Statement of Principles concerning eosinophilic oesophagitis (Balance of Probabilities) (No. 30 of 2022)

The Statement of Principles defines a short list of core concepts and working rules that decision-makers will use when assessing whether EoE is connected with relevant service. The principal medical definition is set out in s 6(2): EoE is a chronic, immune-mediated oesophageal disease characterised by symptoms related to oesophageal dysfunction together with eosinophil-predominant inflammation of the oesophageal epithelium. The instrument clarifies typical adult symptoms (note to s 6(2) Note 1), a histological threshold (peak values of at least 15 eosinophils per high-power field on oesophageal biopsy) (note to s 6(2) Note 2), and endoscopic findings that may increase diagnostic suspicion (note to s 6(2) Note 3). The instrument also directs a full clinical assessment to evaluate other conditions that could account for oesophageal tissue eosinophilia, specifically including gastro-oesophageal reflux disease, Crohn disease, infections and connective tissue disorders (note to s 6(2) Note 4). Those diagnostic elements are the baseline medical concept framework the RMA uses.

Causation standard and framing are explicitly expressed. The instrument is determined on the “balance of probabilities” standard in both its title and s 7, where the RMA states it is of the view that “it is more probable than not” that EoE and death from EoE can be related to relevant service. That is an evidentiary benchmark for administrative decision‑makers who apply the Statement to claims governed by s 120B VEA or s 339 MRCA (s 4).

Section 8 lists seven discrete factors that, if present and related to relevant service, provide the necessary link for claims: (1) aspirin desensitisation exposure (average ≥600 mg/day for at least three months before clinical onset), (2) carbamazepine daily for at least seven days before clinical onset, (3) oral or sublingual allergen immunotherapy at the time of clinical onset, (4) similar aspirin exposure before clinical worsening, (5) carbamazepine exposure before clinical worsening, (6) allergen immunotherapy at the time of clinical worsening, and (7) inability to obtain appropriate clinical management for EoE (s 8(1)-(7)). The instrument differentiates onset factors (s 8(1)-(3)) from aggravation factors (s 8(4)-(6)) and contains a service‑relationship limitation: subsections 8(4)-(7) apply only to material contribution or aggravation where the person’s EoE was suffered or contracted before or during (but did not arise out of) relevant service (s 9(2)). In other words, those subsections are expressly targeted at pre‑existing or service‑present conditions that were worsened by later service events, not to service that caused initial onset.

Schedule 1 supplies working legal definitions that determine the scope of “relevant service”: (a) eligible war service (other than operational service) under the VEA; (b) defence service (other than hazardous service and British nuclear test defence service) under the VEA; and (c) peacetime service under the MRCA (Schedule 1, definition of relevant service). “Terminal event” is also defined in Schedule 1 by an enumerated list that includes pneumonia, respiratory failure, cardiac arrest, circulatory failure and cessation of brain function; s 6(3) adopts death from EoE to include death from a terminal event or condition contributed to by EoE.

Finally, s 10 creates a cross‑reference mechanism: where a factor in s 8 refers to an injury or disease already covered by another Statement of Principles made under s 196B(3) of the VEA, 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 provides a dynamic link across Statements and signals that decision-makers should apply the contemporaneous terms of other Statements where relevant.

Primary affected parties are veterans, former members of the Forces, and serving members who make claims that fall under section 120B of the Veterans' Entitlements Act 1986 or section 339 of the Military Rehabilitation and Compensation Act 2004, because the instrument “applies to a claim to which section 120B of the VEA or section 339 of the MRCA applies” (s 4). The Schedule’s definition of “relevant service” (Schedule 1) further limits the pool to persons whose service falls into one of three categories: eligible war service (other than operational service), defence service (other than hazardous service and British nuclear test defence service), or peacetime service under the MRCA. As a practical matter, claimants must therefore be within those service definitions for this Statement to be relevant.

Secondary parties affected include medical practitioners, treating clinicians, and institutions preparing or supplying the clinical evidence used in claims. The Statement sets detailed clinical thresholds,histology thresholds (peak ≥15 eosinophils per high-power field), symptom descriptions, and endoscopic findings,that clinicians will need to document (s 6(2) and its notes). For exposure-related factors, specific medication dosages, durations and timing relative to clinical onset or worsening are required (s 8(1)-(6)). Those evidentiary specifications define what treating clinicians and medical records must show if a claimant intends to rely on a particular factor.

Administrators and decision-makers within the Department responsible for adjudicating VEA or MRCA claims are also affected. The RMA’s Statement provides the medical-scientific framework those decision-makers are to apply when assessing causal connection in relevant claims (s 3, s 7, s 4). The Statement will shape which documentary materials and service records are sought and assessed.

Other affected entities include those providing relevant exposures or interventions: clinicians administering aspirin desensitisation, prescribers of carbamazepine, and providers of oral or sublingual allergen immunotherapy. By identifying these specific interventions as potential causal or aggravating factors, the Statement links particular medical practices to claims outcomes, which can affect record-keeping practices and informed-consent conversations.

Finally, families or estates are indirectly affected for death claims. The instrument includes death from EoE where EoE contributed to a terminal event or condition (s 6(3) and Schedule 1 definition of “terminal event”), so dependants seeking benefits related to a deceased person’s EoE will need to align documentary evidence of EoE and any listed factor with service records.

The instrument is prescriptive in terms of which factual predicates must exist to establish a service connection for claims, but it does not create rights of payment or a standalone entitlement; rather it supplies the RMA’s medical-scientific assessment that decision-makers use within the claim processes governed by the VEA and MRCA. The RMA’s duty in making the instrument is statutory: it was made under subsection 196B(3) of the VEA (s 3). The primary practical duty that follows for claimants is to establish, on the balance of probabilities, both the medical diagnosis of EoE and the existence of one or more of the listed factors as related to relevant service (ss 6-9).

For claimants, the instrument imposes evidentiary duties. The medical definition requires documentation of symptoms consistent with oesophageal dysfunction and histological confirmation (peak values of at least 15 eosinophils per high-power field on biopsy) or endoscopic findings that increase diagnostic suspicion (s 6(2) and notes). The factors in s 8 impose duties to show exposure or intervention with specific parameters: for example, average aspirin intake of at least 600 milligrams per day for at least three months for desensitisation purposes, or taking carbamazepine daily for at least seven days prior to onset or worsening (s 8(1)-(6)). For the ability-to-obtain‑treatment factor (s 8(7)), claimants must establish the “inability to obtain appropriate clinical management”; the instrument does not define the precise evidentiary standard for that ability, so claimants bear the duty of providing material that demonstrates such inability within the claim process.

Decision-makers have a duty to apply the Statement when deciding relevant claims under the cited statutory provisions. Section 10 creates an additional duty for decision-makers to apply the factors in any other Statement of Principles that the s 8 factor refers to, in accordance with that other Statement as in force from time to time. Decision-makers must also ensure the relationship to “relevant service” is met,Schedule 1 sets out the categories of relevant service,because s 9(1) requires that any s 8 factor must be related to the person’s relevant service.

The Statement confers no freestanding private rights beyond its role in claims assessment. It does not itself award compensation, order treatment, or impose affirmative duties on health providers. The rights that flow from establishing a connection remain those that exist under the VEA and MRCA regimes; this instrument only defines the RMA’s view of the medical and service-related causal links that will support such rights in the relevant claim processes.

The instrument itself contains no penalty provisions, enforcement mechanisms or criminal sanctions. Its operative form is a Statement of Principles made under subsection 196B(3) of the VEA (s 3), intended to be used in administrative determination of claims under section 120B of the VEA or section 339 of the MRCA (s 4). It does not purport to create offences or prescribe monetary penalties.

Enforcement in practical terms is indirect and administrative. The Statement’s primary effect is evidentiary: it provides the RMA’s medical-scientific criteria that adjudicators will apply when considering whether, on the balance of probabilities, EoE or death from EoE is connected with relevant service. Accordingly, the “enforcement” is the acceptance or rejection of a claim for entitlements governed by the VEA or MRCA based on whether the claimant can establish the required factual predicates and the service relationship specified in the Statement (ss 6-9, Schedule 1).

Because the Statement does not include enforcement provisions, the instrument leaves enforcement of the underlying legislation’s entitlement decisions to the administrative processes and remedies that exist under the VEA and MRCA. The Statement does, however, shape those outcomes by specifying discrete exposure and clinical circumstances that, if proven and related to relevant service, satisfy the RMA’s causation assessment. Section 10 imposes an administrative obligation to apply the terms of any other relevant Statement of Principles that covers an injury or disease to which a factor in s 8 refers, “as in force from time to time,” which delegates a continuing administrative compliance task to claim decision-makers to track and apply other Statements.

Practically, this means that the consequences for a claimant are administrative,acceptance of a claim and consequent access to whatever entitlements are available under the VEA or MRCA,rather than punitive. The instrument does not specify timeframes, review mechanisms or appeals; those procedural and enforcement details fall to the statutory and administrative frameworks of the VEA and MRCA and associated departmental practice, which are outside the text of this instrument.

The instrument is made under VEA s 196B(3) and expressly applies to claims under specified parts of the VEA and MRCA, therefore it operates within the statutory architecture of those Acts. Section 3 identifies the source of the RMA’s power (s 196B(3) VEA), and section 4 specifies that the Statement applies to claims to which s 120B of the VEA or s 339 of the MRCA applies. The instrument’s role is thus to provide the RMA’s medical-scientific view for use in adjudicating claims under those statutory provisions.

Section 10 establishes an interactional rule with other Statements of Principles made under s 196B(3) of the VEA: where a factor in this Statement refers to an injury or disease covered by another Statement, 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 dynamic, cross-referential interaction: decision-makers must look to contemporaneous terms of other Statements when s 8 refers to conditions already addressed elsewhere. The instrument therefore does not operate in isolation; it integrates with the wider suite of Statements the RMA may have issued.

The Schedule’s definition of “relevant service” also delimits the interaction with service-related definitions in the VEA and MRCA. It adopts categories that carve out operational service and hazardous service and British nuclear test defence service from some definitions (Schedule 1, relevant service definition), meaning the Statement’s application will differ depending on the statutory characterisation of a person’s service under the underlying Acts. For example, the instrument’s definition excludes certain forms of service from “relevant service” categories; those exclusions will interact with eligibility criteria and service classification rules embedded in the VEA and MRCA. The instrument itself does not amend those Acts; it presupposes their classifications.

Medical standards in the Statement interact with clinical practice and medical records. The histological threshold (≥15 eosinophils per high-power field) and the list of differential diagnoses that must be evaluated (s 6(2) Note 2 and Note 4) create points of interaction with clinician diagnostic processes, hospital records, and pathology reporting standards. The instrument’s factors that require specified dosages and durations (s 8) interact with prescribing practices and pharmaceutical records.

The Statement does not purport to alter other statutory entitlements, procedural appeal rights or remedies available under the VEA or MRCA; rather it provides the RMA view that administrative decision-makers will apply within those existing legal frameworks. The instrument itself does not contain a provision modifying other legislation; its operational effect depends on its use within the claim decision processes mandated by the referenced Acts.

The instrument identifies itself as No. 30 of 2022 and is dated 4 March 2022; it commences on 4 April 2022 (ss 1-2 and front matter). The instrument was made under subsection 196B(3) of the VEA and bears the Common Seal of the Repatriation Medical Authority (front matter showing the seal and Chairperson signature block). The Schedule 1 definitions and the substantive sections 6-10 constitute the content of this iteration as at commencement.

The instrument includes an express mechanism that links it to other Statements of Principles “as in force from time to time” (s 10). That language indicates an intended dynamic relationship: where s 8 refers to an injury or disease already covered by another Statement, the other Statement’s current terms apply. Although the instrument itself does not provide an amendment schedule or versioning log, the cross‑reference anticipates that other Statements may be amended and that such amendments will affect application of this Statement when s 8 interacts with those other conditions.

No prior versions, revocations, or amendment dates are provided in the text supplied. The instrument’s front matter and provisions do not include an explicit “revocation of previous instrument” clause, nor do they list transitional provisions beyond the commencement date. The instrument therefore appears as a standalone Statement made and commencing in 2022; any subsequent amendments, revocations or replacements would need to be reflected in later instruments or notices issued by the RMA, but such documents are not present in this instrument. For users of the instrument, the operative cross-reference language in s 10 requires attention to the current terms of other Statements that may be amended after this instrument’s commencement.

The instrument itself contains no litigation history, judicial commentary, or references to court decisions. It is a statutory administrative instrument determined under subsection 196B(3) of the VEA (s 3) and there are no sections or notes within the instrument that record any litigation, judicial review, or appellate treatment of this Statement. The document’s text does not purport to summarise any cases or offer guidance derived from judicial authorities.

Because the instrument is a determination of the RMA intended for administrative application in claims under the VEA and MRCA, any litigation relevant to its application,such as challenges to how it is applied in individual claims, procedural disputes about reliance on the instrument, or judicial review of administrative decisions that reference the instrument,would be external to the instrument and thus not recorded herein. The absence of litigation content in the instrument means the instrument should be read as the RMA’s contemporaneous medical-scientific assessment as at the date of its making; it does not contain or refer to post‑determination adjudicative developments.

Users and advisers should therefore treat the instrument as primary administrative material without embedded case law commentary. If litigation or appellate decisions arise that interpret or challenge the application of this Statement, those developments would need to be sourced and analysed separately from this instrument, because no such material appears in the text provided.

Several concrete features of the Statement create points of potential misunderstanding or evidentiary difficulty for claimants and decision-makers; these arise directly from the instrument’s drafting.

1. Strictly specified exposures and timings. The listed factors are precise about dosage, duration and timing. For example, aspirin desensitisation is only a factor where the person was “taking an average of at least 600 milligrams of aspirin per day for the desensitisation of aspirin‑exacerbated respiratory disease for at least the 3 months before the clinical onset” (s 8(1)), and the same threshold applies before clinical worsening (s 8(4)). Carbamazepine is a factor only when taken daily for at least seven days immediately before clinical onset or worsening (s 8(2), s 8(5)). Oral or sublingual allergen immunotherapy is a factor only if it was in place “at the time of the clinical onset” or “at the time of the clinical worsening” (s 8(3), s 8(6)). The implication is that typical, lower or shorter exposures, or non‑desensitisation uses of aspirin, will not meet these factors. Claimants relying on these factors must match the instrument’s exact parameters.

2. EoE diagnostic threshold and differential diagnosis. The instrument requires histological evidence of eosinophil‑predominant infiltration shown by peak values of at least 15 eosinophils per high‑power field on oesophageal biopsy as a diagnostic element (s 6(2) Note 2). It also directs that clinicians must evaluate other conditions that could account for oesophageal tissue eosinophilia (s 6(2) Note 4). The combination of a numeric biopsy threshold and the need to exclude other causes means that partial or borderline pathology reports and incomplete exclusion of alternative diagnoses may leave claims unsupported by the Statement.

3. “Inability to obtain appropriate clinical management” is conceptually broad and undefined. Section 8(7) lists inability to obtain appropriate clinical management as a factor that can establish connection. The instrument does not define what counts as “appropriate clinical management” or what proof suffices to show inability to obtain it. That open formulation creates administrative discretion and places the burden on claimants to assemble contextual evidence (referrals, waitlists, denial letters, geographic constraints) to establish the factor in the claim process.

4. Application to pre‑existing disease is limited. Subsections 8(4)-(7) are expressly limited to material contribution or aggravation of EoE “where the person's eosinophilic oesophagitis was suffered or contracted before or during (but did not arise out of) the person's relevant service” (s 9(2)). That means those aggravation factors are not intended to apply where EoE first arose out of service; they are focused on pre‑existing conditions that were worsened. Understanding and proving the timing of onset relative to service is therefore crucial.

5. Narrow definition of “relevant service”. Schedule 1 defines “relevant service” by reference to certain categories and excludes operational service and particular forms of hazardous or British nuclear test defence service in the definitions of eligible service (Schedule 1). If a person’s service falls outside those categories, the Statement will not apply to their claim even if they have a qualifying EoE diagnosis and exposures.

6. Cross‑Statement dependencies. Section 10 means that, where an s 8 factor refers to an injury or disease covered by another Statement, the other Statement’s factors apply “as in force from time to time.” Practitioners must therefore identify when an s 8 factor depends on another Statement and ensure they rely on that other Statement’s current terms. Failure to track amendments to other Statements could produce evidentiary gaps.

7. Instrument is administrative, not procedural. The Statement provides medical-scientific guidance but does not specify procedural requirements for lodging claims, the evidentiary standard beyond the “balance of probabilities” assertion in s 7, or the form of documentary proof. Practitioners must translate the medical and exposure requirements into claim‑grade evidence within the broader administrative framework of the VEA and MRCA.

8. Death coverage tied to terminal events. Death from EoE is encompassed only where EoE contributed to a terminal event or condition listed in Schedule 1 (s 6(3), Schedule 1 terminal event definition). Claimants seeking death-related entitlements must establish both the EoE and its contribution to a listed terminal event.

Complying with this Statement of Principles for the purpose of a claim means assembling and presenting the specific kinds of evidence the Statement requires and ensuring the required relationship to “relevant service” is demonstrated. Practically, this will involve the following actions, each linked to the instrument’s provisions.

1. Establish the medical diagnosis of eosinophilic oesophagitis. Provide clinical records documenting symptoms of oesophageal dysfunction (difficulty swallowing, chest pain, upper abdominal pain, heartburn, acute food bolus obstruction) and histopathology demonstrating eosinophil‑predominant infiltration with peak values of at least 15 eosinophils per high-power field on oesophageal biopsy as directed in s 6(2) and its notes. Include endoscopy reports noting rings, furrows, exudates, oedema, strictures, narrowing or crepe-paper mucosa where available (s 6(2) Notes 1-3).

2. Demonstrate exclusion of alternate causes. Include clinicians’ notes, specialist assessments and investigations that have evaluated and excluded,where clinically relevant,gastro‑oesophageal reflux disease, Crohn disease, infections and connective tissue disorders, as the Statement requires a full clinical assessment to consider these potential explanations (s 6(2) Note 4).

3. Provide documentary evidence of the relevant exposure or intervention in s 8. For each factor relied upon:

   • Aspirin desensitisation factors (s 8(1) and 8(4)): provide prescriptions, physician orders, hospital or clinic desensitisation protocols, pharmacy dispensing records or contemporaneous clinical notes showing an average intake of at least 600 mg aspirin per day, that the purpose was desensitisation for aspirin‑exacerbated respiratory disease, and that this regimen extended for at least three months before clinical onset or before clinical worsening, as applicable.
   • Carbamazepine factors (s 8(2) and 8(5)): provide prescription records, medication charts, treatment notes or other documentation showing carbamazepine was taken daily for at least seven days immediately before the clinical onset or clinical worsening of EoE.
   • Oral or sublingual allergen immunotherapy factors (s 8(3) and 8(6)): provide clinic records, immunotherapy administration logs, practitioner notes or consent forms showing the person was receiving oral or sublingual allergen immunotherapy at the time of clinical onset or at the time of clinical worsening.
   • Inability to obtain appropriate clinical management (s 8(7)): compile evidence such as referral rejections, long waiting‑list notifications, correspondence from health services documenting inability to obtain care, geographic or resource constraints evidence, and any contemporaneous complaints or steps taken to obtain care. Because the Statement does not define “appropriate clinical management,” stronger documentary context will be required.

4. Demonstrate the temporal relationship to relevant service. For any s 8 factor to be operative in a claim, the existence of that factor must be related to the person’s relevant service (s 9(1)). Provide service records, medical service records from deployment or postings, unit health records, service medical officer notes, or other official documentation showing the timing and linkage of the exposure or inability to obtain care to the service episode classified as relevant service under Schedule 1 definitions.

5. For aggravation factors, establish timing of EoE relative to service. Where relying on s 8(4)-(7) (material contribution to or aggravation of EoE), ensure the medical history shows EoE was suffered or contracted before or during the person’s relevant service, but did not arise out of the relevant service (s 9(2)). Evidence of pre‑service or service-onset diagnosis, contrasted with subsequent documented worsening tied to the listed factors, will be necessary.

6. Link factors to other Statements where applicable. If an s 8 factor refers to an injury or disease covered by another Statement of Principles, identify that other Statement and provide evidence in the terms that the other Statement requires, because s 10 makes those other Statement factors applicable “as in force from time to time.” Ensure you are relying on the current version of any cross-referenced Statement.

7. Assemble death-related evidence when relevant. For a death claim, provide medical records, death certificate, pathology and clinical notes that show EoE contributed to a terminal event listed in Schedule 1, for example pneumonia, respiratory failure or cardiac arrest (s 6(3), Schedule 1 terminal event definitions).

8. Anticipate administrative discretion and evidentiary gaps. Where records are incomplete,for example, absence of precise medication dosing in old charts,prepare corroborative material such as contemporaneous clinic letters, pharmacy summaries, witness statements from treating clinicians, or other documentary evidence that supports the factual assertions required by s 8.

9. Present material in claim formats required by the VEA/MRCA processes. The Statement does not itself set out claim forms, procedural timeframes or appeal routes; practitioners should submit the medical and service evidence within the relevant claim processes established under section 120B of the VEA or section 339 of the MRCA (s 4), using whatever procedural requirements those statutory processes specify.

10. Keep cross‑references and amendments under review. Because s 10 requires decision-makers to apply other Statements “as in force from time to time,” advisers should verify the current texts of any relevant other Statements at the time of claim lodgement and when pursuing reviews or appeals.

In summary, compliance requires translating the Statement’s medical and exposure thresholds into contemporaneous and service-linked documentary proof and presenting that proof within the administrative claim process to satisfy the “more probable than not” standard the RMA states in s 7.