Statement of Principles concerning heart block (Reasonable Hypothesis) (No. 23 of 2022)

The instrument rests on several anchor concepts, and each drives particular evidentiary and administrative consequences:

• Definition of heart block: The Statement supplies a clinical definition rather than relying exclusively on ICD codes (s 7(2)-(4)). Heart block is defined as a conduction disorder with delay or interruption of impulse conduction from atria to ventricles due to anatomical or functional impairment of the AV node, bundle of His or bundle branches, and explicitly includes atrioventricular block and bundle branch block while excluding congenital heart block, long QT syndrome and transient physiological heart block (s 7(2)(a)-(c)). The Statement notes common clinical presentations and observes that heart block may be asymptomatic (s 7(2) notes 1-3). Although ICD‑10‑AM codes are referenced (s 7(3)-(4)), the instrument says the operative meaning is that in s 7(2).

• Reasonable hypothesis standard: The RMA states that it has sound medical‑scientific evidence indicating that heart block can be related to relevant service (s 8). The listing of factors in s 9 establishes the minimum medical circumstances that the RMA treats as raising a reasonable hypothesis connecting heart block (or death from it) to service.

• Temporal and exposure thresholds: Many factors include specific temporal windows or exposure durations. Examples include drugs from the specified list taken within 3 weeks before clinical onset (s 9(12)), chloroquine/hydroxychloroquine taken for at least 1 year before onset (s 9(13)), pulmonary thromboembolism within 7 days before onset or worsening (s 9(2), s 9(35)), bone marrow/stem cell transplant within 24 hours before onset/worsening (s 9(20), s 9(53)), blunt chest injury within 60 days (s 9(18), s 9(51)), and envenomation within 24 hours (s 9(24), s 9(57)). These thresholds are deterministic in application: either the exposure falls within the window or it does not for the purpose of raising the RMA’s reasonable hypothesis.

• Distinction between clinical onset and clinical worsening: The instrument separately lists factors relevant at the time of clinical onset of heart block (s 9(1)-(33)) and those relevant at the time of clinical worsening (s 9(34)-(66)), with an additional factor of inability to obtain appropriate clinical management for heart block (s 9(67)). The separation matters because s 10(2) confines a large block of factors (s 9(34)-(67)) to situations where the heart block was suffered or contracted before or during, but did not arise out of, relevant service.

• Cross‑reference to other Statements of Principles: If a listed factor refers to another injury/disease that itself is the subject of a Statement of Principles, the other Statement governs how that factor is treated (s 11). Practically, that means an assessor must check and apply the terms of any other relevant Statement that covers the referred condition.

• Scope in relation to death: The Statement extends to death from heart block where heart block contributed to a terminal event or condition, and defines terminal event in the Schedule to include cardiac arrest, respiratory failure, pneumonia, circulatory failure and cessation of brain function (s 7(5); Schedule 1).

• Specified lists and definitions: The Schedule supplies the lists that feed into s 9 factors: specified list of drugs (a long enumerated list), infiltrative diseases (amyloidosis, hereditary haemochromatosis, sarcoidosis), autoimmune diseases, mineral/electrolyte abnormalities, thyroid conditions, binge drinking, blunt chest injury examples, MET definition, and the definition of relevant service (Schedule 1). The instrument's applicability therefore depends on reading the Schedule alongside the main body.

These concepts translate into precise operational tasks for claim preparation and decision‑making: establish the diagnosis as per s 7(2), determine whether any s 9 factor existed within the temporal limits, confirm that the factor is linked to the veteran’s relevant service (s 10), and where a factor refers to another disease covered by its own Statement, invoke that Statement (s 11). The instrument thereby turns what can be a broad clinical causal question into a checklist of medically‑specified scenarios recognised by the RMA as sufficient to raise a reasonable hypothesis.

Primary affected parties

• Veterans, serving members and their dependants who lodge claims under the VEA or MRCA: The Statement applies to claims to which section 120A of the VEA or section 338 of the MRCA applies (s 5). This includes persons asserting that their heart block was caused by, materially contributed to, or aggravated by relevant service as defined in the Schedule (operational, peacekeeping, hazardous, British nuclear test defence service under the VEA; warlike and non‑warlike service under the MRCA).

• The Department/decision‑makers (Repatriation Commission / Veterans’ Affairs decision bodies): The Statement provides the RMA’s medical view that decision‑makers will use when assessing causation. Although the instrument itself does not directly compel a particular administrative outcome, it supplies the RMA’s evidentiary yardstick for raising a reasonable hypothesis (s 8, s 9), which feeds into claim processing and entitlement decisions.

Secondary affected parties and stakeholders

• Treating clinicians and specialists: The Statement creates a checklist of medical conditions, tests and temporal associations that specialists will be asked to address in medico‑legal reports. For example, clinicians may be asked to document whether viral myocarditis, infiltrative disease, prior thoracic surgery, exposure to listed drugs, or episodes of pulmonary thromboembolism occurred within the specified windows and whether they were related to service (s 9, Schedule 1). The Schedule’s definitions (for binge drinking, METs, specified lists) are clinical standards that affect how clinicians interpret histories and activity levels.

• Legal practitioners and advocates handling veteran claims: Lawyers and advocates will need to marshal the specific documentary and clinical evidence identified by the Statement,procedure records, medication histories, radiology, histology, toxicology, operation notes, and contemporaneous service records,because the Statement’s factors are time‑bounded and condition‑specific (s 9, s 7, Schedule 1).

• Insurers and actuaries (where relevant): Where entitlements, rehabilitation or compensation obligations are determined on the basis of these Statements, actuarial and funding calculations depend on which claims are accepted. The instrument’s narrowing or widening of acceptable causative factors has downstream budgetary implications for public compensation schemes, but the Statement does not itself set benefits levels.

• Administrative medical reviewers and independent medical examiners: The Statement will inform the scope of independent medical examinations and the questions posed by reviewers, including whether to investigate other Statements of Principles where a factor references another injury/disease (s 11).

Who decides and who pays

• Decision‑makers applying the Statement are the RMA (in issuing the Statement) and those administrative decision bodies responsible for applying the VEA and MRCA to claims; the Statement explicitly binds the RMA’s view on the medical evidence it treats as raising a reasonable hypothesis (s 3, s 8). Costs of obtaining the medical evidence to satisfy the Statement,such as specialist reports, diagnostic testing, retrieval of service records,are borne initially by the claimant, although procedures for assistance are outside this instrument and are governed by the VEA/MRCA systems more broadly.

Behavioural change induced

• The Statement changes the behaviour of claimants and their advisers by requiring targeted evidence collection tailored to the listed factors and timeframes. It changes the behaviour of clinicians and reporting specialists by signalling which medical causative pathways are relevant to the RMA’s reasonable hypothesis test. It changes administrative behaviour by narrowing the scenarios that will automatically raise a reasonable hypothesis and by requiring decision‑makers to consider cross‑referenced Statements of Principles when a factor points to another injury/disease (s 11).

Who does not fall within scope

• Persons whose heart block is congenital, attributable to long QT syndrome, or a transient physiological heart block are explicitly excluded from the Statement’s ambit (s 7(2)(c)). The Statement applies only to claims under the VEA or MRCA provisions cited in s 5; private clinical disputes, worker’s compensation claims or non‑veteran public law contexts lie outside its direct application.

Concentration of effects

• The instrument concentrates benefits and administrative clarity for claimants whose histories include any of the enumerated, time‑bounded factors. Conversely, claimants who cannot identify a listed factor within the temporal limits will face a higher evidentiary hurdle, as the RMA has prescribed what, minimally, raises a reasonable hypothesis (s 9). The concentration of impact is therefore tied to the frequency of those factors in veteran populations and the practical ability to document them.

Duties imposed by the instrument

• Duty on decision‑makers to treat the RMA’s medically‑based factors as the minimum that raises a reasonable hypothesis: The Statement represents the RMA’s view about what medical‑scientific evidence indicates a link between heart block and relevant service (s 8). Administrative bodies that apply the VEA and MRCA will use this Statement in assessing causation, meaning they are expected to consider whether at least one of the factors in s 9 exists and is related to service (s 9, s 10).

• Duty to relate factors to relevant service: The Statement requires that every factor listed in s 9 must be related to the person’s relevant service (s 10(1)). This means claimants must provide evidence tying a factor,say, a surgical procedure, exposure to a drug, or an episode of myocarditis,to service circumstances or to service time‑periods.

• Duty to apply cross‑referenced Statements: If a s 9 factor refers to an injury or disease that has its own Statement of Principles, 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" (s 11). Decision‑makers must therefore check and apply any relevant Statement covering the referred condition.

Rights created or clarified

• Right to have a claim assessed against a clearly enumerated medical framework: For claimants, the Statement clarifies the RMA’s medical criteria for a reasonable hypothesis in relation to heart block. If a claimant can establish at least one factor set out in s 9 and show it is related to relevant service, that satisfies the RMA’s minimum evidentiary threshold for raising a reasonable hypothesis.

• Right to link death from heart block to service where heart block contributed to a terminal event: The Statement explicitly extends to death-from-heart-block where heart block contributed to a terminal event or condition, and defines terminal event in the Schedule (s 7(5); Schedule 1).

Administrative discretion and limits

• The instrument does not remove decision‑maker discretion to evaluate the totality of evidence. It sets out factors that will, minimally, raise a reasonable hypothesis, but does not mandate outcomes beyond the causation threshold. It binds neither the courts nor other administrative bodies to a particular ultimate entitlement outcome; it supplies the RMA’s medical criteria for raising a reasonable hypothesis.

• The narrowing in s 10(2) limits how subsections 9(34)-9(67) are applied by reference to the temporal relationship of the initial heart block to service. This places a duty on decision‑makers to evaluate the chronology: whether heart block was "suffered or contracted before or during (but did not arise out of) the person's relevant service" (s 10(2)). That is a fact‑sensitive enquiry that can affect whether those later factors count as material contribution or aggravation.

Procedural implications for rights to review and challenge

• The Statement does not itself outline appeal routes or procedural rights; those are contained in the VEA and MRCA and the broader administrative review framework. However, by specifying the RMA’s medical view, the Statement becomes a key evidentiary input in decisions that are reviewable under statutory administrative procedures. Practitioners should therefore treat the Statement as a focal starting point in preparing evidence for administrative review or tribunal proceedings.

Practical duties for claim preparation

• Claimants and advisors must assemble: (a) diagnostic evidence meeting the s 7(2) definition of heart block, (b) contemporaneous records evidencing any s 9 factor within its temporal window, (c) documentation connecting the factor to relevant service (s 10), and (d) where a factor invokes another Statement, evidence addressing that other Statement’s criteria (s 11). The Schedule’s definitions prescribe how certain thresholds are measured (for example, binge drinking quantities, METs), creating duties on clinicians and report writers to quantify history in those terms.

No penal provisions in the instrument

• The Statement of Principles is a medical determiner rather than a penal statute. It contains no criminal offences, civil penalties or administrative fines. It neither creates nor prescribes enforcement actions against individuals for failing to comply with its terms. The instrument’s function is evidentiary and guidance‑based for decision‑makers in the veterans’ entitlements environment (s 3, s 8-11).

Enforcement in the sense of application to claims

• The practical "enforcement" mechanism is administrative application: decision‑makers responsible for determining entitlements under the VEA or MRCA will apply the RMA’s Statement as the RMA’s view of what medical‑scientific evidence minimally raises a reasonable hypothesis that heart block is related to relevant service (s 8, s 9). If a claimant does not have evidence of at least one listed factor related to service, an administrative decision may find that the reasonable hypothesis is not raised, with consequent denial of service connection. Those administrative outcomes are enforceable in so far as they affect entitlements and the flow of benefits.

Review and appeal pathways (procedural enforcement)

• The Statement does not set the review mechanisms but is used within established VEA/MRCA frameworks where decisions may be subject to internal review, review by the Veterans’ Review Board, or judicial review in the Federal Court depending on statutory pathways. The Statement will be part of the evidentiary base considered on review and can be challenged on the facts or legal construction by claimants and their advisors, but the instrument itself does not create or alter appeal rights.

Risk of administrative reliance

• Because the Statement standardises what the RMA regards as sufficient to raise a reasonable hypothesis, there is a risk that decision‑makers may treat the listed factors as exhaustive when they are stated to be "at least one" of the factors that must exist (s 9). The instrument does not purport to be an exhaustive catalogue of every conceivable causative mechanism; it states the RMA’s view of sound medical‑scientific evidence that indicates a relationship (s 8). The degree to which decision‑makers explore non‑listed causative pathways will affect whether some claimants face effectively higher burdens if their causal evidence is atypical.

No self‑executing compensation or entitlement change

• The Statement does not directly confer entitlement or create payment obligations. It informs decisions that can produce payments under the VEA/MRCA administrative machinery. The fiscal consequences and the enforcement of benefits arise from those downstream administrative decisions, not from the Statement itself.

Relationship to the VEA and MRCA

• The instrument is made under subsection 196B(2) of the VEA (s 3) and expressly applies to claims to which s 120A of the VEA or s 338 of the MRCA applies (s 5). It therefore operates within the statutory framework for veterans’ entitlements and compensation, and is designed to be the medical input into causation assessments performed under those Acts. The Statement does not revise provisions of the VEA or MRCA; it supplies the RMA’s medico‑scientific criteria for applying those provisions.

Cross‑referencing other Statements of Principles

• Where a factor in s 9 refers to an injury or disease that is itself covered by another Statement of Principles, s 11 requires that the Statement covering that injury/disease applies "in accordance with the terms of that Statement of Principles as in force from time to time." Practically, assessors must examine the state of any related Statements when applying this instrument. This creates an interaction effect: causation for heart block may require simultaneous application of another Statement that could have different temporal rules or evidentiary lists.

Interaction with diagnostic coding systems

• The Statement notes ICD‑10‑AM codes for heart block (s 7(3)-(4)) but establishes its operative meaning by a clinical description in s 7(2). Decision‑makers and clinicians should therefore prioritise the instrument’s substantive clinical definition over a rote reliance on diagnostic codes, while recognising that administrative medical records will frequently refer to ICD codes.

Overlap with other administrative regimes

• This instrument is directed specifically at determinations under the VEA and MRCA. It does not purport to bind other administrative bodies, workplace compensation schemes, national healthcare entitlements, or private insurers. Those regimes may have different causation tests, definitions, or timeframes. Practitioners must therefore avoid assuming that a favourable finding under this Statement automates a favourable outcome in other legal contexts.

Evidence law and procedural rules

• The Statement interposes medical thresholds into the evidentiary analysis useable in administrative decision‑making. However, evidentiary burdens, admissibility rules and standards of proof remain governed by the VEA/MRCA procedures, tribunal rules and applicable administrative law principles. The Statement shapes what medical facts are persuasive to raise a reasonable hypothesis, but it does not change procedural law: the decision‑maker must still consider credibility, probative value, and legal standards for entitlement.

Constitutional and statutory limits

• The instrument is subordinate legislation in form: an executive body’s medical determination under the enabling statute (s 196B(2) VEA). It does not purport to override primary legislation. Where the VEA or MRCA contain defined legal tests or statutory presumptions, those legal rules govern. The Statement must be applied in a way that respects statutory rights under the VEA/MRCA and applicable judicial interpretations of those Acts.

Practical coordination across medical frameworks

• Because the Schedule contains definitions (for METs, binge drinking, specified drug lists, etc.), practitioners must coordinate clinical reporting to meet the particular measurement standards the Statement expects. For example, assessing strenuous physical activity requires calculation in METs (Schedule 1), which is a specific physiological metric; claimants should ensure clinical reports quantify exposure accordingly.

Instrument creation and repeal

• This Statement of Principles concerning heart block (Reasonable Hypothesis) (No. 23 of 2022) was made by the RMA on 4 March 2022 and commenced on 4 April 2022 (s 3, s 2). It expressly repealed the Statement of Principles concerning heart block No. 1 of 2014 which was recorded in the Federal Register of Legislation as F2014L00007, and which had been made under subsections 196B(2) and (8) of the VEA (s 4). The current instrument therefore replaced the 2014 Statement in totality as of its commencement date.

Scope of repeal and continuity

• The repeal indicates that the RMA intended to update the medical criteria and factors that raise a reasonable hypothesis for heart block; however the instrument itself does not set out a clause‑by‑clause comparison or explain specific textual changes from the 2014 instrument. Practitioners must therefore treat the 2022 Statement as the operative RMA medical statement for heart block from 4 April 2022 onwards and consult archive copies if comparisons to the 2014 wording are needed for cases spanning the repeal date.

Amendment mechanism and as‑in‑force reference

• Section 11 refers to other Statements of Principles "as in force from time to time," signifying that related Statements may be amended independently and that decision‑makers should apply the contemporaneous text of any cross‑referenced Statement (s 11). The RMA and the underlying enabling statute provide the administrative mechanism for future amendments; any subsequent amendment would be expected to be published in the Federal Register of Legislation and to state its commencement.

Implications for ongoing claims across repeal date

• Claims with events predating the 4 April 2022 commencement will still be assessed by decision‑makers; however, practitioners should consider whether the RMA’s revised factors alter the causation analysis for events that occurred prior to the new instrument. The Statement itself does not specify transitional arrangements. Therefore, when handling claims that straddle the repeal date, practitioners should check the RMA and departmental guidance as to whether the 2022 Statement applies to claims lodged before its commencement or to claims where adjudicative steps were taken under the 2014 Statement.

Recordkeeping and retrospective evidence

• Given the repeal and replacement, parties should ensure that medical records, expert reports and service documentation are preserved and that expert witnesses know which version of the Statement to address. The Schedule provides defined measurement criteria (for example, binge drinking, METs, specified lists) that may have altered from the prior instrument; practitioners should therefore confirm which definitions apply to the claim.

No further amendment history recorded in the instrument

• The instrument itself records only the repeal of the 2014 Statement and its own commencement. It does not list subsequent amendments or modifications. To identify any later amendments, users must consult the Federal Register of Legislation or the RMA’s published instruments database for any Statements of Principles that have amended or superseded No. 23 of 2022 since its commencement.

Instrument does not record litigation

• The Statement of Principles, as provided, does not reference any litigation history or judicial consideration of its terms (there are no cases mentioned in the instrument). The RMA’s notice is a medical instrument and not a judicial pronouncement, and the document itself contains no summary of litigation.

Where litigation might arise

• In practice, disputes concerning the interpretation or application of Statements of Principles commonly arise in administrative review and judicial review contexts because the Statement can be determinative of causation in veterans’ claims. Litigated issues that could relate to this Statement include whether a particular factor in s 9 actually existed in the required temporal window, whether a factor was sufficiently related to relevant service under s 10(1), and whether the application of cross‑referenced Statements under s 11 was correct. The Statement does not itself outline judicial review routes; those procedural pathways are governed by the VEA/MRCA and administrative law.

How to check for any litigation or authority interpreting this Statement

• Because the Statement as provided does not contain litigation references, practitioners seeking legal authority that interprets or applies this specific RMA Statement must search case law databases (for example AustLII, Federal Court decisions, Administrative Appeals Tribunal/Veterans’ Review Board determinations, and specialist veterans’ law reports) for decisions citing Statement No. 23 of 2022, or for decisions addressing causation in heart block claims under the VEA/MRCA. The instrument’s absence of litigation history in its text does not imply that no judicial or tribunal consideration exists; it simply means that such material is outside the instrument and must be sourced externally.

Potential judicial focus points if litigation occurs

• When litigious review occurs, courts or tribunals typically focus on: (a) whether the medical evidence met the requirement of raising a reasonable hypothesis as the RMA described (s 8, s 9), (b) the correctness of factual findings about temporality (clinical onset versus clinical worsening, timing windows in s 9), (c) whether s 10’s requirement that a factor be related to relevant service was properly assessed, and (d) whether correct cross‑application of other Statements under s 11 occurred. These are possible grounds for contention, but the instrument itself does not signal any particular case law or precedent.

No named cases in the instrument

• The Statement names no cases. Practitioners should not assume the existence of authoritative judicial pronouncements about this precise Statement from the instrument alone. Any litigation history must be verified by external legal research.

Ambiguity between clinical onset and clinical worsening

• The Statement distinguishes factors relevant to clinical onset (s 9(1)-(33)) from those relevant to clinical worsening (s 9(34)-(66)). Practitioners must carefully establish which stage is at issue in a claim. Misidentifying onset versus worsening can change which factors are operative and whether the s 10(2) restriction applies to the later factors.

Temporal windows are strict and varied

• Many factors include tight temporal limits that are often narrower than clinicians or claimants might expect. Examples: drugs from the specified list within 3 weeks before clinical onset/worsening (s 9(12), s 9(45)); pulmonary thromboembolism within 7 days (s 9(2), s 9(35)); bone marrow/stem cell transplant within 24 hours (s 9(20), s 9(53)); blunt chest injury within 60 days (s 9(18), s 9(51)); chloroquine/hydroxychloroquine for at least 1 year (s 9(13), s 9(46)). If documentary evidence does not place the exposure within the stated window, the factor will not, by this instrument, raise the RMA’s reasonable hypothesis. Practitioners must therefore assemble contemporaneous records that precisely date exposures, procedures and incidents.

Requirement that factors be related to relevant service

• The Statement requires that any factor in s 9 be related to the person's relevant service (s 10(1)). This is more than temporal coincidence; it requires evidence linking the factor to service circumstances. For instance, a drug exposure during civilian life will not serve as a service‑related factor unless it can be shown to be connected to relevant service. This linkage can be difficult to prove, especially where service and civilian timelines abut.

Subsection limitation for aggravation/material contribution factors

• Subsections s 9(34)-s 9(67) are expressly confined to cases where the heart block was "suffered or contracted before or during (but did not arise out of) the person's relevant service" (s 10(2)). This is a frequent gotcha: if heart block itself arose out of service, those aggravation/material contribution factors do not apply; they apply only when heart block pre‑existed or was not caused by service but was aggravated by service.

Interaction with other Statements of Principles

• If a s 9 factor refers to a condition covered by another Statement, s 11 mandates application of that other Statement. The risk for claimants is failing to identify whether a referred condition (for example, infiltrative disease such as amyloidosis or sarcoidosis) has its own Statement and specific criteria that must be met. Practitioners should always check cross‑references rather than assuming s 9’s bare citation suffices.

Definition overrides simple coding

• The instrument provides its own operative clinical definition of heart block (s 7(2)) and explicitly states that, although ICD‑10‑AM codes are noted, the meaning is that in subsection (2) (s 7(3)-(4)). Practitioners relying solely on discharge summaries or coding may miss the need to demonstrate the anatomical/functional conduction impairment described in s 7(2).

Specified lists require exact identification

• Several factors refer to "specified lists" in the Schedule (drugs, infiltrative diseases, autoimmune diseases, etc.). A medication not on the specified list cannot be used under s 9(12)/s 9(45) even if it has cardiac effects; conversely, specified drugs such as beta blockers, amiodarone or certain chemotherapeutic agents are included and require precise prescription histories. Practitioners must read the Schedule closely rather than relying on general drug classes.

Unusual or rare windows: bone marrow transplant and graft versus host

• The transplant factor timing in s 9(20) and s 9(53) is very narrow: a bone marrow or stem cell transplant within 24 hours before clinical onset or worsening. Such a precise window may apply only to extremely acute peri‑procedural events. Similarly, graft versus host disease is listed as a factor (s 9(21), s 9(54)) and requires documentation that the condition existed at the time of onset/worsening.

"Cannot obtain appropriate clinical management" is a factor but open to interpretation

• s 9(67) admits "inability to obtain appropriate clinical management for heart block" as a factor relevant to clinical worsening. That factor is qualitative and may be contentious; claimants will need contemporaneous evidence of attempts to obtain care, systemic barriers, or service‑related reasons for lack of treatment. Decision‑makers will weigh such evidence, and the Statement does not prescribe the precise evidentiary standard for proving inability to obtain care.

Death link requires contribution to terminal event

• For death claims, the Statement covers death from heart block where heart block contributed to a terminal event or condition (s 7(5); Schedule 1 defines terminal event). Practitioners must therefore establish a causal contribution to terminal events such as pneumonia, respiratory failure, cardiac arrest, circulatory failure or cessation of brain function. Simple temporal proximity between heart block and death will not suffice without evidence of contribution.

Terminology pitfalls: exclusion of congenital heart block and long QT syndrome

• The exclusions in s 7(2)(c) remove congenital heart block and long QT syndrome from the RMA’s heart block Statement. Cases involving these conditions require a different evidentiary approach and possibly different Statements; conflating them with the present Statement’s heart block definition is a common error.

Metrics and measurement: METs and binge drinking

• The Schedule requires the use of METs to quantify strenuous physical activity (MET definition in Schedule 1). Binge drinking is defined quantitatively (Schedule 1) and uses specific drink counts and blood alcohol concentrations. Clinical reports must quantify exposures in those terms, not simply provide qualitative descriptions.

Stepwise practical approach for claimants and practitioners

1. Confirm the diagnosis under the instrument’s operative definition

   • Establish that the person has heart block as defined in s 7(2): evidence should address conduction delay or interruption at the atrioventricular node, bundle of His or bundle branches, and exclude congenital heart block, long QT and transient physiological heart block (s 7(2)(a)-(c)). Provide ECGs, cardiology reports, pacemaker insertion records if any, and clinician opinions that reference the anatomical or functional impairment described in s 7(2). Note that although ICD‑10‑AM codes are noted (s 7(3)-(4)), the substantive clinical definition in s 7(2) controls.

2. Identify whether the claim concerns clinical onset, clinical worsening, or death

   • Determine whether the event to be linked to service is the initial clinical onset of heart block, a subsequent clinical worsening, or death from heart block. This affects which s 9 factors to target (onset factors are in s 9(1)-(33); worsening factors are in s 9(34)-(66); death has the s 7(5) contribution requirement).

3. Produce documentary evidence for at least one s 9 factor within its temporal window

   • For each candidate factor, collect records that demonstrate its existence at the relevant time and within the temporal limits the Statement specifies. Examples:
     • Medication history: pharmacy dispensing records, prescription charts and inpatient medication charts to show drugs from the specified list taken within 3 weeks (s 9(12), s 9(45)), or chloroquine/hydroxychloroquine taken for at least one year (s 9(13), s 9(46)).
     • Surgical and procedural records: operation notes, anaesthetic records, transcatheter procedure records for thoracic or invasive cardiac procedures within one year (s 9(17), s 9(50)).
     • Trauma records: ambulance, emergency department, and operative notes for penetrating trauma to the heart within one year (s 9(16), s 9(49)) or blunt chest injury within 60 days (s 9(18), s 9(51)); Schedule 1 lists examples of causes of blunt chest injury.
     • Infection and myocarditis: microbiology, serology, histology, imaging and clinical notes showing viral myocarditis, non‑viral myocarditis, or infective endocarditis at onset/worsening (s 9(7)-(11), s 9(40)-(43)).
     • Pulmonary embolism: objective imaging such as CT pulmonary angiogram or ventilation/perfusion scan within 7 days (s 9(2), s 9(35)).
     • Transplants and graft versus host disease: transplant records and timing to show bone marrow/stem cell transplant within 24 hours or presence of graft versus host disease (s 9(20)-(21), s 9(52)-(54)).
     • Radiation: oncology treatment plans and radiation dosimetry showing the heart was in the field (s 9(22), s 9(55)).
     • Strenuous physical activity: quantify activity in METs per Schedule and show 10+ hours/week average over at least five continuous years (s 9(23), s 9(56); Schedule 1 MET definition).
     • Lifestyle exposures: evidence for cannabis use within 7 days, binge drinking within 2 days as defined in Schedule 1 (s 9(28)-(29), s 9(61)-(62)).
     • Mineral/electrolyte abnormalities: pathology and electrolyte panels showing abnormalities from the specified list at onset/worsening (s 9(11), s 9(44); Schedule 1).
   • Ensure exact dating is available and that the evidence places the exposure within the instrument’s required window.

4. Demonstrate that the factor is related to relevant service

   • Collect service records, deployment histories, clinical notes made during service, medication logs from service medical facilities, surgical records from service hospitals, and witness statements linking the factor to service. s 10(1) requires the factor be related to the person’s relevant service. For example, if a noisy environment on a deployment caused a procedural exposure, or an injury was sustained on a vessel or in theatre, collect contemporaneous service documentation.

5. Where a factor references another disease with its own Statement, apply and comply with that Statement

   • Identify whether the factor points to another injury/disease that has an RMA Statement. If so, obtain and apply that Statement’s criteria and gather any additional evidence required by it (s 11). For example, if s 9 refers to an infiltrative disease such as amyloidosis, check whether amyloidosis has a separate Statement and address the tests and timelines that Statement requires.

6. For death claims, link heart block to a terminal event

   • If the claim concerns death, demonstrate via death certificate, post‑mortem, clinical summaries and treating notes that heart block contributed to the terminal event (s 7(5); Schedule 1 terminal event list). Establishing contribution is factual and medical; obtain cardiology and forensic opinions as needed.

7. Prepare medico‑legal reports that map clinical facts to the Statement language

   • Ensure that expert reports directly address s 7’s clinical definition, identify which s 9 factor(s) are relied on, document timing precisely against the Statement’s windows, and expressly opine on the relationship of the factor(s) to relevant service (s 7, s 9, s 10). Where metrics such as METs or binge drinking thresholds are relevant, experts should quantify history using the Schedule’s standards.

8. Document attempts to obtain management where s 9(67) may apply

   • If inability to obtain appropriate clinical management is relied upon (s 9(67)), compile contemporaneous evidence of healthcare access problems: referrals, waiting list correspondence, service access denials, evidence of service restrictions while deployed, and clinical notes showing management was not available or delayed.

Evidence quality, chain of custody and contemporaneity

• Since the Statement requires precise timing and specific exposures, contemporaneous records carry significantly greater weight than retrospective statements. Practitioners should obtain original medical records, hospital discharge summaries, operation notes and pharmacy dispensing records. If records are missing, obtain affidavits or corroborative statements explaining the absence and seek objective corroboration such as unit logs, incident reports or witness statements.

Checklist for practitioners

• Confirm heart block diagnosis per s 7(2).
• Identify whether claim concerns onset, worsening or death.
• Locate at least one s 9 factor that exists within its temporal window.
• Gather objective documentary evidence dated to the required period.
• Demonstrate the factor’s relation to relevant service (s 10(1)).
• Check and apply any other Statements per s 11.
• Obtain expert medico‑legal reports framed to the Statement’s language.
• For death claims, document contribution to terminal event (s 7(5)).
• Where inability to obtain care is asserted, document attempts and failures to access care (s 9(67)).

Administrative practice points

• Always cite the specific subsection(s) of this Statement in submissions and expert reports to show alignment with the RMA’s criteria (for example, "relying on s 9(2) , pulmonary thromboembolism within 7 days before clinical onset"). That helps adjudicators locate the claimed linkage quickly.

• When medication is central, obtain pharmacy dispensing logs rather than relying on patient recall; the specified list in the Schedule is exhaustive for the purposes of s 9(12)/s 9(45).

• Where the claimant’s history is ambiguous as to onset date, focus on establishing a reliable clinical onset date with supporting ECGs, outpatient notes, or hospital records. Uncertainty on onset date can be fatal because of the strict timing windows.

• If a factor refers to another Statement, obtain that Statement immediately and read both instruments in parallel. Failure to do so risks missing additional evidentiary requirements.

• Where service records are incomplete, request Departmental assistance in retrieving service medical and operational logs; administrative delays in obtaining these documents should be anticipated and planned for.

By following the Statement’s textual structure and the Schedule’s defined metrics, practitioners can assemble a focused evidentiary package targeted to the RMA’s medically‑specified minimums for raising a reasonable hypothesis that heart block is related to relevant service.