Statement of Principles concerning coeliac disease (Balance of Probabilities) (No. 30 of 2020)

The instrument’s core medical concept is a statutory definition of coeliac disease tailored to veterans’ claims. Coeliac disease is defined as a malabsorption disorder in susceptible people due to immune‑mediated mucosal inflammation of the small intestine, characterised by villous atrophy and crypt hyperplasia, and triggered by hypersensitivity to ingested gluten (s7(2)(a)). The instrument explicitly excludes non‑coeliac gluten sensitivity, non‑coeliac wheat protein sensitivity, and wheat allergy (s7(2)(b)). Notes attached to s7 record that coeliac disease is associated with autoantibodies (tTG‑IgA and EMA‑IgA) and has gastrointestinal and extraintestinal manifestations; these are advisory clinical reminders within the Statement (Note 1 and Note 2 to s7).

The Statement also sets out what constitutes death from coeliac disease for claims purposes: death is included if the terminal event or condition leading to death was contributed to by the person’s coeliac disease (s7(5)). The term “terminal event” is defined in the Schedule 1 dictionary to include proximate or ultimate causes such as pneumonia, respiratory failure, cardiac arrest, circulatory failure, or cessation of brain function (Schedule 1: terminal event). The instrument confirms that, although coeliac disease corresponds to ICD‑10‑AM code K90.0, the statutory meaning in s7(2) controls (s7(3)-(4)), so indexing to the ICD code does not change the definition that governs claims.

Causation and connection are handled through a discrete list of factors. Section 9 lists four alternative factors any one of which must exist before connection can be made on the balance of probabilities: (1) treatment with interferon alpha within six months before clinical worsening; (2) treatment with a proton pump inhibitor (PPI) or histamine‑2 receptor antagonist (H2RA) on more days than not for at least six months before clinical worsening; (3) inability to maintain a gluten‑free diet at the time of clinical worsening; and (4) inability to obtain appropriate clinical management for coeliac disease (s9(1)-(4)). The instrument provides non‑exhaustive examples of PPIs and H2RAs in notes to s9.

The Statement contains procedural and limiting concepts in s10 and s11. Section 10 requires that any factor in s9 must be related to the person’s relevant service (s10(1)). Section 10(2) limits the application of s9(1)-(4) to material contribution or aggravation of pre‑existing coeliac disease that was suffered or contracted before or during relevant service but did not arise out of the person’s service. Section 11 imports, where applicable, the factors in other RMA Statements of Principles when a factor in s9 refers to an injury or disease already the subject of another Statement.

Finally, the instrument records the RMA’s evidential posture: it has formed the view, on the sound medical‑scientific evidence available, that connection is more probable than not in some circumstances (s8). That statement is the RMA’s declared evidentiary basis for adopting the listed factors as sufficient for establishing connection for claims falling within the referenced provisions of the VEA and MRCA.

This Statement affects persons making claims under the specific claim‑provisions referenced in the instrument , claims to which section 120B of the VEA or section 339 of the MRCA applies (s5). The instrument does not itself pay benefits or adjudicate claims; it prescribes the medical criteria to be applied when determining whether coeliac disease or death from coeliac disease can be connected with relevant service for the purposes of those claim provisions. Therefore the immediate practical users of the Statement are claimants (veterans and members of the Forces), their medical practitioners, and the decision‑makers who apply the VEA/MRCA claim provisions.

The Schedule 1 dictionary defines “relevant service” for the purposes of the Statement as 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; or peacetime service under the MRCA (Schedule 1, relevant service). That means the instrument applies only within those service categories; the Statement does not on its face apply to operational service, hazardous service, or British nuclear test defence service as those terms are excluded in the definition of relevant service.

Claimants with clinical presentations that are excluded by the statutory definition will not fall within the Statement’s scope. Section 7(2)(b) excludes non‑coeliac gluten sensitivity, non‑coeliac wheat protein sensitivity, and wheat allergy. Practitioners and claimants must therefore ensure the clinical diagnosis corresponds to the statutory definition in s7(2)(a) and is not one of the excluded entities.

The Statement also affects death claims where the person’s coeliac disease contributed to the terminal event that caused death (s7(5)). The definition of “terminal event” in the dictionary identifies typical proximate causes (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function) that, if contributed to by coeliac disease, bring the death within the Statement.

Because the factors in s9 only apply to material contribution or aggravation of coeliac disease that was suffered or contracted before, or during, but not arising out of, relevant service (s10(2)), the Statement primarily affects persons whose coeliac disease pre‑existed service or began during service but was not caused by service. Persons whose coeliac disease “arose out of” service may require a different analytical pathway; the Statement’s factors do not purport to cover disease that arose out of relevant service.

Finally, the Statement has secondary effect on decision‑makers and administrators across agencies implementing the VEA and MRCA because it prescribes the RMA’s view of sufficient medical factors for establishing service connection for coeliac disease and coeliac‑related death; they will use these factors when assessing claims within the identified statutory provisions (s5).

This instrument itself does not impose duties of conduct in the sense of prescriptive behavioural obligations on the public. Rather, it creates a set of evidentiary conditions and definitions to be applied in claims handling. The key operational duty created by the Statement is for decision‑makers adjudicating claims to treat the specified factors in s9 as the threshold matters that must exist, and to ensure any such factor is related to relevant service as required by s10(1). Decision‑makers must also observe the limit in s10(2) that the s9 factors apply only in cases of material contribution or aggravation where the person’s coeliac disease was suffered or contracted before or during (but did not arise out of) relevant service.

For claimants, the Statement establishes what medical and factual circumstances will, on the balance of probabilities, be sufficient for establishing connection. A claimant has the right to have their case assessed against these criteria when their claim falls under the VEA s120B or MRCA s339 (s5). The Statement also provides claimants with definitional clarity: the clinical definition of coeliac disease, the exclusions (s7(2)), and the inclusion of death where coeliac disease contributed to a terminal event (s7(5)). Those are rights of informational clarity rather than statutory entitlements created by this instrument itself.

Where a factor in s9 refers to another injury or disease that is the subject of a different Statement of Principles, s11 requires that the factors in that other Statement “apply in accordance with the terms of that Statement of Principles as in force from time to time.” That imposes a duty on decision‑makers to consult and apply the relevant other Statement when such cross‑reference arises, and it gives claimants the right to have the cross‑referenced Statement applied where applicable.

The RMA’s duty under the statute is to determine Statements of Principles under subsection 196B(3) of the VEA, and it has exercised that power here (s3). The Statement records the RMA’s view based on the available medical evidence (s8). The Statement does not itself create enforcement mechanisms or penalties; it is a rule‑making instrument setting evidentiary criteria to be used in assessment processes conducted under the VEA and MRCA.

Practically, the Statement imposes evidentiary duties on claimants and their medical advisers: to adduce records and opinions showing that at least one s9 factor existed and that the factor was related to the person’s relevant service (s9; s10(1)). For example, the claimant will need to provide medical records demonstrating the timing and duration of drug treatments (interferon alpha; PPI/H2RA), records or sworn statements evidencing inability to maintain a gluten‑free diet at the relevant time, or evidence of inability to obtain appropriate clinical management. The Statement signals to decision‑makers that these are the specific lines of inquiry and proof that should determine connection for the disease in question.

The Statement of Principles is an evidentiary instrument and does not itself create penalties, sanctions, or criminal offences. It is made under the RMA’s statutory power in subsection 196B(3) of the VEA (s3) and is intended to be applied by decision‑makers assessing claims under section 120B of the VEA or section 339 of the MRCA (s5). The instrument neither prescribes a regime of enforcement nor attaches fines or criminal sanctions to non‑compliance.

Enforcement in the practical sense occurs through the administrative claim process under the VEA and MRCA, which is outside the text of this Statement. The Statement establishes the criteria for establishing a causal or service connection; decision‑makers using those criteria will accept or reject claims, and any administrative consequences derive from the underlying statute’s benefits and entitlements provisions rather than from this Statement. The instrument contains no administrative penalty provisions and does not directly change the entitlement‑granting mechanisms in the VEA or MRCA.

The Statement includes no express investigatory powers, compliance monitoring mechanisms, or civil penalties. Where factual disputes arise about whether a listed factor existed or was related to relevant service, those disputes would be resolved through the relevant adjudicative processes under the VEA or MRCA, using the Statement as an evidentiary standard. The instrument makes clear that the RMA’s determinations are based on the medical‑scientific evidence available (s8), which implies that adjudicators will interpret and weigh that evidence in applying the s9 factors. Any consequences for incorrect or fraudulent claims would be governed by the penal or corrective provisions in the VEA or MRCA themselves, not by this Statement.

Because the Statement cross‑references to other Statements when a factor relates to another injury or disease (s11), enforcement or effect in those cases will depend on the terms and application of the other Statements as in force. The instrument therefore can alter an administrative outcome by changing the established evidentiary template, but it contains no standalone penalty or enforcement mechanism; practical enforcement is carried out by claim processors and tribunals under the parent Acts.

The Statement is made under a specific power in the Veterans' Entitlements Act 1986 (s3) and is explicitly intended to be applied in the adjudication of claims under identified provisions of the VEA and the MRCA (s5). The instrument’s legal effect is to bind decision‑makers applying those claim provisions to the RMA’s declared medical view and the enumerated factors. The instrument also cross‑references other RMA Statements of Principles where overlap exists: s11 provides that if a factor in s9 refers to an injury or disease covered by another Statement determined under subsection 196B(3) of the VEA, then the factors in that other Statement apply “in accordance with the terms of that Statement of Principles as in force from time to time.” That creates a hierarchy of application where the terms of the other Statement prevail for the matters it covers.

The Statement treats ICD‑10‑AM coding as a descriptive reference only. It confirms that although coeliac disease attracts ICD‑10‑AM code K90.0, the statutory meaning for the purposes of the Statement is the definition in s7(2), not the ICD code (s7(3)). The instrument specifies the particular edition of ICD‑10‑AM referenced (Tenth Edition, effective 1 July 2017) and identifies the source (Independent Hospital Pricing Authority) (s7(4)). This makes explicit that classification coding should not be used to override the statutory definition.

The Statement implicitly affects how VEA/MRCA decision‑makers apply medical causation in claims. It sets a list of factors which, if established and related to relevant service, are sufficient on the balance of probabilities to establish connection for coeliac disease or death from coeliac disease (s9; s10). That approach interacts with the statutory standards of proof and the procedures of the VEA and MRCA but does not amend those Acts. The Statement is therefore a source of interpretive guidance for applying the VEA/MRCA statutory tests.

Finally, where medical treatments or comorbid conditions referred to in s9 implicate other Statements, the cross‑reference in s11 requires decision‑makers to apply those other Statements’ factors. For example, where a s9 factor refers to an injury or disease already the subject of an existing Statement, the decision‑maker must apply the other Statement’s criteria “as in force from time to time” (s11). The Statement therefore operates within the broader network of RMA instruments and the statutory claims framework, modifying only the evidentiary assessment of coeliac disease connection while leaving the substantive entitlements schemes of the VEA and MRCA intact.

This instrument expressly repeals a previous RMA Statement on the same subject: the Statement of Principles concerning coeliac disease No. 2 of 2011, Federal Register of Legislation No. F2010L03249 (s4). The instrument indicates it is the successor to that earlier Statement and advances the RMA’s current view as of the date of the instrument (24 April 2020), with commencement on 25 May 2020 (s2). No other amendments or prior versions are referenced in the instrument.

The Schedule 1 dictionary and the main body include specific definitional, temporal and cross‑reference clarifications that update or replace the prior Statement’s content. For example, the instrument sets out precise limitations on when the s9 factors apply, notably confining them to material contribution or aggravation of pre‑existing disease that was not caused by service (s10(2)). It also restates the RMA’s evidentiary posture in s8, indicating that the RMA’s conclusion is based on the “sound medical‑scientific evidence available” and that it is “more probable than not” that coeliac disease and death from coeliac disease can be related to relevant service.

The instrument’s notes provide examples of drug classes (Notes to s9) and link the clinical definition to ICD‑10‑AM code K90.0 while making clear that the statutory definition governs (s7(3)-(4)). The adoption of ICD‑10‑AM version details (Tenth Edition, effective 1 July 2017) is an explicit temporal anchor for the external classification referenced (s7(4)). The repeal of the 2011 Statement is an unqualified repeal; the instrument contains no transitional provisions specifying how claims pending at commencement are to be treated. The absence of transitional wording means decision‑makers must apply this Statement from its commencement date to claims that fall within the identified statutory claim provisions, replacing the 2011 Statement’s criteria.

No subsequent amendments, variations, or modifications to this instrument are recorded in the text supplied. The instrument refers to the application of other Statements “as in force from time to time” (s11), which indicates an expectation that RMA Statements may be updated and that cross‑references should track those updates. Any further amendment history beyond the repeal of the 2011 Statement is not contained in this instrument.

The instrument itself does not record or set out any litigation history. It is a Statement of Principles determined by the Repatriation Medical Authority and, as presented, contains no annexure or schedule describing litigation or judicial consideration of its provisions. The text makes no reference to cases, tribunal decisions, or judicial interpretations that have construed this or earlier Statements. Therefore, based solely on the instrument, there is no litigation history recited within this document.

The absence of recorded litigation in the instrument does not preclude disputes arising from its application. Practical areas where litigation or administrative review might occur include contested interpretations of key terms used in the Statement , for example, “clinical worsening,” “inability to maintain a gluten‑free diet,” “inability to obtain appropriate clinical management,” or what constitutes the requisite causal relation to relevant service under s10(1). The instrument provides definitions for some terms (for example, “relevant service” and “terminal event” in Schedule 1) but leaves others to be assessed clinically and factually. Where tribunals or courts are called upon to apply the Statement, they will necessarily have to interpret these phrases and weigh the medical evidence against the s9 factors and the limits in s10(2). The instrument does not itself prescribe interpretive rules or illustrate applying the factors to sample facts.

Another potential source of contest in litigation would be the Statement’s reliance on the RMA’s assertion in s8 that, on the sound medical‑scientific evidence available, it is more probable than not that coeliac disease and death from it can be related to relevant service. Challenges could focus on the sufficiency or currency of the underlying evidence in a specific claim, or on whether a particular claimant has actually met the listed factors and the service‑relation requirement. However, the instrument contains no description of the RMA’s evidentiary base or methodology; those matters would surface through administrative records or expert evidence in a dispute rather than within this text.

Because the instrument cross‑references other Statements where a factor in s9 refers to another injury or disease (s11), litigation could also involve contention about which Statement applies in overlapping clinical scenarios. The Statement requires application of the other Statement “as in force from time to time,” so disputes could arise over which iteration of an earlier or later Statement governs a particular claim. None of these points are recorded as having been litigated in the instrument itself.

The instrument contains several drafting and substantive features that create practical pitfalls for claimants, practitioners, and decision‑makers. These are matters to be anticipated in case preparation and adjudication.

1. Exclusions in the clinical definition. The statutory definition in s7(2)(a) is specific and the instrument explicitly excludes non‑coeliac gluten sensitivity, non‑coeliac wheat protein sensitivity, and wheat allergy (s7(2)(b)). A diagnosis that uses lay terms or alternative labels but is not demonstrably the condition described in s7(2)(a) risks falling outside the Statement. ICD coding alone is not determinative: although the code K90.0 is referenced (s7(3)), the statutory definition controls; reliance solely on an ICD code without clinical correlation to s7(2)(a) is a potential misstep.

2. The “clinical worsening” trigger is not defined. Several s9 factors require a temporal relation to “the clinical worsening of coeliac disease” (s9(1)-(2)). The instrument does not define “clinical worsening,” so claimants must enable adjudicators to identify the point or period of worsening through contemporaneous clinical records, laboratory data, or treating practitioner statements. If timing is equivocal, establishing the necessary pre‑worsening treatment or inability to maintain diet may be difficult.

3. Narrow application where disease arose out of service. Section 10(2) constrains s9(1)-(4) to situations of material contribution to, or aggravation of, coeliac disease where the disease was suffered or contracted before or during, but did not arise out of, relevant service. That means if the claimant’s coeliac disease genuinely arose out of service, the s9 factors do not apply as written and a different causal analysis will be needed. Failing to recognise this distinction may produce the wrong evidentiary approach.

4. Broad but vague lifestyle and access factors. The s9(3) and s9(4) factors , inability to maintain a gluten‑free diet and inability to obtain appropriate clinical management , are fact‑intensive and potentially open‑ended. The Statement does not define “appropriate clinical management” or give examples of what evidence will satisfy “inability” in these contexts. Practitioners should prepare detailed documentary evidence (appointments, referrals, geographic/operational constraints, supply disruptions) because adjudicators will need concrete proof.

5. Medication‑use proof requirements. For drug‑related factors s9(1) and s9(2), the Statement specifies timing and duration: interferon alpha within six months before clinical worsening (s9(1)); PPI or H2RA “on more days than not” for at least six months before clinical worsening (s9(2)). These are precise thresholds; pharmacy dispensing records, hospital charts, and prescription histories are likely required. The instrument gives examples of drug names (Notes to s9) but does not list every drug in the classes; practitioners must ensure the drugs relied upon fall within the stated classes.

6. Cross‑reference complexity. If a s9 factor refers to another injury or disease covered by a different Statement, s11 requires the other Statement’s factors to apply. That can complicate analysis in cases involving comorbidities, as multiple Statements may need to be read together and the most recent iterations of those other Statements will apply “as in force from time to time” (s11). Failure to locate and apply the correct iteration of a cross‑referenced Statement could lead to incorrect application.

7. Death claims require a contribution link. For death claims the instrument includes death “from a terminal event or condition that was contributed to by the person's coeliac disease” (s7(5)). The Schedule defines “terminal event” in terms of proximate causes such as pneumonia and respiratory failure (Schedule 1). To succeed in a death claim, evidence must show that coeliac disease contributed to that terminal event; a mere presence of coeliac disease on the death certificate may be insufficient without linkage to a terminal event listed in the dictionary.

8. No transitional provisions noted. The repeal of the 2011 Statement is unqualified (s4) and the instrument contains no transitional provisions specifying application to pending claims. Decision‑makers will need to determine whether to apply this Statement from its commencement date to claims pending at that time, and this could raise procedural issues not addressed in the instrument itself.

Recognising these “gotchas” early will shape the evidence strategy: precise timing, class confirmation of medications, contemporaneous clinical records marking worsening, and documented barriers to diet and clinical care will be central.

Compliance, in practical terms, means enabling a decision‑maker assessing a VEA s120B or MRCA s339 claim to find that at least one of the s9 factors existed and that the relevant factor was related to the person’s relevant service as required by s10(1). Below are concrete steps for claimants, clinicians, and advisers, tied to the instrument’s specific provisions.

1. Establish the diagnosis strictly against s7(2). Assemble contemporaneous clinical documentation that demonstrates coeliac disease as defined in s7(2)(a): evidence of immune‑mediated small intestinal mucosal inflammation, villous atrophy/crypt hyperplasia, and gluten sensitivity. Include serology records (tTG‑IgA, EMA‑IgA) where available, as referenced in Note 1 to s7. Ensure the clinical picture excludes the specific listed exclusions in s7(2)(b) (non‑coeliac gluten sensitivity, non‑coeliac wheat protein sensitivity, wheat allergy). Do not rely solely on an ICD‑10‑AM code (K90.0); the statutory definition in s7(2) controls (s7(3)).

2. Precisely identify the timing of “clinical worsening.” For any s9 factor tied to a period before clinical worsening (s9(1)-(2)), document the date or period when clinical deterioration occurred. Use clinic notes, hospital admission records, objective laboratory or endoscopic findings, and treating specialist letters to anchor the point of worsening. The Statement uses “clinical worsening” as the temporal trigger without defining it; clear documentation is therefore critical.

3. For interferon alpha (s9(1)), obtain records showing administration dates. Hospital oncology or infectious diseases records, immunology clinic notes, and pharmacy or infusion service documentation should indicate interferon alpha use within the six months before the documented clinical worsening.

4. For PPI or H2RA exposure (s9(2)), assemble pharmacy dispensing records, prescription histories, or notes demonstrating use “on more days than not” for at least six months prior to clinical worsening. The instrument lists example drugs in a Note (s9 Note 1 and Note 2); ensure the medication used falls within the PPI or H2RA classes noted. Where hospital inpatient charts indicate regular administration, collate those as well. Precisely quantify duration and frequency to satisfy the “more days than not” threshold.

5. To prove inability to maintain a gluten‑free diet (s9(3)), obtain documentary evidence showing the claimant lacked practical ability to adhere to the diet at the time of clinical worsening. Examples of useful evidence include armistice or posting orders that restricted diet, records of ration or mess food content, contemporaneous reports of food supply issues, occupational limitations preventing procurement of suitable foods, clinical notes documenting dietary lapses due to environment or operational constraints, and dietitian assessments. Sworn statements from the claimant and witnesses contextualising the dietary environment will aid assessment.

6. To show inability to obtain appropriate clinical management (s9(4)), gather evidence of missed or delayed appointments, referrals not actioned, geographic access barriers, cancellation records, or administrative denials. Medical correspondence indicating that appropriate assessment or specialist treatment was unavailable, or delays in accessing endoscopy or serology testing, will assist. Be specific about timing and scope of missed care in relation to clinical worsening.

7. Demonstrate the relation to relevant service required by s10(1). For any of the above factors, produce material connecting the factor to relevant service. This may include service records, deployment orders, medical centre attendance logs while on service, and contemporaneous service documentation showing the circumstances (e.g., location, treatment availability, rationing) that led to the factor’s existence. The Statement requires that a s9 factor be related to relevant service; concrete service records are therefore essential.

8. Observe the limit in s10(2). If the claimant’s coeliac disease arose out of service, s9(1)-(4) do not apply to material contribution or aggravation as described. Determine whether the disease was suffered or contracted before or during service and whether it “arose out of” service. If the disease arose out of service, alternative lines of causal argument consistent with the VEA/MRCA and other applicable Statements may be necessary.

9. For death claims, connect the disease to the terminal event (s7(5)). Assemble the death certificate, hospital records, and treating clinician statements showing that coeliac disease contributed to the terminal event (for example, pneumonia, respiratory failure). The Schedule defines “terminal event” with examples (pneumonia; respiratory failure; cardiac arrest; circulatory failure; cessation of brain function). Evidence linking coeliac disease pathophysiology to the fatal event is required.

10. Check for cross‑reference application (s11). If a s9 factor depends on another injury or disease that is the subject of an existing RMA Statement, identify that Statement and ensure the factors in that Statement are satisfied. The instrument mandates applying those other Statements “as in force from time to time,” so use the most current version applicable.

11. Prepare expert medical opinion. Because the Statement sets medical thresholds and temporal relationships, provide treating specialist opinions that specifically address the statutory criteria: confirm the diagnosis under s7(2), set out dates of clinical worsening, opine on medication causation or contribution, comment on the feasibility of adhering to the diet in the relevant service circumstances, and address whether coeliac disease contributed to a terminal event for death claims. Opinions should explicitly tie the facts to the s9 factors and the service relation in s10.

12. Maintain documentary chain and chronology. Because several criteria turn on timing and frequency, produce a clear timeline correlating service events, treatments, dietary constraints, clinical worsening, and health system access. This will facilitate the decision‑maker’s application of the Statement’s factors.

Following these steps aligns claim preparation with the exact requirements of the Statement: diagnosis consistent with s7(2), demonstration of at least one s9 factor, and evidence the factor was related to relevant service per s10(1), with s9(1)-(4) applied only where s10(2) permits. The Statement provides specific thresholds and examples for some items (drug classes and timing), and preparation should prioritise evidence that addresses those precise thresholds.