Statement of Principles concerning heart block (Balance of Probabilities) (No. 24 of 2022)

The core legal and medical concepts in the instrument are threefold: (1) the medical meaning and scope of “heart block” for claims purposes (s7); (2) the Statement of Principles mechanism under the VEA that produces a statutory view about whether a condition can be connected to service on the balance of probabilities (s3, s8); and (3) the conditioned list of factors that, if present and related to relevant service, suffice to establish connection on the balance of probabilities (s9-s11).

Medical definition and scope

• Heart block is defined as a cardiac disorder caused by delay or interruption of conduction from atria to ventricles through the atrioventricular node, bundle of His or bundle branches, owing to anatomical or functional impairment (s7(2)(a)). The definition expressly includes atrioventricular block and bundle branch block, and excludes congenital heart block, long QT syndrome and transient physiological heart block (s7(2)(b)-(c)). Notes in s7(2) expand the clinical subtypes (first, second and third degree AV block; right/left bundle branch block; Mobitz types I and II). The instrument recognises asymptomatic presentations and lists typical symptoms (s7(2) Note 3).

Balance of probabilities and the SoP role

• Section 8 records the RMA’s view, based on the medical‑scientific evidence available to it, that it is “more probable than not” that heart block and related death can be related to relevant service. The SoP therefore functions as a statutory expression of the medical nexus standard applicable to claims falling under s120B VEA or s339 MRCA, rather than a clinical guideline for treatment.

Enumerated causative or contributing factors

• Section 9 is the operational engine. It contains an exhaustive list of factors, any one of which must exist for the SoP to support a finding that the condition is service‑connected on the balance of probabilities. The list covers:
  • Chronic cardiac pathology (ischaemic heart disease, cardiomyopathy, hypertensive left ventricular hypertrophy, rheumatic heart disease).
  • Infiltrative and inflammatory myocardial disease (amyloidosis, sarcoidosis, viral and non‑viral myocarditis, infective endocarditis).
  • Neoplasms involving the heart.
  • Mechanical compression of conduction tissue by lesions (with examples).
  • Thromboembolic events with tight temporal windows (pulmonary thromboembolism within 7 days).
  • Mineral/electrolyte abnormalities limited to hypercalcaemia, hyperkalaemia and hypermagnesaemia (Schedule 1).
  • A specified list of drugs and particular durations (drugs within 3 weeks; chloroquine or hydroxychloroquine taken for at least 1 year).
  • Ingested cardiac glycoside plants within 7 days.
  • Trauma, surgical and invasive procedures with defined look‑back windows (penetrating trauma/ thoracic or invasive cardiac procedure within 1 year; blunt chest injury within 60 days).
  • Transplants (heart transplant; bone marrow/stem cell transplant within 24 hours before onset; graft versus host disease).
  • Therapeutic radiation exposing the heart, and certain high‑intensity prolonged physical activity defined through MET thresholds (MET defined in Schedule 1).
  • Systemic disease risk factors such as diabetes mellitus and an enumerated list of autoimmune diseases.
  • Acute rheumatic fever and rheumatic heart disease.
  • A final discrete factor for clinical worsening, inability to obtain appropriate clinical management (s9(55)).

Onset vs worsening; death

• The instrument distinguishes clinical onset and clinical worsening, reproducing the majority of factors for each circumstance (s9). Death from heart block is incorporated where the heart block contributed to a terminal event or condition (s7(5) and Schedule definition of terminal event).

Cross-reference and hierarchical application

• Section 11 requires decision‑makers to apply the terms of other SoPs where a listed factor refers to an injury or disease already the subject of a different SoP.

Definitions that narrow or enable application

• Schedule 1 supplies working definitions for blunt chest injury, MET, the specified lists of drugs, autoimmune diseases, and electrolyte abnormalities, the definitions of MRCA, VEA and relevant service, and terminal event. Those definitions are integral to how the factors are applied.

Taken together, these elements mean the SoP is a ruleset: it converts a heterogeneous set of medical states, exposures and procedures into a discrete set of evidentiary triggers that can satisfy the statutory test of service connection for heart block on the balance of probabilities, provided the factor itself is related to the person’s relevant service (s10(1)).

Direct statutory subjects

• The instrument applies expressly to claims to which section 120B of the VEA or section 339 of the MRCA applies (s5). That means the primary audience comprises veterans and serving or former members of the Australian Defence Force bringing claims for disability or compensation under those statutory provisions where heart block or death from heart block is alleged. The Schedule defines “relevant service” as certain categories of VEA service and MRCA peacetime service; therefore claimants must have rendered one of those classes of service for the SoP to be applicable (Schedule 1: “relevant service”).

Decision‑makers, clinicians and advisers

• Administrative decision‑makers within the Department of Veterans’ Affairs, the Veterans’ Review Board, and judges in judicial review or merits appeals will use the SoP as part of their medical nexus analysis where it applies. Clinicians and medical experts retained to prepare opinions for claimants or the Department will use the SoP to structure opinions about whether a listed factor existed and whether it was related to relevant service. Legal practitioners, veterans’ advocates and claims managers will need to align evidence‑gathering and submissions with the list of factors and the timing windows set out in s9.

Indirectly affected groups

• Health providers (hospitals, surgeons, cardiologists) who hold the contemporaneous records that document surgical procedures, transplants, procedural complications, infections, drug exposures and trauma will be routinely contacted for records. Employers and sporting organisations may be sources of evidence for prolonged strenuous activity above the MET threshold (s9(22) and s9(49)). For claims involving inability to obtain appropriate clinical management (s9(55)), administrators of public health waitlists, records of referrals, and documentation of access barriers may also be relevant.

Who pays and who decides

• The SoP itself does not authorise payments; it is a medical nexus tool that feeds into the VEA and MRCA decision framework (s3, s5). Under those Acts, the Australian Government’s veterans’ compensation framework is the payer when entitlement is established. The Repatriation Medical Authority made the SoP (s3); decisions about individual entitlement remain with the decision‑maker under the VEA or MRCA and their statutory decision processes, using this SoP as an evidentiary instrument.

Profile of affected claims

• The SoP covers both incident (clinical onset) and progression (clinical worsening) of heart block and death where heart block is contributing. It targets claims where one of the enumerated proximal or distal factors can be established. Some factors are narrowly time‑limited (e.g. pulmonary thromboembolism within 7 days; certain drugs within 3 weeks), which may reduce the number of claims that satisfy the SoP, whereas chronic states such as ischaemic heart disease, diabetes, cardiomyopathy, infiltrative disease and autoimmune diseases are ongoing and more commonly documented and so may generate a larger share of successful nexus findings, contingent on the factor being related to the person’s relevant service (s10(1)).

Potential concentration of evidence burden

• The instrument concentrates evidentiary work on specific, often medical records‑dependent items (drug prescriptions and durations, surgical operation dates, transplant timing, documented myocardial infections, biopsy or imaging evidence for infiltrative disease, MET activity documentation). Claimants without contemporaneous records for these factors may face difficulty establishing the presence of a listed factor, and thus in demonstrating statutory connection via this SoP.

Duties created by this instrument

• The SoP imposes no criminal or civil sanctions; it instead prescribes evidentiary criteria that decision‑makers must apply when considering whether heart block or death from heart block is connected with relevant service for the purposes of claims under certain provisions of the VEA and MRCA (s5, s8, s9). The Repatriation Medical Authority has the duty (or power) under subsection 196B(3) of the VEA to determine Statements of Principles; this instrument records the exercise of that power (s3).

Specific operational duties for decision‑makers and claimants

• Decision‑makers are obliged to apply the instrument where it applies. Section 9 structures the decision‑making duty: at least one factor from the enumerated list must exist before the decision‑maker can say, on the balance of probabilities, that heart block or death from heart block is connected with the circumstances of the person’s relevant service. Section 10(1) adds the additional requirement that the existence of the factor must be related to the person’s relevant service. Section 11 requires decision‑makers to apply other SoPs where a factor refers to an injury or disease already covered by another SoP; this imports an obligation to consult and apply those other instruments’ terms.

Rights implicated

• Claimants have the right to have their claim considered against the SoP where their claim falls under the sections specified in s5. Where a listed factor is established and related to relevant service, the statutory view embodied in the SoP is that it is more probable than not that heart block may be related to service (s8). Claimants also have procedural rights under the governing Acts (VEA and MRCA) to have decisions reviewed and appealed under the statutory appeal processes, although those procedural rights are not described in this instrument.

How the definitions condition duties and rights

• Schedule 1 supplies operative definitions that shape the duties of evidence production and the rights to succeed: for example, MET is precisely defined (Schedule 1), and particular drug lists, electrolyte abnormalities and autoimmune diseases are specified. Thus, a claimant asserting strenuous activity as the connecting factor must engage with the MET threshold as defined, while a claimant relying on a drug must show exposure to a drug in the “specified list of drugs” in Schedule 1.

Duty to establish relation to relevant service

• Section 10 places an explicit duty on the claimant (or on the evidence tendered) to show that the factor itself is related to the person’s relevant service. The instrument does not set procedural specifics for how that relation is to be proven, but the legal effect is clear: showing a listed factor in a vacuum is insufficient if that factor cannot be tied to the person’s relevant service.

No duty to pay or criminal penalties in the instrument

• The instrument does not itself create a duty to pay benefits or impose punitive measures. Its legal effect is evidentiary and advisory within the VEA/MRCA decision‑making framework, not penal or regulatory.

No criminal or civil penalties in this instrument

• The Statement of Principles is an evidentiary instrument; it does not prescribe monetary penalties, fines, imprisonment or other punitive sanctions. The instrument makes no provision for enforcement action against individuals or entities for non‑compliance with its terms, because it operates as a medical‑nexus determinant used by decision‑makers under the VEA and MRCA (s3, s5).

Administrative enforcement is through statutory decision processes

• Enforcement of the SoP’s application occurs indirectly through the administrative decision processes under the VEA and MRCA. Decision‑makers will apply the SoP to determine whether the threshold for service connection is met. The instrument does not specify procedural enforcement mechanisms, timeframes for decisions, or administrative remedies; those are governed by the VEA and MRCA statutory schemes to which the SoP applies. The SoP, therefore, influences entitlement outcomes rather than imposing direct sanctions.

Consequences for inaccurate or fraudulent claims

• The instrument does not address false claims or fraudulent evidence; any legal consequences for fraudulent claims would be governed by the VEA, MRCA or the general law (not specified here). The SoP itself provides the framework for assessing medical connection but does not create separate enforcement liabilities.

Practical enforcement touchpoints

• The points at which the SoP materially affects claim outcomes, and hence where "enforcement" in practice occurs, are:
  • The evidentiary threshold: the decision‑maker must find at least one listed factor and that the factor is related to relevant service (s9, s10).
  • Cross‑reference application: where a factor refers to another condition with its own SoP, the decision‑maker must apply that other SoP (s11).
  • Repeal and succession: the 2014 SoP is repealed (s4), so decision‑makers must apply the 2022 instrument from its commencement date (s2).

Appeals and review

• While the instrument does not itself establish appeal rights, decisions that implement the SoP will be subject to the statutory review and appeal routes under the VEA and MRCA. Those processes provide the mechanism by which the SoP’s application can be challenged, but the instrument contains no detail on enforcement remedies, procedural timeframes, or sanctions.

Enforcement risk and certainty

• Because the instrument is a deterministic checklist of factors, the primary enforcement risk arises from the quality of medical evidence and factual disputes about whether a listed factor existed and whether it is related to relevant service. The SoP shifts those disputes into the administrative decision process rather than setting out independent criminal or civil penalties.

Statutory parentage: VEA and MRCA

• The SoP is made under subsection 196B(3) of the VEA (s3). Section 5 states it applies to claims to which s120B of the VEA or s339 of the MRCA applies. Consequently, the SoP operates inside the legal framework established by those Acts: it is an instrument that defines which medical factors will support a finding of a service connection for heart block under those statutory provisions. The Schedule defines MRCA and VEA as terms (Schedule 1).

Cross‑reference to other Statement of Principles

• Section 11 imposes an explicit interaction rule: if a section 9 factor refers to an injury or disease that is covered by another SoP, then the factors in that other SoP apply in accordance with their terms "as in force from time to time". This creates hierarchical and dynamic inter‑SoP interdependencies: decision‑makers must identify whether a listed factor invokes another SoP and then apply the up‑to‑date terms of that SoP.

ICD coding and clinical classification

• Section 7(3)-(4) references ICD‑10‑AM codes (I44, I45.0, I45.1, I45.2, I45.3, I45.4, I45.9) and specifies that, in applying this instrument, the meaning of heart block is that given in s7(2). The instrument therefore makes clear that the clinical definition in s7(2) governs for claim purposes even though ICD coding is noted. The ICD reference also creates an interaction with diagnostic classification systems used in clinical records and hospital coding.

Medical and administrative records law

• The SoP will interact practically with laws and policies governing access to medical records, privacy and disclosure (not addressed in this instrument). Because many of the factors require contemporaneous medical, surgical and pharmaceutical documentation, the SoP will be operationally dependent on record access rules under privacy and health records law. The instrument itself does not modify those rules; it assumes records can be obtained in accordance with the usual legal channels.

Decision‑making and merits review provisions

• The SoP does not alter procedural rights under the VEA and MRCA, but its application interacts with those Acts’ decision‑making and merits review structures. Decisions that rely on this SoP will be subject to review processes provided under the governing Acts and associated tribunals and courts. The instrument requires decision‑makers to apply the factors as worded; appellate bodies will, where necessary, review whether the SoP was applied correctly in specific decisions.

Overlap with general tort or compensation law

• The SoP is specific to the veterans’ entitlements and military rehabilitation compensation statutes. It does not displace or modify general tort law, workers’ compensation regimes, or private insurance entitlements. However, evidence collected for other proceedings may be used to support a claim under the VEA/MRCA where permitted by confidentiality and evidentiary rules.

Regulatory and clinical standards

• The SoP references clinical entities and exposures (for example, immune checkpoint inhibitor therapy, transcatheter aortic valve implantation, radiation where the heart is in the field) that are regulated in other contexts (therapeutic use approvals, radiation safety, professional regulation). The SoP’s determinations about factors may therefore intersect with regulatory files, clinical records, and professional practice documentation without altering regulatory obligations.

Temporal and repealed instruments

• The 2014 SoP is expressly repealed (s4). Section 11’s “as in force from time to time” language means other SoPs that are updated or replaced will be applied according to their current wording, so decision‑makers must be attentive to the contemporaneous state of all relevant SoPs.

In short, the SoP interacts with the VEA and MRCA as an evidentiary tool, with other SoPs by cross‑reference, with clinical classification systems through ICD references, and with ordinary administrative processes (record access, appeals, medical expert evidence) needed to establish the presence of listed factors.

This instrument contains its own immediate amendment information and limited historical context within the text.

Current instrument and commencement

• The Statement of Principles concerning heart block (Balance of Probabilities) (No. 24 of 2022) is dated 4 March 2022 and commences on 4 April 2022 (s2, front matter).

Repeal of earlier instrument

• Section 4 expressly repeals the Statement of Principles concerning heart block No. 2 of 2014 (Federal Register of Legislation No. F2014L00005), which had been made under subsections 196B(3) and (8) of the VEA. The text provides no further detail about the 2014 instrument beyond its repeal; users need to consult the Federal Register of Legislation for the full history and content of the repealed instrument to compare differences.

No other amendments recorded in this instrument

• The instrument itself does not record any interim amendments, variations, or prior versions beyond the 2014 instrument that it replaces. It does not list any historical amendments to the definitions or enumerated factors prior to the repeal, nor does it set out a schedule for future amendments. Any future amendments will appear as new determinations or revisions published by the Repatriation Medical Authority under the authority cited in s3.

Dynamic operation with other SoPs

• Section 11’s requirement to apply other SoPs “as in force from time to time” means that, although this instrument may remain unchanged, its practical interaction with other SoPs can vary as those other instruments are amended. Thus, this instrument’s effective application is contingent on the contemporaneous text of any other SoP that is invoked by a section 9 factor.

Practical implication for record‑keeping and comparison

• Practitioners handling claims that span the repeal date should note the commencement date (s2) and the repeal (s4). Claims made in respect of events predating the commencement or relating to decisions made under the 2014 instrument will need careful chronological analysis to determine which SoP applied at the time of the decision and whether any transitional provisions exist in the underlying statute or administrative policy. The instrument itself does not specify transitional arrangements; those must be checked in the governing statutes or administrative practice notes.

Where to check for further amendment history

• To track further amendments, practitioners should monitor:
  • the Federal Register of Legislation for amendments or replacement instruments under subsection 196B(3) of the VEA;
  • the Repatriation Medical Authority notices and determinations; and
  • associated policy and procedural guidance from the Department of Veterans’ Affairs.

Instrument contents

• This instrument does not record any litigation history. It contains no case references, judicial interpretations, or summaries of prior litigation concerning heart block or Statements of Principles. The only cross‑instrument legal references are to the enabling statutory provision (s196B(3) of the VEA) under which the RMA made the Statement (s3), and to the statutory provisions under which the SoP applies (s120B VEA; s339 MRCA) (s5).

Implications for litigation risk

• Although no cases are cited in the instrument, the SoP will inevitably be engaged in administrative decisions that are subject to review and possible judicial challenge under the VEA and MRCA. Areas likely to generate dispute in litigation or review, based on the text, include:
  • Interpretation of timing windows, e.g. what constitutes the relevant “within 7 days” for pulmonary thromboembolism (s9(2), s9(29)).
  • Proof of exposure to specified drugs and the required temporal relationship (specified list of drugs, Schedule 1; s9(12), s9(39), and the special duration rule for chloroquine/hydroxychloroquine at s9(13), s9(40)).
  • The meaning and evidentiary standard for “related to the relevant service” (s10(1)).
  • The operation of s10(2), which limits subsections 9(28) to 9(55) to material contribution or aggravation where the heart block pre‑existed and was suffered or contracted before or during (but did not arise out of) relevant service.
  • The meaning of “clinical onset” and “clinical worsening” and how to determine the dates for each in the medical record.
  • The threshold for strenuous physical activity defined in METs and what evidence adequately demonstrates the intensity and duration (s9(22), s9(49); MET defined in Schedule 1).

No case law recorded in the instrument

• Because the instrument does not itself cite case law, practitioners cannot rely on the instrument for precedential synthesis. Any jurisprudence relevant to the interpretation of SoPs, the VEA or MRCA sections named must be sought through legal research in administrative, appellate and federal courts, and through decisions of the Veterans’ Review Board and other tribunals.

Practical litigation considerations

• Key factual disputes that might arise in review or litigation will be heavily medicalised and record‑driven. Expert evidence will be central to disputed issues such as the causal plausibility of a factor leading to heart block in a particular clinical context, the interpretation of chronological windows, and whether a listed factor was in fact “related to the person’s relevant service” (s10(1)). Section 11 will also give rise to procedural litigation points where a factor invokes another SoP and parties disagree about which version of that SoP applies at the time of decision.

Recommendation for litigators and reviewers

• Given the absence of litigation history in the instrument, practitioners should:
  • Ascertain the version of all SoPs in force at the time of the decision under review.
  • Obtain contemporaneous clinical records to establish dates and durations for exposures, procedures and onset/worsening.
  • Prepare medical expert evidence that addresses both the existence of a listed factor and the required “relation to relevant service” (s10(1)).
  • Be prepared to argue about the proper construction and temporal application of s10(2) where aggravation or material contribution is alleged.

Temporal windows are strict and multiple

• The instrument sets numerous discrete timeframes: pulmonary thromboembolism within 7 days before clinical onset or worsening (s9(2), s9(29)); drugs within 3 weeks before onset or worsening (s9(12), s9(39)); chloroquine/hydroxychloroquine for at least 1 year before onset/worsening (s9(13), s9(40)); ingestion of cardiac glycoside plants within 7 days (s9(14), s9(41)); penetrating trauma or thoracic/invasive cardiac procedures within 1 year (s9(15)-(16), s9(42)-(43)); blunt chest injury within 60 days (s9(17), s9(44)); bone marrow/stem cell transplant within 24 hours before onset/worsening (s9(19), s9(46)). Practitioners must align evidence to these windows; small discrepancies in dates can be determinative.

“Related to the relevant service” requirement

• Section 10(1) requires the factor itself to be related to the person’s relevant service. That is not the same as simply proving the factor existed. For example, showing a thoracic surgical procedure occurred is not sufficient unless there is evidence that the procedure was itself related to the person’s relevant service. The instrument does not set out how that relation is to be proved, so claimants must prepare specific evidence linking the factor to service.

Different rules for pre‑existing conditions

• Section 10(2) limits the operation of subsections 9(28) to 9(55) to material contribution or aggravation only where the person’s heart block was suffered or contracted before or during (but did not arise out of) relevant service. That wording is subtle: it does not allow these factors to operate as causal factors where the condition arose out of the service. Practitioners must identify whether a claim concerns onset during service, onset after service, or pre‑existing heart block, because different s9 subsections will apply.

Cross‑SoP referrals create chain dependencies

• Section 11 imports other SoPs where a factor refers to a disease covered by another SoP. This can create procedural and evidentiary complexity if the other SoP has different timing windows, definitions, or operative tests. Decision‑makers must apply the “other” SoP “as in force from time to time”, so changes to other SoPs after the event may affect current decision outcomes.

Narrow specified lists

• The Schedule supplies precise lists of drugs (Schedule 1) and autoimmune diseases. A drug or disease not listed cannot be relied on under the corresponding s9 factor. For example, only the drugs in the “specified list of drugs” will satisfy the s9(12)/s9(39) factor; similar strictness applies to autoimmune diseases and electrolyte abnormalities.

MET measurement practicalities

• The MET threshold (greater than 6 METs, at least 10 hours per week, continuous period of at least 5 years) in s9(22) and s9(49) is operational but may be difficult to prove for many claimants. While Schedule 1 defines MET quantitatively, practitioners must translate historical work or training records into METs; the instrument provides no method for doing so and does not address equivalencies or contemporaneous fitness measures.

Ambiguity in “clinical onset” and “clinical worsening”

• The instrument repeatedly uses “clinical onset” and “clinical worsening” but does not define these key terms. Disputes will arise about how to date onset and worsening, particularly when heart block is asymptomatic or when diagnosis was delayed. The SoP’s evidentiary value depends on establishing those dates.

“Unable to obtain appropriate clinical management”

• The inclusion of inability to obtain appropriate clinical management for clinical worsening (s9(55)) is significant but open‑ended. The instrument does not define what counts as “appropriate clinical management” or the standards to prove lack of access. This creates a potential evidentiary minefield unless medical records, referrals, waitlists or correspondence documenting access issues are provided.

Exclusions may exclude otherwise similar conditions

• Congenital heart block, long QT syndrome and transient physiological heart block are excluded from the definition (s7(2)(c)). Claimants should not attempt to fit those clinical entities into this SoP.

Death and terminal events

• Death from heart block is covered only where heart block contributed to the terminal event (s7(5) and Schedule definition of terminal events). Establishing contribution to a terminal event may require detailed cause of death records and expert evidence.

Relevance of ICD codes is limited

• Although ICD‑10‑AM codes for heart block are listed (s7(3)), the instrument makes clear that the meaning of heart block for SoP purposes is the clinical definition in s7(2). Relying solely on coding without clinical evidence tied to s7(2) may be insufficient.

Practitioner action points to avoid the gotchas

• When advising claimants, practitioners should:
  • Rigorously date clinical onset and worsening with supporting records.
  • Translate alleged exposures (drugs, activity levels) into the instrument’s temporal and list requirements.
  • Where a factor must be related to relevant service, assemble evidence showing that service‑connection for the factor itself (for example, an operation was a direct consequence of service) is present.
  • Obtain contemporaneous records to substantiate access‑to‑care problems if relying on s9(55).
  • Check other SoPs where a factor invokes another condition (s11) and confirm the applicable version of that SoP.

Evidence strategy and checklist

• The SoP is a factual checklist instrument. To comply with it in preparing or defending a claim, practitioners should assemble contemporaneous and corroborative evidence that maps directly to the elements in s9 and the definitions in Schedule 1. The primary evidentiary categories are:
  • Clinical records documenting the diagnosis of heart block and dates of clinical onset and any clinically recorded worsening.
  • Hospital and operation notes, imaging reports and cardiology procedure records documenting thoracic or invasive cardiac procedures, transplants, and trauma.
  • Prescription and dispensing records, pharmacy records, and medication charts documenting exposure to any drug on the specified list, with dates and durations (note the special one‑year duration required for chloroquine/hydroxychloroquine at s9(13), s9(40)).
  • Laboratory results for electrolyte abnormalities showing hypercalcaemia, hyperkalaemia, or hypermagnesaemia, with dates close to the onset/worsening.
  • Microbiological, histological or other diagnostic evidence for viral myocarditis, non‑viral myocardial infection, infective endocarditis, amyloidosis or sarcoidosis, and cardiomyopathy.
  • Evidence of pulmonary thromboembolism with precise timing (within 7 days before onset/worsening).
  • Records of ingestion or exposure to cardiac glycoside plants where claimed, including circumstances and dates.
  • Trauma reports, ambulance records, and forensic/clinical evidence for penetrating and blunt chest injuries, with attention to the narrow look‑back windows (1 year, 60 days).
  • Radiotherapy plans or oncology records showing the heart was in the radiation field.
  • Evidence of strenuous physical activity over time: employer records, military fitness logs, training regimens, sports club records, or other contemporaneous documentation that can be translated to METs and show >6 METs, ≥10 hours per week, continuously for 5 years (s9(22), s9(49); MET defined in Schedule 1).
  • Documentation for bone marrow or stem cell transplants and graft versus host disease, with precise timings.
  • Records demonstrating inability to obtain appropriate clinical management where s9(55) is relied on: referrals, waitlist notices, correspondence, contemporaneous clinical notes recording access issues.

Linking factors to relevant service

• Section 10(1) requires the factor found under s9 to be related to the person’s relevant service. Evidence should therefore not only show the factor existed but must show how the factor came about through or because of relevant service. This may involve:
  • Service medical records showing events in service (injuries, procedures, exposures, operational events).
  • Personnel files, incident reports, unit diaries, or other military documentation linking an event to service.
  • Expert opinion explaining a causal pathway between service events and the listed factor (for example, explaining how exposure in service led to pulmonary thromboembolism, infection, or trauma that in turn produced heart block).
  • For post‑service factors, evidence that a condition originating in service persisted or materially contributed to later heart block (noting s10(2) for pre‑existing conditions and the limited application of later subsections).

Expert report scope

• Medical expert reports for claimants should address, explicitly and separately:
  • Whether the claimant had heart block as defined in s7(2) and the dates of clinical onset and any clinically documented worsening.
  • Whether any s9 factor existed with dates and clinical detail.
  • Whether, on the balance of probabilities, the factor caused or materially contributed to onset or worsening of heart block (causation opinion).
  • Whether, on the balance of probabilities, the factor was related to the person’s relevant service (s10(1)). This requires the expert to opine on nexus to service, not merely on medical causation.
  • If the factor invokes another SoP, the report should identify the other SoP and address how its criteria are met (s11).

Document retention and record requests

• Practitioners should seek comprehensive records early: military service medical records, hospital records, pharmacy dispensing data, surgical and anaesthetic records, imaging and pathology, oncology radiotherapy plans, and primary care notes. Given the SoP’s precise timing windows, missing dates will undermine the case. Consent forms and release authorisations should be prepared to obtain private and public hospital records.

Addressing MET and physical activity

• Where relying on strenuous physical activity factors, practitioners should obtain objective and contemporaneous records capable of supporting time, intensity and duration claims. Where records are sparse, consider:
  • Military fitness test results and unit duties logs.
  • Employment records for physically demanding roles with job descriptions and shift patterns.
  • Fitness training logs or coaching records for athletes.
  • Expert conversion of claimed activities into MET equivalents with an explanation of methodology. Remember the SoP does not prescribe a conversion method; the expert evidence must be robust and explain the basis for the MET assessment.

Preparing for adverse evidence

• Anticipate that decision‑makers will query gaps. If a drug exposure is alleged but only anecdotal evidence exists, secure corroborating testimony, pharmacy records or hospital medication charts. If inability to obtain management is alleged, document contemporaneous complaints, referral delays, and official correspondence.

Cross‑SoP coordination

• When a factor points to another SoP under s11, practitioners must obtain and apply the current version of that SoP. An expert report should address both this SoP’s s9 factor and the relevant criteria in the other SoP so the decision‑maker has a single integrated medical view.

Timeliness and chronology

• Build a clear chronology: dates of service, dates of service events, dates of factor onset, dates of clinical onset and worsening, dates of death and terminal event if applicable. Decision‑makers will map these against the instrument’s windows; any ambiguity should be explained and resolved through documentation or credible expert opinion.

Practical format for submissions

• Present a claim submission that:
  • States the legal hook (s120B VEA or s339 MRCA) and identifies the SoP and its commencement date (s2, s3, s5).
  • Lists the s9 factor(s) relied on, with clause references.
  • Provides a point‑by‑point evidentiary mapping of records to each s9 factor and to s10(1) (relation to relevant service).
  • Attaches expert medical reports that address diagnosis, timing, causation, and nexus to service.
  • Where other SoPs are invoked, attach them and explain how their criteria are satisfied (s11).

Record sufficiency and strategic choices

• If a claimant cannot establish any s9 factor, consider alternative avenues under the VEA or MRCA decision framework (for example, general causation avenues not covered by this SoP). The SoP sets out one path to establishing service connection; failure to meet it does not preclude other legal arguments under the governing Acts, but those alternatives are beyond the instrument’s text and require separate strategic considerations.

In sum, compliance turns on meticulous documentary assembly, precise chronology, targeted expert opinion addressing nexus to both medical causation and relation to relevant service, and careful attention to the specified lists and timing windows contained in the SoP and Schedule 1.