obstructive pulmonary disease" or "diabetes mellitus", the relevant standalone SoP for COPD or diabetes (if any) governs how those conditions are to be assessed for causation. Section 11 thus creates a hierarchy and cross‑reference mechanism between SoPs.

• Use of ICD coding with a caveat. The instrument notes that although AF/AFL attract ICD‑10‑AM code I48, "in applying this Statement of Principles the meaning of atrial fibrillation and atrial flutter is that given in subsection (2)" (subsections 7(3)-(4)). The Schedule also references the particular edition of ICD‑10‑AM (Tenth Edition, effective 1 July 2017) for possible coding cross‑checks. This allows adjudicators to use clinical coding where appropriate but mandates reliance on the RMA’s textual clinical definitions for legal application.

• Interaction with medical practice standards. The Schedule adopts clinical measurement units and thresholds (BMI, METs, pack‑years, glucocorticoid equivalence). These are clinical benchmarks that will be reconciled with existing clinical records, diagnostic tests, pharmacotherapy records and treatment notes. The SoP therefore intersects with the general standard of care and record‑keeping practice in clinical medicine, because those records are primary evidence for the SoP’s thresholds.

• Relationship with veterans’ entitlement adjudication principles. Although the instrument does not reproduce VEA/MRCA procedural or evidentiary rules, it must be applied within them. For example, VEA/MRCA statutory provisions that require application of medical opinion, consideration of service records, or allocation of burden of proof will interact with the SoP’s factor list. The SoP narrows the medical question to enumerated possible causal factors and defined thresholds; the ultimate legal application is determined under the parent Acts and their administrative processes.

• No explicit interaction with other federal laws (e.g. criminal, taxation) in the instrument. The SoP is narrowly framed to operate within the veteran entitlements context; it contains no broad cross‑references to other Commonwealth statutes beyond VEA and MRCA and the ICD standard cited in the Schedule.

In effect, the SoP integrates with the VEA/MRCA adjudicative mechanisms by supplying the RMA’s medical‑scientific view on which factors, and defined thresholds, can link AF/AFL to relevant service. Where other SoPs exist for related diseases, section 11 makes them the controlling medical framework for those particular factors.

This instrument documents a discrete amendment event in the RMA's determinations for AF/AFL. The explicit amendment history contained in the instrument is as follows:

• Repeal of the 2014 Statement. Section 4 states that the Statement of Principles concerning atrial fibrillation and atrial flutter No. 50 of 2014 (Federal Register of Legislation No. F2014L00482), made under subsection 196B(3) of the VEA, is repealed. That is the principal formal amendment: the 2014 instrument is removed and replaced by this 2023 determination.

• New determination number and dates. The instrument is titled "Statement of Principles concerning ATRIAL FIBRILLATION AND ATRIAL FLUTTER (Balance of Probabilities) (No. 2 of 2023)." It was dated 23 December 2022 (maker’s sign‑on - Professor Terence Campbell AM, Chairperson) and stipulates commencement on 23 January 2023 (section 2). The formal repeal and commencement dates enable administrators to determine which SoP applies to claims with relevant dates.

• Implicit amendment path. The instrument is made under subsection 196B(3) of the VEA, which is the statutory power that allows the RMA to determine and redetermine Statements of Principles. Although the instrument does not itself record any prior internal drafting versions or consultation logs, the existence of a newer SoP replacing a 2014 version implies that the RMA re‑evaluated the medical evidence and issued an updated determination.

• Versioning and "in force from time to time" cross‑references. Section 11 requires application of other SoPs "as in force from time to time." This wording anticipates future amendments to other SoPs and preserves their dynamic application. The SoP itself could be subsequently amended or replaced under the same statutory power, and section 11 ensures that cross‑referenced SoPs apply in their then‑current form.

• No transitional provisions in the text. The instrument does not contain express transitional provisions specifying how existing claims in process as of the commencement date are to be handled. The instrument simply repeals the 2014 SoP and commences on the stated date. Therefore, interpreting transitional effect (if any) will depend on the VEA/MRCA statutory processes and administrative practice rather than on specific transitional clauses in this SoP.

For legal practitioners and administrators, the practical consequence of this amendment history is that, from 23 January 2023, the 2023 SoP is the operative RMA determination for AF/AFL claims to which the cited VEA/MRCA sections apply, and the 2014 SoP should no longer be consulted as authoritative for those claims.

The instrument as provided contains no references to court decisions, litigation outcomes, or precedent involving this SoP. The document does not name any cases nor does it summarise judicial treatment of the earlier 2014 SoP or RMA determinations. The only judicial or litigation‑type content in the instrument is the RMA’s own stated view that "on the sound medical‑scientific evidence available" it is of the view that AF/AFL can be related to relevant service on the balance of probabilities (section 8).

Because the document itself is a medical‑scientific administrative instrument rather than a judicial ruling, any litigation history bearing on its interpretation, validity, or application would be found in decisions that cite or challenge RMA SoPs within the context of VEA/MRCA appeals or judicial reviews of administrative decisions. None of those decisions are present in the instrument’s text.

Practically, this means:

• There is no litigation record in the instrument to indicate how courts have treated the RMA’s list of factors for AF/AFL, or whether particular factors or thresholds have been subject to judicial testing.

• Where legal advisers or researchers need to understand how the SoP performs in adjudication, they must consult VEA/MRCA decisions, tribunal decisions, and any judicial reviews external to this instrument. Those sources are not reproduced in this document.

• Absent a litigation history in the instrument, uncertainties about ambiguous terms (for example "clinical onset", "clinical worsening", or "inability to obtain appropriate clinical management") will be resolved in practice by administrative decisions and, potentially, by tribunal or court determinations. Until such adjudicative interpretations are published, the precise application of some terms may remain a matter of administrative discretion and expert medical interpretation.

In short, the instrument contains no litigation history; assessing how its provisions perform in dispute resolution requires consulting the body of VEA/MRCA decisions and any court judgments that post‑date the instrument’s commencement.

This SoP contains numerous technical thresholds, temporal windows and cross‑references that can cause claim assessment traps or evidentiary difficulties if not anticipated. The following are practical "gotchas" grounded in the instrument’s text and the Schedule definitions:

1. At least one factor must exist and be related to relevant service. The SoP does not allow a causal inference without at least one enumerated factor (section 9) and a demonstrated relationship to relevant service (section 10(1)). Claimants with AF/AFL but without any listed factor or without evidence linking a factor to service will not meet the SoP’s criterion.

2. Timing windows are strict and variable. Many factors include precise time limits; examples include: pulmonary thromboembolism within 30 days before clinical onset (section 9); thoracic surgical procedure or invasive cardiac procedure within 1 year before onset (section 9); non‑cardiothoracic surgery under general/regional anaesthesia within 30 days before onset (section 9); glucocorticoid therapy cessation effects within 30 days (section 9). Failure to prove exact dates can be decisive.

3. Some factors apply only to aggravation/material contribution. Subsections 9(38)-9(75) (the instrument enumerates many subsections) apply only where AF/AFL was suffered or contracted before or during service but "did not arise out of" service (section 10(2)). Misapplying these factors to new‑onset AF/AFL claims or ignoring their limited remit can produce incorrect causation analyses.

4. Measurement thresholds require documentary or clinical proof. Several factors use precise numerical thresholds: being overweight/obese defined by BMI >=25 or waist circumference thresholds (Schedule); alcohol consumption threshold of at least 150 grams per week for 5 continuous years (section 9 and Schedule , note that the Schedule fixes 1 standard alcoholic drink at 10 grams); smoking threshold of at least 10 pack‑years with a 5‑year cessation window for former smokers (section 9 and Schedule); glucocorticoid dose thresholds are set in the Schedule table. Reliance on retrospective self‑report without corroborating records is riskier given these numeric concretisations.

5. Undefined clinical terms left to interpretation. The SoP uses "clinical onset" and "clinical worsening" repeatedly but these terms are not defined in Schedule 1. The absence of a statutory definition means adjudicators and experts will need to interpret them clinically and consistently; that may create disputes over onset/worsening dates (for example, whether symptom onset or first documented ECG constitutes "clinical onset").

6. "Inability to obtain appropriate clinical management" is open textured. The inclusion of inability to obtain appropriate clinical management for AF/AFL as a factor (last item in section 9) is broad and susceptible to evidentiary contest. The instrument does not define what level or type of management is "appropriate", nor does it specify how inability is to be demonstrated. This opens room for argument about access to care, service circumstances interfering with care, and the temporal nexus.

7. Cross‑SoP dependencies. Section 11 requires application of other SoPs where a section 9 factor refers to a disease that has its own SoP. Failure to identify and apply those other SoPs correctly can lead to inconsistent adjudication. Practitioners must check whether referenced conditions (e.g. COPD, diabetes, spinal cord injury) have their own current SoPs and apply those factors "as in force from time to time" (section 11).

8. Operational measurement of METs and "strenuous physical activity" is challenging. The SoP requires evidence that the person undertook strenuous activity greater than 6 METs for an average of at least 20 hours per week for 5 continuous years to trigger certain factors (section 9). MET is defined in the Schedule. Turning occupational or recreational histories into average weekly MET-hours for retrospective periods will generally require specialist assessment and may produce contested expert opinions.

9. Pack‑year conversions for non‑cigarette tobacco. The Schedule converts other tobacco forms (pipe, cigars, loose tobacco) with a 1 gram of tobacco = 1 cigarette equivalence. For those with mixed tobacco histories, precise conversion will be necessary and may be technically awkward where quantity records are incomplete.

10. Drugs and therapies have narrow temporal windows. The "specified list of drugs" (adenosine, dobutamine, milrinone) must have been taken within 7 days before clinical onset or worsening (section 9 and Schedule). Systemic chemotherapy and certain agents are listed as examples; proving contemporaneous administration (and linking it to service, where necessary) can be record‑dependent.

11. Repeal without transitional detail. The instrument repeals the 2014 SoP but contains no express transitional provision. Practitioners handling claims spanning the commencement date must attend to administrative guidance or statutory rules under the VEA/MRCA to determine which instrument governs particular claims.

12. "Malignant neoplasm, excluding non‑melanotic malignant neoplasm of the skin." Many cancers are included as factors; however, the instrument excludes non‑melanotic skin cancers. Practitioners must be careful in characterising cancer histories accordingly.

These "gotchas" highlight that small procedural or evidentiary shortfalls , missing dates, absent drug records, lack of measured BMI or waist circumference, or ambiguous definitions of onset , can materially affect claim outcomes given the SoP’s reliance on defined thresholds and time windows.

Compliance from the claimant and adviser perspective means assembling the documentary, clinical and service evidence necessary to demonstrate that at least one of the RMA‑listed factors existed and that the factor is related to the person's relevant service (sections 9 and 10(1)). Below is a practical, source‑grounded checklist of steps and documentation to consider, matched to the instrument’s requirements and Schedule definitions.

1. Establish the clinical diagnosis and dates.

   • Obtain clinical records showing a diagnosis of atrial fibrillation and/or atrial flutter, including ECG tracings, cardiology notes, admission/discharge summaries and dates. The SoP anchors causal windows to "clinical onset" and "clinical worsening" (section 9), so establish the earliest documented date of onset and any documented dates of worsening.

2. Map service exposure and relevant service dates.

   • Secure service records that identify "relevant service" as defined in Schedule 1 (eligible war service, defence service other than hazardous and British nuclear test service under the VEA, or peacetime service under the MRCA). Then link the RMA‑listed factor(s) to those service periods to satisfy section 10(1).

3. Document procedural exposures and surgical history.

   • For thoracic surgical procedures or invasive cardiac procedures (e.g. CABG, open heart surgery, heart transplant, TAVI), obtain operation notes, anaesthetic charts, and hospital discharge summaries showing procedure type and date. The SoP uses 1 year and 30 day windows for some surgeries (section 9), so exact dates are crucial.

4. Capture pharmacotherapy and chemotherapy records.

   • For specified drugs (adenosine, dobutamine, milrinone) and systemic chemotherapy agents (examples given: anthracyclines, trastuzumab, ibrutinib), obtain pharmacy dispensing records, chemotherapy infusion notes, scripts and treatment summaries showing dates. For glucocorticoid therapy "as specified", collect dosing history and calculate cumulative doses against the Schedule’s equivalency table to demonstrate whether thresholds are met.

5. Record alcohol consumption and binge drinking history.

   • To meet the 150 grams/week for 5 continuous years threshold, compile self‑reported histories corroborated by medical notes, alcohol screening tools, occupational health records, or family testimony where available. Remember the Schedule uses a 10 g per standard drink metric; therefore 150 g/week = 15 standard drinks/week. For binge drinking within 2 days before onset, collate contemporaneous evidence (ED notes, police records, witness statements, hospital toxicology tests).

6. Establish smoking history and pack‑years.

   • Obtain smoking histories, clinician notes and occupational records that specify cigarettes per day and years smoked to calculate pack‑years using the Schedule’s formula. For cessation, ensure dates of stopping are clear because the SoP requires that, if smoking ceased before onset/worsening, the onset/worsening must occur within 5 years of cessation.

7. Document comorbid conditions with dates.

   • For hypertension, ischaemic heart disease, cardiomyopathy, heart failure, COPD, asthma requiring maintenance therapy, thyroid conditions (hyperthyroidism, subclinical hyperthyroidism, thyrotoxicosis), diabetes mellitus (noting the 5‑year duration requirement for some factors), chronic renal failure (Schedule GFR and dialysis criteria), spinal cord injury, sepsis (Schedule definition), amyloidosis or sarcoidosis infiltration, autoimmune/inflammatory diseases (specified list in Schedule) , provide specialist letters, diagnostic imaging, lab tests, GFR calculations, dialysis records, and operation notes with dates.

8. Quantify body habitus and MET‑based activity.

   • For "being overweight or obese", gather recorded BMI (weight and height) or waist circumference measures meeting Schedule thresholds. For the strenuous activity factor, secure employment records, training logs, fitness assessments or occupational physiologist reports capable of translating activity into MET equivalents (the Schedule defines 1 MET and the SoP requires >6 METs average 20 hours/week for 5 continuous years in some factors).

9. Provide ICU, ventilation, sepsis and trauma records.

   • For factors that hinge on admission to intensive care or mechanical ventilation, pulmonary embolism within 30 days, penetrating cardiac trauma within 1 year, or sepsis within 30 days, collate ICU admission notes, ventilation records, ICD coding in discharge summaries, operative notes and imaging reports.

10. Demonstrate inability to obtain appropriate clinical management (if relevant).

    • If relying on this factor, assemble contemporaneous records that evidence attempts to obtain care and the reasons care was unavailable, such as clinic cancellation records, duty‑of‑care denials, communications showing inability to obtain specialist referrals, or service documentation showing barriers to treatment during service. Because "appropriate clinical management" is not defined in the Schedule, credible documentary corroboration will be essential.

11. Cross‑check for overlapping SoPs.

    • If a section 9 factor refers to another disease covered by a separate SoP (section 11), obtain and apply the other SoP’s criteria as in force. For instance, if COPD is relied on as a factor, determine whether the RMA has a distinct COPD SoP and ensure compliance with its factors.

12. Prepare medico‑legal statements addressing causal nexus.

    • Commission medical experts to produce reports that: a) confirm the diagnosis and the dates of clinical onset/worsening; b) demonstrate presence of the specified factor(s) and calculate thresholds (e.g. cumulative glucocorticoid doses, alcohol grams/week, pack‑years, BMI); c) explain how the factor is related to the claimant’s service (section 10(1)); and d) where relevant, address material contribution/aggravation if AF/AFL pre‑existed (section 10(2), subsections 9(38)-9(75)).

13. Anticipate evidentiary gaps and prepare supplementary evidence.

    • Where precise measurements are unavailable (for example, lack of historic waist circumference), consider corroborative evidence: contemporaneous clinician notes, occupational health surveillance, photographs with dated metadata, or reliable third‑party statements.

14. Note the repeal date and applicability.

    • For claims with facts around the commencement date (23 January 2023), confirm which SoP should be applied (the 2014 SoP was repealed by section 4), and cite administrative guidance or statutory rules if a transitional issue arises.

By following these steps and aligning documentary evidence to the specific Schedule definitions and temporal windows in the SoP, claimants and advisers will be best placed to demonstrate that a listed factor existed and was related to relevant service, which is the SoP’s legal prerequisite for establishing causation on the balance of probabilities.