Statement of Principles concerning hyperthyroidism and thyrotoxicosis (Reasonable Hypothesis) (No. 5 of 2022)

The SOP rests on a handful of foundational concepts that shape how evidence is used in claims.

• Reasonable hypothesis as threshold and RMA evidence view. The instrument is framed around raising a "reasonable hypothesis" connecting the condition to relevant service. The Repatriation Medical Authority records it is "of the view that there is sound medical‑scientific evidence" supporting such connections between exposure and disease (s 8). The SOP does not itself set the legal standard of proof, but supplies the factual predicates that meet the RMA’s position on what constitutes a reasonable hypothesis for these conditions.

• Defined conditions and exclusions. The instrument defines hyperthyroidism and thyrotoxicosis (s 7(2)‑(3)) and explicitly excludes several entities from those definitions: euthyroid hyperthyroxinaemia, gestational transient thyrotoxicosis, Graves disease, sick euthyroid syndrome, and toxic multinodular goitre and toxic thyroid adenoma (s 7(2)(b) and s 7(3)(b)). The SOP notes that hyperthyroidism due to toxic multinodular goitre or toxic thyroid adenoma is covered by the Statements of Principles concerning goitre, and that Graves disease is covered by the SOPs for Graves disease (Notes to s 7). That creates a structural division of causation issues across multiple SOPs.

• Factor list with temporal windows. Section 9 lists the discrete "factors that must exist" to raise a reasonable hypothesis. Each factor is expressly tied to timing relative to the "clinical onset" or "clinical worsening" of disease, for example: iodine excess within six months before clinical onset (s 9(1)); iodine-containing radiographic contrast within six months before onset (s 9(2)); amiodarone for continuous period of at least two weeks within the one year before onset (s 9(3)); and parallel items for clinical worsening (s 9(12) to 9(21)). The Schedule supplies precise numerical thresholds and definitions, for example for "iodine excess" (Schedule 1). The instrument also includes factors unique to thyrotoxicosis, such as struma ovarii and specific forms of thyroiditis (s 9(11) and s 9(22), Schedule 1).

• Relationship to relevant service. The SOP requires that any factor established is related to the person's relevant service (s 10(1)). It also places a limitation on the applicability of factors that refer to clinical worsening (s 10(2)): those factors apply only to material contribution or aggravation where the condition was suffered or contracted before or during (but did not arise out of) the person's relevant service. This draws a distinction between conditions that arise out of service and conditions that predate service and are aggravated by service exposures.

• Cross‑application to other SOPs. Where a factor in this instrument refers to an injury or disease for which another SOP exists, the other SOP’s factors apply in accordance with its terms (s 11). This creates an interlocking framework where cause-of-condition predicates in one SOP may import the rules of another.

• Definitions with numerical thresholds and clinical detail. The Schedule supplies operational definitions important to adjudication. For example, "iodine excess" is defined quantitatively (an average intake greater than 1,100 micrograms/day for adults, or urinary iodine concentration greater than 300 micrograms/L, with higher thresholds for pregnant women) (Schedule 1). "Acute precipitating event" is defined with example stimuli and events (Schedule 1). "Thyrotoxic crisis" is defined clinically including characteristic signs and the possibility it may be first presentation (Schedule 1).

Together, these concepts convert clinical and exposure evidence into fixed decision points for compensation adjudication. The SOP thereby reduces some adjudicative uncertainty by listing exposures/conditions and attaching timing windows and numeric thresholds that, if established and linked to relevant service, will support a conclusion that a reasonable hypothesis exists.

Primary parties affected are veterans, members of the Forces, and members of Peacekeeping Forces who have relevant service under the VEA or MRCA and who claim benefits for hyperthyroidism, thyrotoxicosis, or death from those conditions. The instrument applies specifically to claims to which section 120A of the VEA or section 338 of the MRCA applies (s 5). Those are the statutory provisions that rely on Statements of Principles to determine whether a particular injury, disease, or death is connected with service.

Decision makers are the Repatriation Medical Authority (which issues the SOP under s 196B(2) VEA, s 3) and, operationally, the Department of Veterans’ Affairs (DVA) officers or decision makers who apply the SOP to individual claims. The SOP is framed to guide the "reasonable hypothesis" assessment that those decision makers must make when adjudicating claims under the VEA and MRCA , the instrument supplies the medically framed predicates that constitute a reasonable hypothesis for these conditions (s 9).

Medical practitioners, hospitals, radiology providers, and pharmacists are indirectly affected insofar as their records are the primary sources of evidence to establish exposure or medical diagnoses referenced in the SOP. For example, records of radiographic contrast administration, prescriptions for amiodarone, minocycline or listed drugs, pathology reports confirming neoplasms, urinary iodine measurements, and operative or trauma notes will be the evidential basis used in claims. The Schedule sets objective thresholds and definitions (for example, iodine intake thresholds and urinary iodine concentration) that medical reports can support or refute.

Claim preparation professionals, including lawyers, advocates, and claims agents, are also affected because the SOP changes the evidential checklist required to raise a reasonable hypothesis. The instrument’s temporal thresholds and precise definitions will shape the types of medical and exposure documentation that must be obtained and presented.

Third‑party insurers and employers are tangentially affected in cases where non‑service causes overlap with service exposures; the SOP’s exclusions and links to other SOPs (for goitre and Graves disease) may influence where responsibility is attributed. For example, the instrument excludes Graves disease and toxic multinodular goitre from its definitions and refers claimants to other SOPs, which shifts the evidentiary and legal pathway for claims involving those conditions (s 7(2)(b), s 7(3)(b), notes).

Finally, the public purse is affected because successful claims result in benefit payments. The SOP modifies the causation predicate for these conditions by specifying the discrete factors and definitions that can meet the reasonable hypothesis threshold, and that will influence claim acceptance rates and administrative adjudication workload.

The SOP itself does not create new criminal offences or private rights; rather it prescribes the medical‑scientific factors that decision makers should treat as sufficient to raise a reasonable hypothesis that hyperthyroidism, thyrotoxicosis, or death from those conditions is related to relevant service. Its key operational duties and rights are therefore administrative and evidential.

Duty to apply the SOP in relevant claims. Under the VEA and MRCA statutory scheme, decision makers must apply Statements of Principles to determine whether a condition is related to service for certain claims. This SOP, as an instrument made under s 196B(2) VEA (s 3), therefore becomes the operative statement decision makers use for the specified conditions. The instrument requires that at least one of the factors listed in s 9 exist, and be related to the person’s relevant service, before a reasonable hypothesis can be said to have been raised (s 9 and s 10(1)).

Duty to relate factors to relevant service. The SOP requires not only that one of the enumerated factors exist, but that it be related to the person's relevant service (s 10(1)). That places a duty on adjudicators to assess temporal and causal connections between a listed factor and the individual’s service record. For factors dealing with clinical worsening (s 9(12) to s 9(23)), the instrument imposes an additional limitation: those factors apply only to material contribution to, or aggravation of, hyperthyroidism or thyrotoxicosis where the condition was suffered or contracted before or during, but did not arise out of, the person’s relevant service (s 10(2)). That imposes a specific evidential approach to pre‑existing conditions aggravated by service.

Right to rely on numerical and clinical definitions. The Schedule gives precise definitions and quantitative thresholds, for example for "iodine excess" (Schedule 1). Claimants and decision makers have the right to rely on those objective definitions and thresholds when presenting or assessing evidence. Where a laboratory urinary iodine concentration or documented intake crosses the threshold set out, the claimant can point to a defined standard in the instrument.

Duty to follow cross‑references to other SOPs. Section 11 creates a procedural duty: if a factor in this SOP refers to an injury or disease covered by another SOP, then the factors in that other SOP apply in accordance with its terms. This requires adjudicators to cascade the relevant SOPs when a listed factor implicates another instrument.

Duty to consider death relatedness. The instrument includes death from hyperthyroidism or thyrotoxicosis within its scope (s 7(1) and s 7(4)). This means adjudicators must consider whether a terminal event or condition was contributed to by hyperthyroidism or thyrotoxicosis. The Schedule supplies a list of terminal events (for example, cardiac arrest, respiratory failure) (Schedule 1), which guides death adjudication.

Evidentiary duty on claimants. Implicit in the SOP is a practical obligation on claimants to present evidence supporting the existence of one or more listed factors and connecting them to service. That evidence may include medical records, pathology, radiology reports, prescription records, lab data such as urinary iodine concentration, and service records showing timing of exposures relative to service.

Administrative duty to apply temporal windows. The SOP’s multiple timing conditions (for example, within six months, within 48 hours, continuous use for at least two weeks or six months in certain cases) impose a duty on decision makers and claimants to demonstrate that exposures fall within those windows. Where the timing cannot be demonstrated, a reasonable hypothesis as defined by this SOP will be more difficult to establish.

In sum, the SOP imposes duties on decision makers to apply the enumerated factors, to relate them to service, and to cascade to other SOPs where relevant, while claimants must marshal evidence that meets the SOP’s definitions and temporal requirements.

The instrument itself does not create criminal penalties, civil sanctions, or separate enforcement mechanisms. It is an administrative instrument that operates as a determinative guide for the adjudication of claims under the VEA and MRCA. Enforcement in this context means how the SOP is used by administrative decision makers and how determinations are reviewed under the existing statutory appeals and review mechanisms within the veterans’ compensation framework.

Adjudicative effect. The SOP’s primary enforcement consequence is that meeting a listed factor (and linking it to relevant service) will satisfy the RMA’s criteria for raising a reasonable hypothesis of service connection, which influences acceptance of claims under s 120A of the VEA or s 338 of the MRCA (s 5, s 9). Where adjudicators accept that a reasonable hypothesis has been raised, that will typically lead to further administrative steps, for example referral to DVA processes for acceptance and payment of entitlements under the VEA or MRCA. The instrument therefore functions as a binding technical guide for administrative decision making.

Review and merits appeals. The SOP does not amend the statutory review pathways. Decisions applying the SOP remain subject to the VEA and MRCA review and appeal mechanisms, including internal review, merits review by the Veterans' Review Board (or relevant tribunal), and judicial review in courts on questions of law. Any dispute about whether the SOP’s factors are satisfied in a particular case will be resolved through those statutory channels. The instrument does not create or alter penalty regimes for false statements, though existing provisions in the VEA, MRCA or other laws regarding false statements or fraud would remain applicable if relevant.

Operational enforcement by DVA. The Department of Veterans’ Affairs, as the agency administering entitlements, will enforce the SOP operationally by requiring claim documentation that aligns with the factors and definitions in the instrument. DVA can disallow or refuse claims where the evidence does not demonstrate that the required factors existed or were service‑related. The SOP’s detailed temporal windows and objective thresholds may make it easier for decision makers to deny claims where records do not prove the relevant exposure or timing.

No specific sanctions or compliance penalties. The SOP contains no explicit fines, licences, or civil penalties tied to non‑compliance. Its "teeth" are procedural and evidentiary: it either supplies the medical predicates that establish a claim, or it does not. Any enforcement action beyond administrative claim acceptance or refusal would follow existing statutory law rather than the SOP itself.

In practice, therefore, the SOP’s enforcement effect is to shape acceptance rates and evidentiary requirements for benefits, and to provide a clear administrative standard that is then subject to the statutory review and appeal framework under the VEA and MRCA.

This SOP operates within the statutory scheme established by the Veterans' Entitlements Act 1986 and the Military Rehabilitation and Compensation Act 2004. It is made under subsection 196B(2) of the VEA (s 3), and applies to claims under s 120A of the VEA or s 338 of the MRCA (s 5). The instrument therefore sits beneath the statutes; it is not itself the source of entitlements but a medical‑scientific instrument that the statutes require decision makers to apply when assessing causation in claims.

Cross‑SOP interaction. Section 11 provides procedural interaction with other Statements of Principles. If a factor listed in s 9 refers to an injury or disease covered by another SOP determined under subsection 196B(2) VEA, then the factors in that other SOP apply according to its terms (s 11). The instrument also explicitly excludes certain conditions from its definitions , for example, Graves disease and toxic multinodular goitre , and notes that these are covered by separate SOPs for Graves disease and goitre (s 7(2)(b), s 7(3)(b), notes). This creates an interlocking system in which adjudicators must navigate multiple SOPs to determine causation for conditions that overlap diagnostic categories.

Relationship to statutory causation tests. The SOP is designed to furnish the medical predicates that align with the statutory causation tests in the VEA and MRCA. Those statutes require medical acceptance that a condition is connected with service, and SOPs provide standardized causal pathways that, if met, meet the "reasonable hypothesis" requirement under the relevant statutory provisions. The instrument thereby provides decision makers with medically framed rules to apply the statutory standard.

Interaction with clinical and regulatory law. The SOP incorporates clinical definitions and thresholds that will intersect with other areas of law and practice, for example diagnostic standards used in clinical care, pharmaceutical regulation in relation to drug labelling (to determine iodine content), and radiological practice (documentation of contrast administration). The Schedule’s numerical thresholds for iodine intake and urinary iodine concentration (Schedule 1) are laboratory metrics used in clinical practice. Decision makers will rely on clinical laboratory evidence, prescription records, and clinical diagnoses that are created under health regulation frameworks.

Evidence and privacy laws. Claimants will need to obtain and provide medical records, pathology reports, radiology logs, and possibly laboratory results to meet the SOP’s factors. That interacts with privacy and health records law, including obligations of medical providers and the claimant’s consent to release files. The SOP does not alter privacy law, but it increases the practical interaction between claim processes and privacy/compliance obligations on health records custodians.

Appeal and judicial review. Decisions applying the SOP remain subject to review under administrative law, including merits review bodies and judicial review on questions of law. The SOP’s determinations about what factors constitute a reasonable hypothesis will be applied by decision makers and can be challenged if applied incorrectly to facts or in law.

No conflict with criminal or civil liability regimes. The SOP does not create or negate criminal liability, nor does it confer civil causes of action outside the veterans’ compensation framework. It is not a public health regulation imposing duties on private actors beyond their existing medical and regulatory obligations. Its practical effect on other laws is therefore primarily evidentiary and administrative within the veterans’ compensation system.

The instrument replaces a prior Statement of Principles on the same conditions. Section 4 expressly repeals "The Statement of Principles concerning hyperthyroidism and thyrotoxicosis No. 27 of 2013 (Federal Register of Legislation No. F2013L00723)" (s 4). The current instrument is dated 24 December 2021 and commences 31 January 2022 (s 2). No other amendments are recorded within the text of the instrument itself.

The SOP’s Schedule and factors are therefore to be read as the operative version from the commencement date. The instrument also contains notes that indicate certain conditions are handled by different SOPs (s 7 notes). Any subsequent amendments to the VEA, MRCA, or other SOPs that affect cross‑referenced conditions (for example goitre or Graves disease) will interact with this instrument via s 11, but those interactions would arise from changes to the other instruments rather than from this SOP alone.

Because the instrument is a statutory instrument made under the VEA, future amendment or repeal would follow the same enabling provision, subsection 196B(2) VEA. The instrument itself does not provide a history of prior amendments to the 2013 SOP it repeals; it only replaces that earlier instrument. The text does not list a sequence of prior amendments or consultation materials.

Practitioners should note the commencement date for evidentiary purposes. Claims with events before the commencement date may still be governed by the new SOP where the claim is made after commencement and the SOP is the operative instrument for that claim, subject to statutory transitional provisions in the VEA or MRCA and established administrative practice. The instrument does not include transitional provisions, so the starting point is that it is the SOP in force from 31 January 2022.

If a factor in this SOP refers to an injury or disease covered by another SOP, changes in that other SOP after this instrument’s commencement will alter how the factor is applied in relation to that disease (s 11). That creates a dynamic interface where amendment of other SOPs can change the route to acceptance for related claims without amendment of this instrument.

The instrument contains no litigation history. It does not mention any cases in which its provisions have been considered or applied by a tribunal or court. The SOP is an administrative instrument setting medical factors to guide decision makers under the VEA and MRCA; any litigation applying the SOP would arise from individual claims and challenges brought after this instrument’s commencement.

Practitioners should therefore treat the SOP as a newly operative evidentiary statement as of 31 January 2022 (s 2) and anticipate the first wave of litigation or merits review challenges will involve disputed applications of the enumerated factors to particular facts. In the absence of cases referenced in the instrument, there is no authoritative judicial interpretation embodied in the text. Case law that addresses the statutory standard for "reasonable hypothesis" in the VEA or MRCA may still be relevant, but the instrument itself does not cite or summarise such authorities.

Because the SOP cross‑refers to other SOPs where specific subtypes (for example Graves disease or toxic multinodular goitre) are covered, litigation contesting boundary issues between SOPs could arise. Section 11 requires decision makers to apply another SOP’s factors where the factor refers to a disease covered by that SOP, and disputes may arise about which SOP properly governs a particular clinical picture.

Given the absence of litigation history in the instrument, practitioners will need to monitor merits review and judicial decisions for emerging guidance on how tribunals and courts interpret and apply: the temporal windows (for example, the meaning of "within 6 months"); the sufficiency of evidence for quantitative thresholds such as urinary iodine concentration; the evidentiary weight to be given to clinical reports; and the interaction of s 10(2) with pre‑existing conditions aggravated by service.

This SOP contains several features that are likely to be practical pitfalls in claims preparation and adjudication. Attention to the instrument’s precise language, timing windows, and cross‑references is necessary.

1. Narrow definitions and explicit exclusions. Hyperthyroidism and thyrotoxicosis as defined exclude Graves disease and toxic multinodular goitre and toxic thyroid adenoma (s 7(2)(b), s 7(3)(b)). Those excluded entities are covered under separate SOPs. If a claimant or clinician mislabels a condition (for example, uses "hyperthyroidism" but the clinical entity is Graves disease), the wrong SOP may be applied unless pathology and clinical records confirm the subtype. The instrument’s notes emphasise that those entities are managed elsewhere.

2. Quantitative thresholds for iodine excess. "Iodine excess" has numeric thresholds: an average intake of more than 1,100 micrograms/day for adults (or more than 900 µg/day for those aged 18 and under) for a continuous period of at least three months, or urinary iodine concentration greater than 300 µg/L (greater than 500 µg/L for pregnant women) (Schedule 1). Practically, proving an average intake or a urinary iodine concentration meeting those thresholds can be difficult because dietary intake data and urinary iodine results may not be available in service or civilian medical records. Where those data are absent, relying on this factor will be challenging.

3. Short, strict temporal windows. Several factors require exposure within defined windows, often short: administration of iodine-containing radiographic contrast within six months of onset (s 9(2)), amiodarone for at least two weeks within one year of onset (s 9(3)), minocycline for at least six months within the six months before onset (s 9(5)), trauma involving thyroid within 14 days prior to onset (s 9(11)(d)). Demonstrating dates and continuity of medication use to these exact windows will be necessary. Gaps in records may defeat a claim.

4. Different thresholds for onset and worsening. The SOP includes parallel sets of factors for clinical onset and clinical worsening (s 9(1)-(11) and s 9(12)-(22)). Section 10(2) limits the application of the worsening factors to conditions that were suffered or contracted before or during, but did not arise out of, relevant service. This distinction can be a trap: a claimant whose condition first arose after service cannot invoke the clinical worsening factors as material contribution or aggravation.

5. Specified list of drugs and composition thresholds. Some factors require proof of exposure to a "specified list of drugs" (s 9(4), s 9(15)). The Schedule defines the list (immune checkpoint inhibitors, interferon alpha, interleukin‑2, lenalidomide, lithium carbonate, tyrosine kinase inhibitors). Separately, s 9(6) and s 9(17) require taking a drug containing at least 10 mg iodine daily for a continuous period of at least four weeks. Proving the iodine content of a drug or supplement requires product information, which may not be readily available for older medications or off‑label supplements.

6. Inability to obtain appropriate clinical management. Section 9(23) lists "inability to obtain appropriate clinical management for hyperthyroidism or thyrotoxicosis" as a factor. Establishing this requires evidence of actual lack of access, not merely assertion. The SOP does not define "appropriate clinical management" in the Schedule, so the standard will be assessed in the context of available medical practice and records, which creates evidentiary uncertainty.

7. Thyrotoxic crisis may be first presentation. The Schedule defines "thyrotoxic crisis" and notes it may be the first presentation of previously undiagnosed disease (Schedule 1, thyrotoxic crisis Note 2). For claims where thyrotoxic crisis is the first presentation, the acute precipitating event defined in the Schedule must be shown within 48 hours prior to onset to raise a reasonable hypothesis (s 9(10), s 9(21)). The tight 48‑hour window and the need to document specific precipitating events such as abrupt cessation of anti‑thyroid therapy or acute iodine load are practical evidential hurdles.

8. Cross‑SOP dependencies. If a factor refers to an injury or disease covered by another SOP, the other SOP's factors apply (s 11). Practitioners must check related SOPs for conditions that overlap boundary areas, otherwise they risk citing incorrect factors or missing additional requirements.

9. Evidence of relation to service. Section 10(1) requires the factor to be "related to the relevant service rendered by the person." The SOP supplies the medical predicates, but proof of relation to service depends on service records, contemporaneous medical records, and timelines. Absent clear records, establishing that a particular medication, contrast exposure, or iodine intake occurred as a result of service exposures may be difficult.

10. Repeal of the 2013 SOP. The 2013 SOP is repealed (s 4). Claims that were assessed under the previous SOP may be reconsidered under the new instrument depending on administrative practice and transitional rules, which are not stated in this instrument and may require close attention when handling legacy claims.

In practice, these "gotchas" translate into documentary demands: precise dates, continuous medication histories, laboratory evidence for iodine thresholds, product compositions for iodine content, and clinical diagnostics to categorise the thyroid disease correctly.

Compliance in this context means assembling and presenting the evidence necessary to establish that at least one of the factors in s 9 existed and that the factor is related to the person’s relevant service (s 9, s 10(1)). The SOP’s Schedule provides operational definitions and numerical thresholds that should be front and centre in evidentiary preparation.

1. Map the condition to the correct SOP. First, confirm the exact clinical diagnosis. If the clinical entity is Graves disease, toxic multinodular goitre, or toxic thyroid adenoma, this SOP excludes those conditions and directs claimants and decision makers to other SOPs (s 7(2)(b), s 7(3)(b), notes). Avoid mislabelling; obtain endocrinology or pathology reports that state the diagnosis or subtype explicitly.

2. Establish the onset/worsening dates. The SOP’s factors are tied to the "clinical onset" or "clinical worsening" dates. Obtain clinical notes that document symptom onset, biochemical data (T3/T4/TSH levels), admission records, or hospital discharge summaries indicating dates of first recognised disease or explicit clinical worsening. If thyrotoxic crisis is claimed, obtain emergency presentations and ICU records where symptoms and biochemical tests are recorded (Schedule 1).

3. Gather medication and exposure histories with precise dates. For drug‑related factors, assemble prescription records, dispensing records, GP or hospital drug charts, and pharmacy records showing start and stop dates and continuity. Specific examples include:

   • Amiodarone: documentary proof of continuous use for at least two weeks within the year preceding clinical onset (s 9(3)).
   • Minocycline: continuous use for at least six months within the six months before onset (s 9(5)).
   • Drugs on the specified list: confirm the specific agent (immune checkpoint inhibitors, interferon alpha, interleukin‑2, lenalidomide, lithium carbonate, tyrosine kinase inhibitors) and dates (s 9(4), Schedule 1).
   • Drugs containing at least 10 mg iodine daily: obtain drug information sheets or product labels proving iodine content and dates showing continuous use for at least four weeks within six months before onset (s 9(6), s 9(17)).

4. Document iodine exposure quantitatively where possible. For factors based on "iodine excess" (s 9(1), s 9(12)), obtain any available laboratory urinary iodine concentration tests. Where lab values are not available, collate product information for supplements, diet histories, or records of iodinated contrast or medications known to be high in iodine. Remember the numerical thresholds: more than 1,100 µg/day for adults over three continuous months, or urinary iodine >300 µg/L (or >500 µg/L for pregnant women) (Schedule 1).

5. Radiology records for contrast exposure. For the radiographic contrast factor (s 9(2), s 9(13)), obtain imaging reports and radiology department contrast administration logs showing the date of contrast media use. The relevant window is within six months before clinical onset or clinical worsening.

6. Pathology and imaging for neoplasms and pituitary adenoma. For factors concerning neoplasms (s 9(9), s 9(20)) and thyroid-stimulating pituitary adenoma (s 9(7), s 9(18)), obtain histopathology reports, biopsy results, surgical notes, and imaging studies that document the presence and functional status of the tumour at the relevant time.

7. Trauma and precipitating events. For trauma involving the thyroid (s 9(11)(d), s 9(22)(d)), assemble emergency department records, operative notes, or military incident reports documenting blunt or penetrating injury and the date. For acute precipitating events underlying thyrotoxic crisis (s 9(10), s 9(21), Schedule 1), collect records that show the specific event within the 48‑hour window, such as evidence of abrupt cessation of therapy, acute illness admissions, surgery, infection, or documented acute emotional stressors contemporaneous with onset.

8. Evidence of inability to obtain appropriate clinical management. If relying on s 9(23), collect documentation showing attempts to obtain care and the reasons care was unavailable: correspondence with medical facilities, waiting lists, transfer or evacuation records in operational contexts, or contemporaneous GP notes documenting inability to access care. The SOP does not define "appropriate clinical management," so detailed contemporaneous records are essential.

9. Link exposures to relevant service. Section 10(1) requires the factors be related to relevant service. Assemble service medical records, unit logs, mission reports, and deployment health records that show the exposure occurred during service or was caused by an event in service. For exposures that occurred outside service but are alleged to be related, obtain evidence showing a causal link to service events.

10. Prepare clinical expert opinion that references the SOP criteria. Given the SOP’s function as the medical yardstick, medical experts instructed to provide causation opinions should address the specific factors in s 9 and the definitions in Schedule 1. Expert reports should state whether the listed factor is present on the evidence, whether it meets the numerical or timing thresholds, and whether it is related to relevant service as required by s 10(1). Experts should comment on alternative explanations and whether the factor raises a reasonable hypothesis of service connection in the sense contemplated by the SOP.

11. Check cross‑referenced SOPs. If any factor refers to an injury or disease covered by another SOP (s 11), obtain and apply that other SOP to make sure its factors and definitions are satisfied. Examples include SOPs for goitre and Graves disease. Failing to account for cross‑SOP requirements can lead to arguments that the wrong medical framework was applied.

12. Keep documentary chains and contemporaneous records. The SOP’s tight temporal windows and quantitative thresholds make contemporaneous documentation especially valuable. Where possible, secure original medical records, laboratory reports, pharmacy dispensing records, and service records rather than secondary summaries.

13. Anticipate review and appeal points. If a claim is denied for lack of evidence that a factor existed or was service‑related, ensure administrative review or appeals focus on the instrument’s precise wording: timing, continuity of exposure, numerical thresholds, and the requirement that the factor be related to relevant service under s 10.

Following these steps will align claim preparation with the SOP’s structure and evidentiary demands, and will give decision makers the documentation required to apply the SOP’s medical predicates to statutory causation tests.