Statement of Principles concerning Marfan syndrome (Balance of Probabilities) (No. 52 of 2023)

This instrument is compact and conceptually focused. Its core legal-conceptual components are the definition of the disease, the standard of relation to service, the list of compensable factors, the temporal limitation on when the SoP applies to aggravation or contribution, and cross-SoP interaction rules.

Definitions and disease scope

• Marfan syndrome is defined in clinical terms as a genetic disorder of connective tissue typically involving eyes, bones, heart and blood vessels (s7(2)). Although an ICD‑10‑AM code is referenced, the SoP makes clear that its internal definition controls (s7(3)-(4)). Death from Marfan syndrome is included where a terminal event or condition was contributed to by Marfan syndrome (s7(5); Schedule 1: terminal event).

Causation and evidentiary posture

• The RMA frames its determination in probabilistic terms, stating that on the sound medical‑scientific evidence available it is of the view that it is more probable than not that Marfan syndrome and death from Marfan syndrome can be related to relevant service (s8). The title of the instrument also contains the parenthetical “Balance of Probabilities”, reflecting that the causal threshold for the RMA is the civil standard.

Factors necessary for a connection with service

• The instrument lists only two alternative factors that must exist, at least one of which must be established for a positive connection: pregnancy before clinical worsening; or inability to obtain appropriate clinical management for Marfan syndrome (s9). These are express, conjunctive-in-the-sense of alternatives: the claimant needs to establish at least one of them.

Temporal limitation and scope of application

• The factors in s9 apply only to material contribution to, or aggravation of, Marfan syndrome where the person’s Marfan syndrome was suffered or contracted before or during, but did not arise out of, relevant service (s10(2)). That is, the SoP contemplates aggravation or material contribution scenarios where the underlying condition pre-existed or co‑existed with service, excluding cases where the syndrome arose out of service.

Interaction with other Statements of Principles

• If a factor in s9 refers to an injury or disease that is itself the subject of another SoP determined under s196B(3) of the VEA, then the factors in that other SoP apply as they are in force from time to time (s11). The effect is to incorporate by reference other SoPs where overlapping or subsidiary conditions are implicated.

Relevant service and statutory anchors

• “Relevant service” is defined in the Schedule (Schedule 1) to mean eligible war service (other than operational service) under the VEA, defence service (excluding hazardous service and British nuclear test defence service) under the VEA, or peacetime service under the MRCA. The instrument is therefore targeted to the particular categories of service recognised in the veteran compensation framework (Schedule 1).

Terminal events and death

• The SoP expressly enumerates terminal events that are to be taken as included within “death from” where Marfan syndrome has contributed: pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function (Schedule 1). This gives practical contours to how death linked to Marfan syndrome should be treated.

Authority and commencement

• The SoP is made under s196B(3) of the VEA (s3) and comes into force on 23 May 2023 (s2). It also repeals the 2015 instrument (s4).

These concepts form the legal and operational vocabulary that will be used to assess claims under sections of the VEA and MRCA identified in s5. The SoP is procedural in effect: it sets medical-legal thresholds and definitional rules that the decision‑makers within the veteran entitlements system will apply.

Directly affected persons

• Claimants: veterans and members of the Forces who submit claims under section 120B of the Veterans' Entitlements Act 1986 or section 339 of the Military Rehabilitation and Compensation Act 2004 will be assessed against this SoP when their claim involves Marfan syndrome or death from Marfan syndrome (s5). Those seeking to establish that their Marfan syndrome is connected with relevant service will need to establish, on the balance of probabilities, the presence of at least one of the factors in s9 and that the factors are related to their relevant service (s9; s10(1)).

• Relatives/representatives in death claims: where death is alleged to be from Marfan syndrome, the instrument extends to deaths in which a terminal event or condition was contributed to by the person’s Marfan syndrome (s7(5)). Representatives pursuing entitlements related to a veteran’s death will be assessed under these parameters.

Administrators and decision-makers

• The Repatriation Medical Authority (RMA) prepared the SoP under its statutory power (s3). The SoP will be used by decision-makers within the VEA and MRCA frameworks,those administrative bodies that apply SoPs to determine whether a condition is “service-related” for entitlement purposes,although the instrument itself does not name the decision-makers. The RMA’s expressed evidentiary posture is recorded: it is of the view, on the sound medical‑scientific evidence, that a probable relationship between Marfan syndrome and relevant service exists (s8). That view informs how decision-makers are to treat the condition for claims.

Medical practitioners and record-keepers

• Treating clinicians and hospitals will be indirectly affected because claimants will need clinical evidence to establish the factors in s9. The SoP defines Marfan syndrome clinically (s7(2)) and references ICD‑10‑AM coding (s7(3)-(4)), so medical records that identify the diagnosis and document clinical worsening, pregnancy status, management attempts, and causes of death will be material.

Who does not fall under the SoP

• Persons whose Marfan syndrome arises out of relevant service are outside the scope of the SoP’s aggravation/material contribution factors; the instrument states that the factors in s9 apply only where Marfan syndrome was suffered or contracted before or during, but did not arise out of, relevant service (s10(2)). Therefore, primary-onset cases that are alleged to have arisen as a consequence of service activities are not covered by these particular aggravation/material-contribution factors.

Service categories referenced

• The definition of relevant service narrows who is in scope under the VEA/MRCA scheme: eligible war service (other than operational service), defence service excluding hazardous and British nuclear test defence service, and peacetime service under the MRCA (Schedule 1). That definition determines which veterans will have their Marfan syndrome assessed under this SoP when claiming under the specified statutory provisions.

Effect on evidence gathering and litigation posture

• Because the instrument identifies only two factors as the necessary causal elements for a service connection, claimants, medical experts and administrators will focus evidence‑gathering and medico-legal reports on those factors and their temporal relationship to relevant service (s9-s10). The SoP also cross-references other SoPs when a factor invokes a different injury or disease; this affects both claimants and medical experts, who must determine whether additional SoPs govern parts of the causal chain (s11).

In sum, the principal human subjects affected are claimants (or their representatives) and the medical professionals and administrative decision-makers whose records and reports will be used to test the SoP’s two listed factors in the context of the defined categories of relevant service.

The instrument itself is a statement of principles rather than a statute imposing duties or conferring rights directly. Nevertheless, within the veterans’ entitlements framework it establishes legal predicates that create obligations and entitlements through their operational effect.

RMA’s duty to determine a SoP

• The instrument is made by the Repatriation Medical Authority under subsection 196B(3) of the VEA (s3). The RMA has the statutory role of determining SoPs; this instrument records the RMA’s considered medical‑scientific view with respect to Marfan syndrome (s8). The RMA’s duty exercised here is to set out factors that, if established on the balance of probabilities, constitute a link between condition and relevant service.

Claimant duties in practice

• Claimants seeking to have Marfan syndrome or death from Marfan syndrome accepted as connected with service must, under the rules of the decision-making regime into which this SoP feeds, establish at least one of the factors in s9 and that the factor was related to their relevant service (s9; s10(1)). The SoP requires temporal alignment: the syndrome must have been suffered or contracted before or during, but not as a result of, the relevant service for aggravation/material contribution to be considered under these factors (s10(2)). Practically, claimants have the duty to present evidence addressing these factual elements because the instrument sets the causal pathways that will be accepted.

Administrative duties in relation to interpretation and application

• Administrative decision-makers applying the VEA or MRCA provisions to claims involving Marfan syndrome will be required to use this SoP as the operative statement of medical principles for the condition (s5). They will need to test the presence of the factors in s9, the relevance of any cross-referenced SoP (s11), and the temporal relationship to relevant service (s10). The SoP signals the medical questions decision-makers must resolve; it does not itself specify procedural steps, but the decision-makers must interpret clinical wording such as “clinical worsening” and “inability to obtain appropriate clinical management”.

Rights conferred indirectly through the SoP

• By listing specific factors that, if established, will support a determination that Marfan syndrome is connected with service, the SoP creates a predictable legal pathway for claimants. The SoP’s inclusion of death via terminal events (s7(5); Schedule 1) clarifies that claimants asserting death-related entitlements can link death causes such as pneumonia, respiratory failure, cardiac arrest, circulatory failure or cessation of brain function to Marfan syndrome, provided contribution is demonstrated. The SoP thus defines the evidentiary content of an entitlement claim; where a claimant establishes a factor and the relevant causal nexus to service, the entitlement regime’s rights under the VEA or MRCA may follow.

Limits and constraints expressed in the instrument

• The SoP restricts compensable causation for aggravation/material contribution to cases where Marfan syndrome pre-existed or was present during, but not caused by, relevant service (s10(2)). It also limits acceptable causal scenarios to the two factors listed in s9. If a claimant cannot establish either factor, the SoP provides no basis, within its terms, to find that Marfan syndrome is connected with relevant service on the basis of aggravation or contribution under this instrument.

Cross-SoP interaction obligations

• Where a factor in s9 refers to another injury or disease that is subject to a separate SoP, the decision-maker must apply the factors in that other SoP in accordance with its terms (s11). This imposes a duty to identify and apply the correct SoP(s) where overlapping or secondary conditions are implicated.

Standard of proof

• The RMA states the medical connection is assessed on a “more probable than not” basis (s8). The SoP title also indicates “Balance of Probabilities”. This sets the civil standard of proof as the evidentiary benchmark for applying these medical principles when determining service connection within the VEA/MRCA contexts.

In short, the instrument allocates practical duties,primarily evidentiary duties to claimants and interpretive/application duties to administrators,by structuring which factual elements must be established for Marfan syndrome or death from Marfan syndrome to be linked to relevant service.

This Statement of Principles is a determinative technical instrument; it does not itself create criminal offences, civil penalties, or an enforcement regime. The text contains no express sanctions, fine provisions, or enforcement powers. Instead, its enforcement effect is operational and indirect: it sets the medical-legal standards applied in claims processing under specified provisions of the Veterans' Entitlements Act 1986 and the Military Rehabilitation and Compensation Act 2004 (s5).

Enforcement and application mechanism

• The SoP will be invoked by administrative decision-makers when assessing claims under section 120B of the VEA or section 339 of the MRCA (s5). The instrument prescribes the criteria that must be satisfied,on a balance of probabilities,before a claim involving Marfan syndrome or death from Marfan syndrome can be accepted as connected with relevant service (s9; s8). Any practical “enforcement” is therefore exercised through the acceptance or rejection of an entitlement claim by the relevant administrative agencies operating under the VEA and MRCA.

Absence of offence provisions in the instrument

• There are no clauses establishing penalties for non-compliance by claimants, nor penalties for clinicians or administrators. The SoP does not purport to create offences or to prescribe sanctions for incorrect claims, fraudulent statements, or failures by health services to provide care referred to in s9(2). Any penalties that might apply in such circumstances would arise from other statutes, regulations or administrative rules not contained in this instrument; the instrument itself is silent on those matters.

Dispute resolution and review

• The instrument does not set out dispute resolution mechanisms or appeal routes; it is intended to be used within the statutory decision pathways of the VEA and the MRCA. The SoP therefore relies on the enforcement and review mechanisms provided by those Acts and associated administrative procedures which are not described in the instrument (s5).

Implications for decision-makers

• The lack of express enforcement measures in the SoP places the onus on decision-makers to apply the listed factors rigorously when determining service connection. If a decision-maker misapplies the SoP, any remedy would come through the statutory appeal and review processes of the VEA or MRCA frameworks rather than through penalties in the SoP itself. The RMA’s statement about sound medical‑scientific evidence (s8) can be a focal point in administrative review contexts when contesting the medical basis for an acceptance or rejection.

Record-keeping and evidentiary weight

• Because the SoP prescribes specific factors to be established, the functional “enforcement” will operate through documentary and medical evidence: records of pregnancy timing, clinical notes of worsening, evidence of attempts to obtain appropriate clinical management, and medical records of terminal events in death cases (s7(5); s9). Administrative bodies will weigh such evidence against the SoP’s requirements when deciding entitlements.

In summary, the instrument does not itself impose penalties or enforcement powers. Its effect is to guide entitlement determinations under VEA and MRCA; acceptance or rejection of claims, and any consequent uprating or refusal of benefits, constitutes the operational enforcement outcome, undertaken pursuant to the statutory frameworks referenced in s5.

Statutory anchor and scope

• The SoP is made under subsection 196B(3) of the Veterans' Entitlements Act 1986 (s3). Its explicit application is to claims to which section 120B of the VEA or section 339 of the MRCA applies (s5). The instrument therefore functions as an interpretive and determinative adjunct to those statutory claim provisions: it supplies medical principles for assessing whether Marfan syndrome or death from Marfan syndrome is connected with relevant service.

Relationship with other Statements of Principles

• The instrument contains an express cross-reference mechanism. If a factor in s9 refers to an injury or disease that is the subject of another Statement of Principles determined under subsection 196B(3) of the VEA, the factors contained in that other SoP apply in accordance with its terms as in force from time to time (s11). This creates a layering effect where multiple SoPs can be used together: one SoP’s factor may invoke another SoP, which then contributes additional factors or causal pathways. Decision-makers must therefore identify when an overlapping or subsidiary condition is implicated and apply the relevant SoP(s) cumulatively rather than in isolation.

Limitations imposed by the SoP vis-à-vis primary-onset claims

• The SoP explicitly confines its aggravation/material contribution factors to cases where Marfan syndrome was suffered or contracted before or during, but did not arise out of, the person’s relevant service (s10(2)). Consequently, the SoP does not purport to address scenarios where Marfan syndrome is alleged to have arisen as a result of relevant service. Those scenarios may be governed by other provisions of the VEA or MRCA or other SoPs, but this instrument does not operate to bridge to those alternative causation frameworks.

ICD coding and clinical classification

• The instrument refers to an ICD‑10‑AM code (Q87.4) as the code associated with Marfan syndrome but specifies that the legal meaning of Marfan syndrome for the purposes of the SoP is that provided in s7(2), not solely the ICD code (s7(3)-(4)). The instrument therefore recognises the clinical classification system but prioritises its textual clinical definition within the instrument.

Interplay with decision-making provisions of the VEA and MRCA

• The instrument must be read and applied within the procedural and substantive decision-making frameworks established by the VEA and MRCA for claims. The instrument itself does not reproduce those claim processing provisions, thresholds for entitlement beyond causation, or appeal pathways. It is therefore an input into the legal machinery of those Acts; the ultimate legal effect in any particular claim depends on the statutory provisions of the VEA or MRCA as applied by decision-makers.

Potential evidence and administrative law considerations

• Because the SoP formulates medical factors that must be satisfied on balance of probabilities (s8), administrative decision-makers will need to apply administrative law principles when assessing whether the claim meets the articulated medical criteria. The SoP therefore interacts indirectly with administrative law doctrines such as reasonableness, procedural fairness and evidentiary standards as they operate within appeal or internal review processes, but those doctrines and processes are not specified in the instrument.

Replacement of prior instrument

• The SoP expressly repeals the previous Statement of Principles concerning Marfan syndrome No. 26 of 2015 (s4). That repeal creates a legal transition: subsequent VEA/MRCA determinations that rely on a statement of principles for Marfan syndrome will use the 2023 instrument rather than the 2015 instrument, unless transitional or saving provisions elsewhere apply. The instrument itself does not set transitional rules.

In sum, the SoP is a specialised, statutory medical-principles instrument whose legal operation is to be deployed within the VEA and MRCA claim frameworks, to be used alongside other SoPs where relevant, and to be applied by administrative decision-makers in assessing causation on the balance of probabilities.

This instrument contains an explicit, short amendment history limited to its own creation and the repeal of its predecessor.

Creation and dates

• The instrument is titled as Statement of Principles concerning Marfan syndrome (Balance of Probabilities) (No. 52 of 2023). It is dated 24 April 2023 (front page) and the instrument commences on 23 May 2023 (s2). The signature block records that the Common Seal of the Repatriation Medical Authority was affixed at the direction of Professor Terence Campbell AM, Chairperson.

Repeal of prior Statement of Principles

• Section 4 states: “The Statement of Principles concerning Marfan syndrome No. 26 of 2015 (Federal Register of Legislation No. F2014L01838) made under subsection 196B(3) of the VEA is repealed” (s4). That is the sole express amendment action reflected in the instrument. The repeal is unconditional in the text; no transitional provisions are included in the instrument itself.

Basis of authority for amendment

• The instrument is made under subsection 196B(3) of the VEA (s3). The RMA’s authority to determine and thus amend or replace SoPs arises from that statutory provision, as the instrument’s own form evidences.

No other amendments recorded

• There are no other amendments, modifications, or side-by-side comparisons recorded in the instrument. The text does not identify which elements differ substantively from the 2015 instrument, nor does it include any saving, transitional, or transitional application provisions. The only operative directive is repeal of the 2015 instrument (s4) and commencement of this instrument (s2).

Publication references

• The 2015 instrument is identified by its Federal Register of Legislation number (F2014L01838). The current instrument is labelled No. 52 of 2023. The Schedule includes the Dictionary definitions. There are no amendments following commencement recorded in the instrument text provided.

Implications of absence of transitional provisions

• Because the instrument does not set out transitional rules, decisions about which instrument applies to particular claims following the repeal will depend on the statutory decision-frameworks and any general transitional rules those frameworks may contain; the SoP itself does not specify them. Practically, this creates an implementation point for administrators: to determine whether claims in process should be assessed under the old or new SoP, administrators will need to consult the VEA/MRCA procedural rules and any internal guidance not included in the instrument.

In short, the amendment history in the instrument is limited and explicit: it replaces the 2015 SoP with the 2023 SoP, and it is made under the RMA’s statutory power with a clear commencement date.

The Statement of Principles text supplied contains no litigation history. The instrument does not cite any judicial decisions, appeal outcomes, or precedent authorities. It does not record that it has been the subject of litigation, nor does it attach or rely upon case law.

Implications of absence of recorded litigation

• Because there is no litigation history contained within the instrument, any interpretation disputes about the meaning of terms such as “clinical worsening”, “inability to obtain appropriate clinical management”, “material contribution”, or about the temporal rule in s10(2) are not informed by judicial guidance within this instrument. Administrative decision-makers, claimants and medical witnesses will therefore need to rely on the language of the SoP itself, contemporary medical evidence, and the standard administrative review and appeal processes afforded under the VEA and MRCA to resolve disputes.

Where litigation would normally arise

• In practice, issues likely to prompt contested decisions include: whether a claimant establishes pregnancy prior to clinical worsening in a way that causally links to aggravation; the evidentiary threshold and meaning of inability to obtain appropriate clinical management; the determination of whether a person’s Marfan syndrome “arose out of” relevant service or was merely present; and whether death from a terminal event was contributed to by Marfan syndrome (s7(5); s9; s10). The instrument itself does not supply litigation outcomes on these points.

No recorded precedent or interpretative rulings embedded

• The SoP does not include interpretative guidance from courts or tribunals, nor does it reference decisions by the RMA beyond the statement of its medical-scientific view (s8). Users of the SoP must therefore be attentive to administrative guidance, medico-legal reports, and any subsequent jurisprudence that may arise after the instrument’s commencement; none of that post‑commencement material is incorporated into this text.

Consequences for practitioners

• For lawyers, advocates and medical advisors, the absence of litigation history within the SoP means that initial claims and internal reviews will be materially shaped by the plain text of the instrument and by contemporaneous medical evidence rather than by established case law interpreting this specific 2023 instrument. If contentious cases progress to merits review or judicial review, those decisions will form the eventual litigation history, but no such history is embedded in the instrument as provided.

In summary, there is no litigation history in the instrument. The resolution of interpretative disputes will depend on administrative application and any subsequent appeal or judicial decisions external to the instrument.

This instrument is succinct, which concentrates potential practical pitfalls. The following are concrete points the SoP creates or leaves unaddressed, each grounded in the instrument’s text.

1. Narrow list of qualifying factors (s9)

• Only two alternative factors are listed. A claimant who cannot show either being pregnant before the clinical worsening of Marfan syndrome, or inability to obtain appropriate clinical management, will have no grounds under this SoP to establish the necessary causal link. The risk is that common or plausible causal scenarios not captured by those two formulations will not be covered unless another SoP applies and is engaged under s11.

2. Ambiguity of “clinical worsening” and timing (s9(1))

• The SoP requires being pregnant before the clinical worsening of Marfan syndrome. “Clinical worsening” is not defined in the instrument. The absence of a textual definition means outcomes will turn on medical evidence and administrative interpretation of when clinical deterioration occurred relative to pregnancy. Precise documentation of dates and clinical markers will therefore be essential.

3. Vague threshold for “inability to obtain appropriate clinical management” (s9(2))

• The phrase “inability to obtain appropriate clinical management” is open-textured. The instrument does not specify whether the inability must be due to availability, access, resources, clinical contraindication, refusal by providers, or other causes. Evidence to establish attempts to obtain care, barriers encountered, and contemporaneous clinical consequences will be necessary but the SoP provides no checklist.

4. Temporal limitation excluding primary-onset-in-service scenarios (s10(2))

• The SoP only addresses material contribution or aggravation where Marfan syndrome was suffered or contracted before or during service but did not arise out of relevant service. If a claimant alleges that Marfan syndrome arose as a direct consequence of service, this SoP’s factors for aggravation/material contribution will not apply. Practitioners should note that different legal analysis or other SoPs may be needed for those cases.

5. Cross-SoP complexity (s11)

• Where a factor refers to an injury or disease governed by another SoP, the other SoP applies. This creates potential complexity where causal chains involve multiple conditions. Identifying, applying and reconciling multiple SoPs may require careful analysis to avoid gaps or misapplication.

6. Death from terminal events requires demonstration of contribution (s7(5); Schedule 1)

• Deaths that are proximate to terminal events listed in the Schedule (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function) are covered only if the terminal event was contributed to by Marfan syndrome. Establishing contribution to death often requires detailed clinical and forensic evidence linking the syndrome to the terminal event.

7. ICD‑10‑AM reference does not supplant textual definition (s7(3)-(4))

• Although the instrument references ICD‑10‑AM code Q87.4, it explicitly states that the meaning in s7(2) controls. That means reliance on coding alone is insufficient; medico-legal reports must align with the instrument’s textual clinical description.

8. Repeal without transitional provisions (s4)

• The instrument repeals the 2015 SoP but contains no transitional or saving clauses in its text. Practitioners should be alert to the potential need to consult the VEA/MRCA procedural rules about which instrument applies to in‑flight claims and whether administrative guidance exists on dealing with claims straddling the repeal date.

9. “Balance of Probabilities” label and evidentiary expectations (title; s8)

• The title and s8 indicate the RMA applied the balance of probabilities standard in determining the SoP. While this sets the standard for causation, establishing the required factors on that standard still demands clear, contemporaneous medical evidence, and the open-textured terms increase evidentiary unpredictability.

10. Scope limited to defined types of relevant service (Schedule 1)

• The definition of relevant service excludes certain categories (for example the Schedule explicitly excludes operational service within eligible war service and excludes hazardous service and British nuclear test defence service in the defence service definition). Claims by persons whose service falls outside the defined relevant service categories will not be captured by this SoP. Practitioners should confirm which category of relevant service applies in each claim.

Each of these points arises directly from the instrument’s clauses. They translate into practical evidence, timing and interpretation issues for claimants, medical advisers and decision-makers. Addressing these “gotchas” in a claim requires targeted documentation, clear medico-legal reporting, and careful attention to the temporal and definitional constraints the instrument sets.

This section sets out practical steps, focused on documentary and evidentiary actions that follow from the instrument’s requirements. The SoP is a determinative medical instrument used in assessing claims under the VEA and MRCA (s5); compliance therefore means presenting sufficient, targeted evidence to satisfy the SoP’s factors and temporal rules on the balance of probabilities.

1. Establish the diagnosed condition in the instrument’s terms (s7(2)-(4))

• Ensure medical records explicitly reference Marfan syndrome consistent with the instrument’s clinical definition: a genetic disorder of connective tissue typically involving the eyes, bones, heart and blood vessels (s7(2)). While ICD‑10‑AM code Q87.4 may appear in records, prepare medico-legal statements tying the clinical features in the records to the instrument’s textual definition (s7(3)-(4)).

2. If death is claimed, document contribution to terminal events (s7(5); Schedule 1)

• For death claims, assemble the death certificate, hospital records, post‑mortem reports and treating notes that demonstrate how Marfan syndrome contributed to the terminal event (e.g., pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function). The SoP requires contribution to a terminal event, not simply the contemporaneous presence of a terminal event.

3. For s9(1) (pregnancy before clinical worsening): document timing and clinical course

• Collect antenatal records, obstetric notes, and medical records showing pregnancy dates and the clinical course of Marfan syndrome. Clinicians should provide opinionated reports stating when “clinical worsening” occurred, what objective markers indicate worsening, and that pregnancy preceded the worsening. Timing evidence (dates of clinic visits, imaging, specialist letters) is essential because the SoP hinges on pregnancy occurring before worsening (s9(1)).

4. For s9(2) (inability to obtain appropriate clinical management): document attempts and barriers

• Collate contemporaneous records demonstrating attempts to obtain appropriate care and the reasons care was not obtained. This may include referral letters, appointment logs, correspondence with health providers, denial letters, geographical or resource constraints, and clinical notes indicating care was unavailable or inappropriate. Medical expert evidence should explain how inadequate or absent management materially contributed to aggravation, consistent with the SoP.

5. Demonstrate the temporal relation to relevant service (s10(1)-(2); Schedule 1)

• Provide service records that establish the claimant’s type of relevant service as defined in the Schedule (eligible war service other than operational service, defence service excluding hazardous service and British nuclear test defence service, or peacetime service under the MRCA). Combine service documentation with medical records to show the syndrome was suffered or contracted before or during, but did not arise out of, the person’s relevant service, if seeking a finding under these aggravation/material contribution factors (s10(2)).

6. Address cross-SoP issues where applicable (s11)

• If any factor in s9 references another injury or disease covered by a different SoP, obtain and apply the factors from that SoP. Practically, that means identifying overlapping conditions in medical records and securing medico-legal reports that address both the Marfan-related factors and any factors required by the other SoP.

7. Use expert medical opinion that ties facts to the SoP’s criteria and the balance of probabilities (s8)

• Engage treating specialists and forensic/medical experts to provide opinion evidence that explicitly addresses the SoP’s criteria: diagnosis under the textual definition, the occurrence and clinical markers of worsening, the causal role of pregnancy or lack of management, the contribution to terminal events in death cases, and the relation to relevant service. Experts should state whether, on the balance of probabilities, the factor(s) in s9 and their connection to relevant service are satisfied.

8. Anticipate administrative scrutiny and prepare contemporaneous evidence

• Because the SoP requires factual findings (timing, failed access to care, causal contribution), contemporaneous evidence is more persuasive than retrospective statements. Keep appointment logs, referral letters, test results, imaging, hospital discharge summaries and correspondence with service medical authorities where relevant.

9. Pay attention to coding but prioritise clinical content (s7(3)-(4))

• While ICD‑10‑AM coding may appear in hospital or clinic records, ensure that medical narratives and diagnoses map onto the instrument’s textual definition of Marfan syndrome. Medico-legal reports should not rely solely on a diagnostic code.

10. Consider administrative timelines and which instrument applies (s2-s4)

• Note the commencement date (23 May 2023) and that the 2015 SoP has been repealed (s2; s4). For claims spanning the repeal, confirm with the administering agency which instrument applies to the specific claim; where ambiguity exists, supply evidence compliant with both versions where practical.

11. Prepare submissions on interpretation where terms are unclear

• Where terms are inherently open (for example “clinical worsening”, “appropriate clinical management”, “contributed to”), include in submissions expert definitions and explanations of how those terms are to be applied to the facts of the case. Doing so reduces the interpretive burden on decision-makers and frames the evidentiary record to meet the balance of probabilities.

12. Maintain audit trail and advocate cross-referencing SoPs

• If another SoP is implicated, provide a clear cross-referencing map in the claim submission that identifies the other SoP and sets out how its factors are met alongside the Marfan SoP requirements (s11).

Following these steps aligns an evidentiary package with the specific, limited factors the SoP requires. The ultimate finding that a condition is service-connected under the VEA or MRCA will depend on a decision-maker’s application of the SoP to the documentary and medical evidence presented; the SoP provides the legal medical thresholds that must be addressed.