Statement of Principles concerning inflammatory bowel disease (Balance of Probabilities) (No. 91 of 2020)

The core legal concept is an administrative Statement of Principles used to guide determinations of service connection for IBD under the VEA/MRCA claim pathways. The Statement sets a threshold of causation expressed as a balance of probabilities, as stated by the RMA in section 8. It does not purport to define legal liability, criminal fault, or statutory penalties; rather it supplies medically‑based factual factors that, if proved and linked to relevant service, establish connection between IBD and service.

Definitions are central. The instrument defines inflammatory bowel disease for its own purposes as a chronic, relapsing and remitting inflammatory autoimmune disorder of the gastrointestinal tract, including Crohn disease, ulcerative colitis, and unspecified types, but excluding bowel inflammation unrelated to autoimmunity (s 7(2)). The Statement also expressly states that, while IBD attracts ICD‑10‑AM codes K50 or K51, the operative meaning for the Statement is the textual definition in s 7(2) rather than reliance solely on the ICD code (s 7(3)-(4)). Death from IBD is included where the terminal event or condition was contributed to by the person’s IBD (s 7(5)).

The instrument lists discrete factors which, singly, are sufficient to connect IBD to service if they exist and are related to the person’s relevant service (s 9). These factors are a mixture of drug exposures (for example, nonsteroidal anti‑inflammatory drugs taken with specific frequency, interferons, tumour necrosis factor antagonists, immune checkpoint inhibitors, combined oral contraceptive pill), clinical events (organ or tissue transplantation, excluding corneal transplant), behavioural exposures (smoking measured in pack‑years, with different rules for Crohn disease and ulcerative colitis), stressors classified into severity categories (category 1A, 1B and 2 stressors), and an administrative/clinical access factor described as inability to obtain appropriate clinical management (s 9(1)-(16)). The instrument also recognises distinct phases: some factors relate to clinical onset whereas others relate to clinical worsening of an existing disease (s 9).

Section 10 governs the required relationship to service. Subsection 10(1) states that any factor established must be related to the person’s relevant service. Subsection 10(2) imposes a temporal and causal limitation on factors listed at s 9(8)-(16): those factors operate only to demonstrate material contribution to or aggravation of IBD where the disease was suffered or contracted before or during, but did not arise out of, the person’s relevant service. This produces a twofold analytical track: some factors may be used to connect IBD that arose out of service; others operate only as aggravating or contributing causes where pre‑existing disease exists.

The Schedule defines technical terms used in the factors. Important definitional elements include the category stressor definitions, what counts as a corpse, rules for calculating pack‑years and one pack‑year, the definition of a regular smoking habit as specified, the meaning of organ or tissue transplantation, the specified list of drugs, and the definition of terminal event (Schedule 1). A cross‑reference provision directs that if a factor in s 9 refers to an injury or disease covered by another Statement of Principles, the factors in that other Statement apply in accordance with that Statement as in force from time to time (s 11).

Primary affected persons are veterans, members of the Australian Defence Force, and former members who lodge claims under the Veterans' Entitlements Act 1986 or the Military Rehabilitation and Compensation Act 2004 where those claim provisions are identified in s 5. The instrument explicitly applies to claims to which s 120B of the VEA or s 339 of the MRCA applies (s 5). The Schedule defines relevant service to include eligible war service (other than operational service) under the VEA, defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA (Schedule 1, relevant service). Thus, the Statement reaches persons whose service meets those statutory categories. The instrument also applies to death from IBD where the person’s IBD contributed to the terminal event or condition (s 7(5)).

Advisers, medical practitioners preparing reports for claims, departmental decision‑makers, and tribunal members are materially affected. The Statement prescribes the factual content that must be established before a finding of service connection is available under the specified VEA/MRCA claim provisions. Decision‑makers will use this Statement to determine whether the required factor exists on the balance of probabilities, and whether that factor is related to relevant service (s 10(1)). The instrument therefore shapes evidentiary requirements for claimants and the approach of medical assessors instructed in claims.

Different claimant populations face materially different evidential paths. Persons diagnosed with Crohn disease face particular additional criteria: smoking exposure of at least two pack‑years before clinical onset, with timing rules where smoking has ceased (s 9(6)); similarly for clinical worsening (s 9(15)). Persons with ulcerative colitis are subject to a separate smoking‑related factor: a prior history of regular smoking habit and permanent cessation between one and 20 years before clinical onset (s 9(7)). Those who have disease arising out of service will have access to some factors for onset; those who had pre‑existing disease at the time of service or contracted disease during but not out of service have access to a different set of factors for material contribution or aggravation (s 10(2)).

The instrument affects people who took particular medicines or underwent specific clinical procedures. The specified list of drugs in the Schedule includes interferons, nonsteroidal anti‑inflammatory drugs and tumour necrosis factor antagonists; immune checkpoint inhibitors are separately listed in s 9(3) and s 9(9). The NSAID factor in s 9(1) is precise: at least ten days per month, for a continuous period of at least two months before clinical onset, and with last dose within 14 days before clinical onset. People who underwent organ or tissue transplantation, other than corneal transplant, are within scope of specified factors (s 9(5) and s 9(11)), with organ or tissue transplantation defined in the Schedule.

Finally, persons whose claims hinge on psychosocial or traumatic exposures will be affected by the stressor categories defined in the Schedule. The categories are tightly described: category 1A covers severe traumatic events such as being subject to a serious physical attack including rape or experiencing a life‑threatening event; category 1B covers severe events involving witnessing or causing death or serious injury or participating in clearance of corpses; category 2 covers chronic negative life events producing ongoing distress such as caregiving burden, social isolation, relationship breakdown, serious legal issues, workplace or school stress, or severe financial hardship (Schedule 1). These definitions supply the elements claimants must prove for stressor‑based factors in s 9(12)-(14).

The Statement itself does not directly impose statutory duties or create freestanding civil rights. Instead, it functions as an authoritative medical‑evidentiary instrument made by the RMA under its statutory power (s 3), which decision‑makers must apply when determining claims within the instrument’s stated application (s 5). The key rights and procedural consequences are therefore derivative: claimants have the benefit of a clear list of factors which, if established on the balance of probabilities and related to relevant service, are sufficient to support a finding that IBD or death from IBD is connected with service (s 9, s 8). That creates a predictable legal threshold for claimants and their advisers to meet.

Decision‑makers have the duty to apply the Statement when assessing claims that fall within s 5. While the instrument stops short of prescribing the mechanics of decision‑making, it does require that any factor relied upon be related to the person’s relevant service (s 10(1)). For factors listed at s 9(8)-(16), decision‑makers must also verify that the person’s IBD was suffered or contracted before or during, but did not arise out of, relevant service before using those factors to establish material contribution or aggravation (s 10(2)). This imposes an evidentiary sequencing duty in decisions: establish the disease chronology and service relation before treating aggravating factors as operative.

Medical practitioners and report writers who assist claimants effectively face an evidentiary duty: to provide precise, dated medical and procedural records that align with the definitions and timing requirements in the Statement. Examples include medication histories that demonstrate the precise frequency and duration for NSAID use required by s 9(1), smoking histories calculated in pack‑years consistent with the Schedule’s definition and examples, and documentation that substantiates the nature, timing and severity of any stressor that is relied upon. The Schedule supplies specific calculation methodology for pack‑years and a conversion to grams for non‑cigarette tobacco forms, which must be followed to meet the technical definition.

Claimants have the right to have the factors assessed on a balance of probabilities standard as articulated by the RMA in s 8. Section 11 confers an interactional right: where a factor refers to an injury or disease covered by another Statement of Principles, the other Statement’s factors apply in accordance with that Statement as in force from time to time, which can alter the evidentiary basis applicable to the claim (s 11). The Statement therefore interacts with other RMA Statements and may import their content where references exist.

Practically, the Statement allocates evidentiary burdens rather than imposing sanctions. It delineates which factual circumstances create a legally relevant connection to service. The Schedule’s careful definitions reduce flexibility in interpretation and require matchable evidence for each element. For example, the term corpse excludes closed body bag or viewing a body in an open‑casket coffin, which matters when evaluating a claimed category 1B stressor occurrence (Schedule 1, corpse).

This instrument does not create criminal offences, civil penalties, or administrative fines. It is an evidentiary Statement of Principles, made under the RMA’s statutory authority, intended for use in administrative decision‑making about veterans’ entitlement claims. The text contains no penalty provisions or enforcement mechanisms within itself. Instead, its operative effect is to shape outcomes in decisions made under s 120B of the VEA and s 339 of the MRCA, by identifying which factors, if proved and related to relevant service, establish connection on the balance of probabilities (s 5, s 8, s 9).

Enforcement in practice is therefore administrative and procedural. Responsible bodies within the Department of Veterans’ Affairs, medical assessors and decision‑makers will apply the Statement when determining entitlement claims. The instrument supplies standards and definitions those decision‑makers must apply. Where a claimant’s entitlement is accepted or rejected on the basis of the Statement, any rights of administrative review, internal review, or merits review under the VEA or MRCA, or judicial review in courts, would be governed by the relevant statutes and procedural rules, not by the Statement text itself. The Statement does not set those review pathways or time limits; the compilation before you does not include those procedural provisions.

There is an enforcement implication in evidential quality. Because the Statement prescribes precise temporal and quantitative thresholds for many factors, failure to document those thresholds in evidence is likely to result in denial of a finding of connection. For instance, failure to establish NSAID use at the required frequency and timing in s 9(1), or failure to demonstrate organ or tissue transplantation as defined in the Schedule, will lead the decision‑maker to conclude the relevant factor is not established. The instrument therefore enforces accuracy and completeness of evidence through exclusion rather than through fines or sanctions.

The RMA’s statement that its view is founded on “sound medical‑scientific evidence” and that the standard is “more probable than not” (s 8) sets the causal standard applied in administrative determinations. The Statement itself does not describe monitoring, auditing or compliance regimes for how decision‑makers apply it; those implementation and supervisory arrangements are matters for the VEA/MRCA administrative architecture outside the instrument.

The instrument explicitly ties into the Veterans' Entitlements Act 1986 framework by being made under subsection 196B(3) of that Act (s 3). It applies to claims that fall within specified provisions of the VEA and the MRCA, namely s 120B of the VEA and s 339 of the MRCA (s 5). The Schedule defines VEA and MRCA as terms of art within this instrument, and defines relevant service in terms that match service categories under those statutes (Schedule 1, relevant service). Thus there is a direct normative interaction: decision‑makers applying the VEA and MRCA claim provisions must use this Statement as the RMA’s medical evidence standard for IBD where those claim provisions are invoked.

Section 11 is an express cross‑reference mechanism. It states that where a factor in this Statement refers to an injury or disease covered by another Statement of Principles determined under subsection 196B(3) of the VEA, the factors in that other Statement apply in accordance with that Statement as in force from time to time (s 11). This means the present Statement does not operate in isolation: it imports external Statements where references exist. For example, if a s 9 factor refers to an exposure or condition that is addressed in another RMA Statement, decision‑makers must consult that other Statement and apply its factors per their terms.

The instrument also interacts, in descriptive terms, with clinical classification systems: it notes that although IBD generally attracts ICD‑10‑AM codes K50 or K51, the operative meaning for the Statement is the textual definition in s 7(2) and a reference to ICD‑10‑AM code is to the Tenth Edition, effective 1 July 2017 (s 7(3)-(4)). This clarifies that ICD codes are a helpful cross‑reference but not dispositive; the legal meaning for claims is the instrument’s definition.

The Schedule’s definition of one pack‑year and the conversion rules provide technical interaction with medical and forensic smoking history evidence. The one pack‑year definition, including conversion to grams and examples, standardises how smoking exposure should be presented and assessed in claim records. That interacts with medical records and forensic occupational health evidence used in claims.

The instrument does not purport to amend or displace other statutory provisions of the VEA or MRCA beyond setting evidentiary content. It does not amend those Acts within its text. The endnotes show amendments to the Statement itself (see Amendment history below) but the Statement does not contain transitional or savings provisions affecting other Acts. Any interaction with appeal or review mechanisms, time limits, or compensation schedules remains governed by the primary statutes and their regulations, not by the Statement text in this compilation.

The compilation notes and endnotes attached to the instrument record the legislative history and amendments to this Statement of Principles as at the compilation date. The original instrument was registered on 2 November 2020 and commenced on 30 November 2020, recorded in Endnote 3. An amendment instrument, Veterans' Entitlements (Statements of Principles,definition of "one pack‑year") Amendment Determination 2022 (No. 94 of 2022), was registered 26 August 2022 and commenced 19 September 2022, and its effect is included in the compilation (endnotes and compilation header). The compilation date is 19 September 2022 and includes amendments up to that 2022 Amendment Determination.

Endnote 4 provides a provision‑level amendment history for affected parts. It records that subsections related to the definition of one pack‑year in the Schedule were revised by No. 94 of 2022. The amendment history entry shows that notes to subsections 9(6) and 9(15) were revised by No. 94 of 2022 as well. The top‑level notes to the compilation explain that uncommenced amendments, if any, are not shown and that modifications by other laws may affect operation even where the text is not amended; users should consult the Legislation Register for uncommenced amendments or modifications.

Mechanically, the 2022 amendment changed the numerical or conversion methodology for one pack‑year, and updated accompanying notes in the Crohn disease and Crohn clinical worsening smoking notes. The compilation includes those changes as they were in force as at 19 September 2022. The instrument’s endnotes also explain that misdescribed amendments would be annotated if present, and list the standard endnote categories used in the compilation. For practitioners, the immediate takeaway is that the technical smoking exposure definitions and examples have been updated, and that any advice about pack‑year calculations in claims should adopt the amended Schedule text as compiled.

No other amending instruments are recorded within the compilation text beyond the 2022 Amendment Determination and the original 2020 registration. The compilation also notes that some administrative sections of the compilation are affected by standard Legislative Instruments Act or Legislation Act modifications that are not shown; the endnotes invite readers to consult the series page on the Legislation Register for more information on uncommenced or external modifications.

The compiled instrument itself contains no litigation history. It does not cite cases, and the endnotes do not refer to judicial decisions. The instrument is an administrative medical standard issued by the RMA under statutory authority, intended for use in administrative claims processes. Any litigation arising from the application of the Statement in a particular claim, such as merits review or judicial review of a decision that relied on the Statement, would be recorded in external case law databases or in the public record of the VEA/MRCA decision processes. Those sources are not part of the compiled instrument text before you.

Practitioners should therefore treat the Statement as a medical evidentiary instrument rather than as a source of case law. The Statement’s application in decisions may subsequently give rise to litigation concerning interpretation of specific factors, timing relationships, or the sufficiency of evidence. Where such litigation exists, it will be necessary to consult tribunal and court decisions outside of this instrument to see how the Statement has been interpreted and applied by decision‑makers and reviewers. The instrument itself provides no examples, precedents or adjudicative interpretations of its clauses.

Given that the RMA expressly frames its conclusions as being based on “sound medical‑scientific evidence” that supports the balance of probabilities standard (s 8), litigation that challenges medical causation findings will likely focus on the factual sufficiency of evidence in individual claims and on whether decision‑makers correctly applied the Statement’s timing and definitional constraints. None of that litigation detail is recorded in the instrument. Users who require insight into contested interpretations must search administrative tribunal and court records for decisions applying this Statement.

This Statement contains a number of technical definitions, timing windows, and conditional mechanisms that can unexpectedly determine the outcome of a claim if not handled precisely.

1. Binary sufficiency of a single factor. The Statement requires that at least one factor listed in s 9 must exist before it can be said IBD is connected with service. That means a claimant establishing a single qualifying factor, properly linked to relevant service, meets the RMA’s factor threshold. Conversely, failure to establish any one factor precisely as defined results in absence of the RMA‑listed causal link, even if other plausible causal narratives exist outside the listed factors (s 9).

2. Precise timing windows for drug exposure. The NSAID factor at s 9(1) requires taking a nonsteroidal anti‑inflammatory drug on at least ten days per month, for a continuous period of at least two months immediately before clinical onset, and the last dose must be within 14 days before onset. Deviation from those precise frequencies or timings in the documentary evidence is fatal to that factor. Similarly, interferons and TNF antagonists require at least the seven days before clinical onset (s 9(2)), immune checkpoint inhibitors have a one‑year window for onset (s 9(3)) and for clinical worsening (s 9(9)), and the specified list of drugs for worsening has a seven‑day minimum before clinical worsening (s 9(8)).

3. Different legal operation for onset versus aggravation. Section 10(2) limits s 9(8)-(16) to material contribution to, or aggravation of, IBD where the disease was suffered or contracted before or during, but did not arise out of, relevant service. That means those factors cannot be used to establish that disease first arose out of service. Practitioners must therefore establish the correct disease chronology. If the disease began out of service, different factors (s 9(1)-(7)) may apply for onset; if the disease pre‑existed, factors at s 9(8)-(16) can be used to show material contribution or aggravation.

4. Smoking metrics are technical and differ by diagnosis. Crohn disease requires at least two pack‑years (s 9(6) and s 9(15)), whereas ulcerative colitis relies on cessation after a prior “regular smoking habit as specified,” which is defined as at least five pack‑years within a continuous five year period and cessation occurring one to 20 years before clinical onset (s 9(7), Schedule 1). The Schedule gives specific conversion rules for one pack‑year and examples (Schedule 1, one pack‑year). Accurate pack‑year calculation is therefore essential.

5. Stressor definitions are narrow and contain exclusions. Category 1A and 1B stressors are defined tightly in Schedule 1. For example, the corpse definition excludes viewing a closed body bag or a body in an open‑casket coffin. Category 2 stressors require chronic negative life events that produce ongoing distress, and includes an illustrative list such as caregiving, social isolation, relationship breakdown, legal issues, workplace stress or severe financial hardship. Evidence must map to the Schedule definitions; generic references to “stress” or “trauma” are unlikely to suffice.

6. The phrase inability to obtain appropriate clinical management (s 9(16)) is not defined in the Schedule. That absence creates potential variability in interpretation and may produce contested disputes about what constitutes “appropriate” clinical management, whether lack of access was due to service‑connected circumstances, and how to measure that inability in evidence. Decision‑makers may look to contemporaneous medical records, referral histories, waiting lists or geographic access indicators, but the Statement itself provides no standard.

7. Cross‑reference to other Statements. Section 11 directs that if a factor refers to an injury or disease covered by another Statement, that other Statement’s factors apply as in force from time to time. A factor in this Statement may therefore import requirements from another Statement, possibly tightening the evidentiary demands unexpectedly.

8. ICD codes are not determinative. Section 7(3) stresses that although IBD attracts ICD‑10‑AM codes, the Statement’s operative meaning is the definition in s 7(2). Reliance on a diagnostic code alone will not meet the Statement’s definition if the clinical characteristics in s 7(2) are not evidenced.

9. Organ or tissue transplantation excludes corneal transplant. Practitioners sometimes aggregate transplants; the Schedule’s exclusion of corneal transplants for the organ/tissue factors in s 9(5) and s 9(11) means corneal transplant alone will not satisfy those factors.

10. The Statement’s administrative status. Because this is an RMA Statement and not primary legislation that prescribes claims procedure, some procedural consequences (for example, how a tribunal should weigh conflicting expert evidence about whether a factor exists) are not specified in the instrument and will be determined by general administrative law and by the operational practices of claims decision‑makers. That can create unpredictability in borderline cases.

These items are not exhaustive. Practitioners should audit evidence against each precise element and definition in the Statement and the Schedule before relying on a particular factor in a claim.

For claimants and their advisers

1. Map the claim to the Statement’s application. Confirm the claim is one to which s 120B of the VEA or s 339 of the MRCA applies (s 5). If not, this Statement may not be the correct evidentiary instrument.

2. Establish the disease classification in clinical terms. Use the Statement’s operative definition of IBD in s 7(2) rather than relying solely on ICD codes. Medical reports should describe IBD in terms that match s 7(2), and where relevant, the distinctions between Crohn disease and ulcerative colitis should be explicitly stated using the Schedule’s characterisations.

3. Pinpoint dates: clinical onset and clinical worsening. Many factors are time‑sensitive. Evidence must establish the date of clinical onset and the date(s) of clinical worsening to satisfy the various timing windows in s 9 (for example, NSAID last dose within 14 days of onset, immune checkpoint inhibitor within one year of onset/worsening). Medical records, hospital discharge summaries, pathology and imaging reports, and contemporaneous primary care notes are primary evidence.

4. Medication history documentation. For drug‑related factors (s 9(1)-(3), s 9(8)-(11)), obtain pharmacy dispensing records, prescription records, hospital medication charts, or treating specialist statements showing drug type, dose, duration, and dates. The NSAID requirement is quantitative and continuous, so evidence must show at least ten days per month for two months and the date of last dose. For the specified list of drugs, ensure the exact drug falls within the Schedule’s specified list and that the seven‑day minimum before worsening is established.

5. Smoking history and pack‑year calculations. Gather detailed smoking histories and verify calculations against the Schedule’s definition of one pack‑year and the example calculations provided. Document daily cigarette counts, duration, cessation dates, and convert to pack‑years, including conversions for other tobacco forms where relevant.

6. Transplant and surgical records. For organ or tissue transplantation factors, secure surgical records and pathology reports. Verify that the transplant is not exclusively corneal, as corneal transplants are excluded (s 9(5), s 9(11), Schedule 1).

7. Stressor evidence. For stressor‑based factors, assemble contemporaneous evidence establishing the nature of the event and that it meets the Schedule’s definitions of category 1A, 1B or 2 stressors. For category 1B involving corpses, note the Schedule’s exclusions. Witness statements, official incident reports, counselling records, police reports, and employer records may be probative.

8. Demonstrate relationship to relevant service. Section 10(1) requires that any established factor be related to relevant service. Evidence that ties the factor to service events, locations, or exposures is essential. For drug exposures, link medication use to treatment or events while in service where possible. Where exposure occurred after separation, provide documentary explanation of causal pathways that connect the service to the exposure.

9. For factors that operate only as aggravation. If relying on s 9(8)-(16), ensure records show IBD was suffered or contracted before or during relevant service but did not arise out of service, per s 10(2). Establish the pre‑existence and timing with medical records predating service or during service.

10. Address “inability to obtain appropriate clinical management”. Where relying on s 9(16), collect evidence of healthcare access limitations, dates and communication showing attempts to obtain care, referrals, waiting lists, geographical or systemic barriers, and any contemporaneous medical deterioration linked to lack of management.

For decision‑makers and medical assessors

1. Apply the RMA’s balance of probabilities standard. The RMA’s stated view in s 8 that the relation is possible on the balance of probabilities frames the causation task. Evaluate whether a stated factor is proved on that standard.

2. Verify definitional matches. Before treating a factor as established, ensure the factual record maps to the Schedule’s definitions. A stressor must match the Schedule’s category descriptions; smoking evidence must be convertible to pack‑years using the Schedule’s method.

3. Sequence and scope checks. For each asserted factor, check s 10: confirm the factor is related to relevant service (s 10(1)). If the factor is one of s 9(8)-(16), confirm disease chronology satisfies s 10(2) so that the factor is being used only as a material contribution or aggravation.

4. Use cross‑references where applicable. If a factor refers to an injury or disease covered by another Statement, apply that other Statement’s factors as required by s 11, and check whether the other Statement’s current terms impose additional requirements.

5. Do not over‑rely on ICD codes. Treat ICD‑10‑AM codes as secondary descriptors; base determinations on the instrument’s textual disease definition in s 7(2) and the clinical record.

6. Document reasons carefully. Administrative decisions should record how evidence meets or fails to meet each element of a cited factor, including dates, quantities, durations, and the specific Schedule definitions used. Where a factor is rejected, explain which element was missing and why.

7. Anticipate contested interpretation of undefined terms. Be prepared to articulate how you interpret “inability to obtain appropriate clinical management” in the factual context of a claim, and support that interpretation with policy, clinical practice standards, or contemporaneous evidence if available.

8. Keep sight of amendments. Apply the Statement as in force at the time of decision; consult the Legislation Register for subsequent amendments that may alter definitional or quantitative rules, including pack‑year calculations revised by the 2022 Amendment Determination.

Checklist for claim preparation (practical)

• Confirm claim falls under s 120B VEA or s 339 MRCA (s 5).
• Obtain dated diagnostic reports and treating specialist letters that describe IBD consistent with s 7(2).
• Identify and date clinical onset and any clinical worsening precisely.
• Produce pharmacy dispensing records, hospital medication charts and GP notes for relevant drug exposures, with dates and frequencies aligning to s 9 timing windows.
• Prepare a detailed smoking history, compute pack‑years per Schedule 1, and document cessation dates.
• If relying on stressor factors, collect police reports, employer records, counselling notes or other contemporaneous evidence mapping to Schedule 1 categories.
• If relying on organ/tissue transplant factors, secure operative and transplant records confirming organ/tissue type.
• If invoking inability to obtain appropriate clinical management, assemble evidence of attempts to secure care, referrals, and how access issues temporally relate to worsening.
• Demonstrate the relationship of the factor to relevant service with service records, medical notes during service, or linkage evidence.
• Cross‑check whether any factor refers to another RMA Statement and obtain that Statement to confirm imported requirements (s 11).

Following these steps aligns claim evidence with the precise elements enumerated in the Statement, reduces the risk of evidential gaps that would preclude a finding under s 9, and addresses the definitional and temporal caveats placed by s 7, s 9 and s 10.